DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II

U.T. CHANDIGARH

[Complaint Case No: 421 of 2011]

Amandeep Kaur wife of Gurinder Singh Dhillon Resident of 3401, First Floor, Sector 40-D, Chandigarh 160036.

                                                                   ---Complainant.

Versus

1.                 HDFC Ergo General Insurance Company Limited through its Director having its corporate office 6^th Floor, Leela Business Park, Andheri Kurla Road, Andheri (East), Mumbai 400059

2.                 HDFC Ergo General Insurance Company Limited having its regional office SCO No.101,102 & 103, 2^nd Floor, Batra Building, Sector 17-D, Chandigarh 160017.

3.                 HDFC Ergo General Insurance Company Limited having its Registered Office at Ramon House, H.T. Parekh Marg, 169, Backbay Reclamation, Mumbai 400020.

---Opposite Parties.

BEFORE:  SHRI LAKSHMAN SHARMA                 PRESIDENT

                   SMT. MADHU MUTNEJA                       MEMBER

                   SHRI JASWINDER SINGH SIDHU       MEMBER

Argued by: Sh. Arun Singla, Advocate for the complainant.

                   Sh. Paras Money Goyal, Advocate for the OPs.

PER LAKSHMAN SHARMA, PRESIDENT

1.                           Smt. Amandeep Kaur has filed this complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as the Act only) praying for the following relief :

          “It is, therefore, respectfully prayed that this complaint may kindly be allowed and this Hon’ble Court may kindly be pleased to pass an appropriate award directing the opposite party to pay the claim amount specified in the claim form submitted by the complainant with the opposite party as per the Insurance Policy issued by them alongwith the interest @ 18% per annum along with the counsel fee and litigation expenses besides awarding compensation/ damages in favour of the complainant for mentally harassing her against the opposite party in the interest of justice. Or any other appropriate orders which this Hon’ble Court/Forum may deem fit in the facts and circumstances of the present complaint.”

2.                           In brief, the case of the complainant is that she took a policy known as Star Package Plus from the opposite parties for the period 7.9.2010 to 6.9.2011. The said policy was also extended to her husband and son for the said period.  The complainant paid a premium of Rs.17,132/- on 6.9.2010.

                   According to the complainant, on 11.4.2011, her husband felt pain in his chest. So he was taken to a hospital at Sri Ganganagar (Rajasthan). The doctor conducted the preliminary tests and referred the patient to Delhi Heart Institute and Research Centre. The complainant took her husband to the said institute and got him admitted there on 11.4.2011 itself. The doctors present there conducted a number of tests and the patient was diagnosed as suffering from Coronary Artery Disease (CAD). The doctors conducted several tests and started treatment.  Angiography was also conducted on him whereafter he was discharged. Subsequently he was re-admitted at Fortis Hospital, Mohali and was also operated upon.  According to the complainant, she paid for the treatment from her own pocket.  After discharge from the hospital, the complainant submitted the claim alongwith all the relevant documents.  However, the claim was repudiated on the ground that her husband was having a pre-existing disease and the complainant was not entitled to the claim as per the terms and conditions of the policy.   Even thereafter, the complainant approached the opposite parties a number of times asserting that her husband was not having pre-existing disease prior to the treatment but to no effect.  In these circumstances, the present complaint has been filed.

3.                           In the written statement filed by the opposite parties, it has been asserted that the complainant did not disclose the true facts at the time of issuance of the policy and she concealed the fact regarding the previous ailment of her husband.  According to the opposite parties, the kind of ailment for which the husband of the complainant was operated upon did not develop overnight and it was on account of the pre-existing disease that such kind of medical emergency occurred.  So, the claim was rightly repudiated.  According to opposite parties, there is no deficiency in service on their part and the complaint deserves dismissal.

4.                           We have heard the learned counsel for the parties and have gone through the documents on record.

5.                           Annexure C-12 is the letter of repudiation dated 23.5.2011 and the operative part of the same reads as under :-

“Subject :       Hospitalization claim of : Gurinder Singh Dhillon

Reference : Policy No.50370155, Policy inception date : 07 Sep 2010, Policy Expiry date : 06 Sep 2011.

·                    Claim No.23428

·                    Claim amount=396013/-

·                    Ailment/Disease/Complaint-For diagnosis of : CAD

·                    Date of Admission : 15 Apr 2011 – 11/4/11 at Sgnr.

·                    Date of Discharge :17 Apr 2011

·                    File Received Date : 10 May 2011

·                    Past history if any : Policy stat dated 07 Sep 2010. CAD diagnosed 22 Jul 2010

Dear Sir,

After scrutinizing the claim documents wrt this claim, we regret to inform you that the above claim lodged by you is not payable because :

                        Reason : Claim has been repudiated due to pre-existing disease.

                        Clause No.6d

                        Clause Description : Pre-existing conditions will not be covered until 48 months of continuous coverage have elapsed, since inception of the first Health Suraksha Policy with us.

                        In view of the aforesaid, we are unable to reimburse any amount under this claim.  In case you need any further clarification, please contact us 18004254075.”

From the perusal of this letter, it is clear that relying upon the discharge summary (Annexure C-4), the opposite parties were of the view that the husband of the complainant was diagnosed as suffering from CAD on 22.7.2010 i.e. even prior to the purchase of the policy in question which covered the period from 7.9.2010 to 6.9.2011.  In the discharge summary issued by the Delhi Heart Institute & Research Centre, Bathinda, the date of admission of Shri Gurinder Singh in the said Institute is mentioned as ‘/7/10’ whereas in the prescription slip the date of admission is mentioned as 11.4.2011 and date of discharge is mentioned as 14.4.2011.  In order to clarify the matter, the complainant wrote a letter to the Director of the Institute requesting him to clarify the dates of admission and discharge of Shri Gurinder Singh in the said Institute.  So, the said institute issued a corrigendum dated 27.8.2011 which reads as under :-

            “Certified that Mr. Gurinder Singh s/o Mr. Didar Singh, Regn.No.11047845 was admitted for treatment from 11/04/2011 to 14/04/2011 in this hospital and earlier to this he was never admitted here.

            The discharge summary issued to him after above treatment was bearing not date of admission & wrong date of discharge due to typographical error/overlook which is now corrected as per hospital records.  The other contents of said discharge summary shall remain unchanged.

            Necessary corrections may kindly be made accordingly in the relevant records.

            This issues as per request applications dated 27/08/2011 from concerned patients/his relatives.” 

6.                           From the perusal of the above said corrigendum, it is apparent that Shri Gurinder Singh was admitted in the said Institute on 11.4.2011 and was discharged on 14.4.2011.  The assumption of the opposite party to the effect that the husband of the complainant was having a pre-existing disease prior to the commencement of the policy is based on the discharge summary (Annexure C-4) which is patently wrong as has been clarified by the corrigendum dated 27.8.2011 (Annexure C-6) by the said Institute.  In these circumstances, the opposite parties have assumed wrongly that Shri Gurinder Singh was having a pre-existing disease. There is no other material on record to prove that Shri Gurinder Singh was having a pre-existing disease at the time of taking the admission.  

7.                           Thus, repudiation of the claim by the opposite parties on the ground that the husband of the complainant was having a pre-existing disease is absolutely wrong and is not based on proper appreciation of the documents placed before it.  It amounts to deficiency in service.

8.                           In view of the above discussion, the present complaint is allowed and the opposite parties are directed to –

i)                   indemnify the expenditure incurred by the complainant on the treatment of her husband to the permissible extent under the provisions of the policy in question;

ii)                pay Rs.30,000/- to the complainant as compensation for mental agony and harassment;

iii)              pay Rs.7,000/- to the complainant as costs of litigation.

9.                           This order be complied with by the opposite parties, within 45 days from the date of receipt of its certified copy, failing which the amounts at Sr.No.(i) & (ii) shall carry interest @18% per annum from the date of this order till actual payment besides payment of litigation costs.

10.                       Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced.

26.7.2012

Sd/-

 (LAKSHMAN SHARMA)

PRESIDENT

Sd/-

 (MADHU MUTNEJA)

MEMBER

Sd/-

(JASWINDER SINGH SIDHU)

MEMBER

hg