Chandigarh

DF-I

CC/369/2020

Hans Raj - Complainant(s)

Versus

HDFC Ergo General Insurance Co. Ltd. - Opp.Party(s)

Satish Kumar

13 Jan 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

 

                    

Consumer Complaint No.	:	CC/369 /2020
Date of Institution	:	14.09.2020
Date of Decision	:	13.01.2023

 

 Hans Raj S/o late Sh. Garib Dass R/o H. No. 2396, Sector 24-C, Chandigarh.

… Complainant

V E R S U S

1.   HDFC Ergo General Insurance Company Limited, registered & Corporate office, 1^st floor, 165-166 Backbay reclamation, H.T. Parekh Marg, Churchgate, Mumbai-400020 through its Director.

     2^nd Address

     D-301, 3^rd floor,  Eastern Business District (Mangat Mall), LBS Marg, Bhandup (west) Mumbai-400078, Maharashtra.

2.   Director, HDFC ERGO General Insurance Company Limited, registered & Corporate office, 1^st floor, 165-166 Backbay Reclamation, H.T. Parekh Marg, Churchgate Mumbai 400020.

2^nd Address

     D-301, 3^rd floor,  Eastern Business District (Mangat Mall), LBS Marg, Bhandup (west) Mumbai-400078, Maharashtra.

3.   Regional Manager, HDFC ERGO General Insurance Company Limited SCO No. 124-125, Madhya Marg, Sector 8-C, Chandigarh 160008.

4.   Duly constituted Attorney, Regional Manager, HDFC, ERGO General Insurance Company Limited SCO No 124-125, Madhya Marg, Sector 8-C, Chandigarh 160008.

5.   Agent HDFC Bank Ltd. Code number 201587086428 HDFC ERGO General Insurance Company Limited SCO No. 124-125, Madhya Marg, Sector 8-C, Chandigarh 160008.

 .  … Opposite Parties

 

CORAM :	PAWANJIT SINGH	PRESIDENT
	SURJEET KAUR	MEMBER

                        

ARGUED BY		Sh. Puneet Thakur, Advocate for the complainant.
		Sh. Nitesh Singhi, Advocate for the OPs.

Per surjeet kaur, Member

1. Briefly stated, complainant got his Maruti Breeza car insured from the OPs valid from 31.8.2018 to 30.1.2021. In the insurance policy apart from vehicle cover certain other covers were also provided to the complainant i.e. Loss of Job, Accidental Death Permanent total disability/permanent partial disability, accidental hospitalization, critical illness, credit shield insurance, garbage cash as also householders coverage.  On 16.5.2019 the complainant suffered heart attack/stock and he was got admitted in General Hospital Sector 16, Chandigarh and thereafter referred to PGIMER, Chandigarh where the complainant got operated and stunts were planted/inserted in heart of complainant thereafter the complainant was discharged on 19.5.2019.  The complainant visited the hospital continuously for treatment. The complainant only in the month of July 2019 got free to approach the OPs for insurance claim and as per instructions of OPs the complainant on 31.7.2019 filled claim form and supplied all the supporting documents of medical treatment through email.  Thereafter when the complainant enquired about the status of the claim he was time and again asked for additional documents which were provided by the complainant as and when asked for by the OPs. Even the OPs asked for medical certificate from Advance Heart Centre, PGIMER however, doctor at Advance Heart Centre told that the bills and other treatment record had already been crossed signed  by them and  they do not issue medical certificate as it is government run institute. The said fact was also intimated to the OPs. Thereafter the complainant many times approached the  OPs to know about status of his claim but  the complainant was unlawfully rejected by the OPs. Aggrieved by the acts and conduct of the OPs the complainant sent legal notice dated 17.7.2020 but to no avail. Alleging the aforesaid act of Opposite Parties deficiency in service and unfair trade practice on their part, this complaint has been filed
2. The Opposite Parties in their reply stated that the complainant himself has not submitted the required documents which were necessary and required to assess the claim of the complainant. It is averred that it was the duty of the complainant to submit necessary documents so that the claim could be decided as per terms and conditions of the policy but instead of supplying the same the complainant approached to this commission with mala fide intention. It is alleged that the complainant failed to supply  necessary document i.e. treating doctor certificate which was required to know the exact cause and duration of the myocardial infarction in DDS/MM/YYYY format alongwith past consultation papers and treatment records.  It is averred that the complaint is premature as the claim of the complainant has never been repudiated but under the compelled circumstance the same was closed and the same is not maintainable. All other allegations made in the complaint has been  denied being wrong.
3. Rejoinder was filed and averments made in the consumer complaint were reiterated
4. Contesting parties led evidence by way of affidavits and documents.
5. We have heard the learned counsel for the contesting parties and gone through the record of the case.
6. As per case of the complainant on purchasing  new Maruti Vitara Breeza from CM Auto Sales on 29.1.2018 he was issued an insurance policy Annexure C-2 by the aforesaid dealer. This policy was valid till 30.1.2021. As per Annexure C-2 apart from the vehicle cover the policy in question provided other covers like   Loss of Job, Accidental Death Permanent total disability/permanent partial disability, accidental hospitalization, critical illness etc. Evidently as per Annexure C-3 and C-4 the complainant felt uncomfortable and had chest pain during the currency of the policy and therefore, after hospitalization ECG was conducted and the complainant was intimated that he had suffered severe heart attack. Due to this critical situation the complainant had to undergo surgery at PGIMER and stunts were planted in his heart and as per Annexure C-6 the complainant got discharged on 19.5.2019 after the surgery.  When the complainant approached the Opposite Parties for insurance claim he was asked to apply for the same and therefore, he submitted his claim alongwith all the documents on the official mail of the Opposite Parties Company. It is apparent from Annexure C-7 and C-8 that the required documents were submitted by the complainant time and again but till date the critical illness claim of the complainant could not be settled.
7.  The stand taken by Opposite Party is that till date the complainant has not submitted the required documents and hence, the claim could not be settled. Thus, the claim in question has been alleged to be premature and as such the complaint is not maintainable being premature.
8. After going through the documents on record it is evident from Annexure C-2 the policy, annexed at page 27 of the paper-book, that the policy in question was valid from 31.1.2018 to 30.1.2021 and the same was having coverage for critical illness as mentioned at point NO.5 under the heading of coverage and the sum insured for the critical illness was to the tune of Rs.1.00 lakh.
9. Admittedly, the complainant got treatment for critical illness of heart attack during the currency of the policy in question. Hence, undoubtedly the critical illness for which the complainant underwent treatment was duly covered under the policy.  However, the plea of the OPs that the required documents were not submitted by the complainant is baseless and not tenable as it is very well proved on record that the required documents were duly submitted by the complainant several times with the OPs even during the pendency of the present complainant but the Opposite Parties wrongly denied the legitimate and valid claim of the complainant, which caused him mental agony and physical harassment and dragged him in the present unnecessary litigation. Hence, deficiency in rendering service is writ large on the part of the Opposite Parties and they are liable to pay the claim of the complainant.     
10.      In view of the above discussion, the present consumer complaint succeeds and the same is accordingly allowed. OPs are directed as under:-

 

1. to pay the insured sum of Rs.1.00 lakh to the complainant  with interest @9% per annum from the date of claim till realization.  

 

2. to pay 30,000/- to the complainant as compensation for causing mental agony and harassment to him;

 

 

3. to pay 10,000/- to the complainant as costs of litigation.

 

11.      This order be complied with by the OPs within thirty days from the date of receipt of its certified copy, failing which, they shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above
12.      Certified copies of this order be sent to the parties free of charge. The file be consigned

 

			Sd/-
			[Pawanjit Singh]
			President
			Sd/-
			[Surjeet Kaur] Member