BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.6 of 2017
Date of Instt. 03.01.2017
Date of Decision: 10.07.2018
Raja Ram Jha aged 30 years S/o Ram Sager Jha, 23-D Link Road, Model Town, Jalandhar-144001 (Punjab).
..........Complainant
Versus
1. HDFC EGRO General Insurance Co. Ltd., Guru Nanak Mission Chowk, Jalandhar City-144001 through its Branch Manager.
2. HDFC ERGO General Insurance Co. Ltd., Corresponding Office, STELLAR IT PARK, TOWER 5th Floor, E-25, Sector- 62, Noida-201301 through its Authorized Signatory.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Sh. Karnail Singh (President)
Smt. Harvimal Dogra (Member)
Present: Sh. KC Malhotra, Adv Counsel for the Complainant.
Sh. RK Sharma, Adv Counsel for the OP No.1 and 2.
Order
Karnail Singh (President)
1. The instant complaint is filed by the complainant, wherein alleged that the complainant obtained individual health Suraksha Policy Silver Plan covering risk of Domiciliary treatment emergency ambulance charges, health checkup to reimburse to the insured person expenses incurred in patient treatment/post hospitalization and for medical/surgical treatment at any hospital/nursing home and for any disease or suffer from any illness/ailments, disease or injury sustained from OPs through its authorized agent for the period stated in the policy schedule effective from 18.08.2015 to 18.08.2016. The complainant has been continuously and uninterruptedly insured himself since 2014 without any gap/break.
2. That only Cover Note and Policy Schedule of Policy was issued in the name of the complainant. The total amount of renewal premium of Rs.9396/- as consideration was paid to the OPs through its authorized agent, which was accepted after fully satisfying the continued insurability and without questioning the credentials of the insured person without any demur and strings. The OP delivered to the complainant Cover Note and Policy Schedule of Health Insurance Policy. The policy document was not issued to the complainant by the OPs during the whole of the period of the policy, whereas it was mandatory and obligatory upon OPs to have issued policy document, which expresses the contact between the insurer i.e. OP No.1 and the insured. The terms and conditions including exclusion clauses were not ever communicated and explained nor made known to the insured and as such, were not part of insurance. The OPs have agreed and undertaken to indemnify for medical and surgical expenses for illness, accident etc. to the full extent without any deduction in any manner. Accordingly, the complainant has got the right of indemnification for whole amount of medical and surgical expenses incurred and for any loss or damages of peril covered during the term of Health Insurance Policy.
3. That the complainant insured with the OPs on 04.10.2016 met with an accident in the vicinity of Green Park, Near Bus Stand, Jalandhar while driving Scooter, which was slipped, whereby the complainant sustained injury and remained admitted in DMC Hospital and Trauma Centre S.A.S. Nagar, Jalandhar from 04.01.2016 to 20.01.2016 and he was treated by Dr. SS. Dhingram M.S. MCH. After discharge from the hospital, the complainant submitted a claim of Rs.1,03,841/- for medical and surgical expenses incurred by the complainant for reimbursement for hospitalization and treatment surgery to OPs. All the relevant documents were also enclosed herewith, but the OP unilaterally, oppressive malafide and arbitrarily on whims and fancy repudiated mediclaim for amounting to Rs.1,03,841/-, vide letter dated 21.06.2016 under Section 10 of policy terms and conditions on the pretext the mediclaim was found to be misrepresented. The repudiation letter is non speaking, vague and does not speak of alleged misrepresentation. Undoubtedly, the complainant sustained injury by accident and remained under treatment as the patient in DMC Hospital & Trauma Centre, Jalandhar and the said repudiation was wrong, unjust, erroneous and perverse. The OPs are guilty of rendering deficient service, negligent and adopted unfair trade practice, which gave rise to the complainant to file the instant complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to reimburse mediclaim amount of Rs.1,03,841/- with interest @ 12% per annum from the date of lodging the claim, till the actually payment to the complainant and further OPs be directed to award compensation for harassment to the complainant, to the tune of Rs.50,000/- and be also awarded cost of proceeding of Rs.10,000/-.
4. Notice of the complaint was given to the OPs and accordingly, both the OPs appeared through their counsel and filed its joint written reply and contested the complaint by taking preliminary objections that the present complaint is not maintainable against the answering OPs and the same is liable to be dismissed. It is further alleged that the subject claim pertains to Health Suraksha Policy having policy No.2952200829676100000 valid from 18.08.2014 to 17.08.2016. The said insurance policy was issued subject to its terms and conditions, which was duly supplied to the complainant and was never disputed. It is further submitted that a claim was lodged with the OPs for reimbursement of expenses for the hospitalization and claim was registered and thereafter, OPs requested to the complainant to submit required documents for the process of claim, after which certain discrepancies were found in the documents. According to the statement of the complainant, he met with an accident on 04.01.2016, but in claim form, the date of accident is mentioned as 03.01.2016 and date of admission is 04.01.2016. There are multiple manipulation in dates in ICP. Further, an investigation was conducted in order to know the genuineness of the claim, but discrepancies were ruled out by the investigator, which confirmed that the claim is manipulated, hence the claim was repudiated. It is further submitted that if the claim submitted was found to be misrepresented and as per policy terms and conditions, the same can be considered as fraudulent and can be repudiated. It is further averred that there is no deficiency in service nor any negligence or unfair trade practice on the part of the OPs and further alleged that the detailed examination of evidences and cross-examination are required for the just and judicious decision in this matter. Therefore, matter can only be adjudicated upon by the concerned appropriate Civil Courts of law. Hence, the present complaint is liable to be dismissed and further alleged that the complainant has suppressed the material facts from the Forum. On merits, the factum in regard to purchase of insurance policy is not denied and it is also admitted that the claim had been submitted by the complainant, but the same was repudiated according to terms and conditions. The other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits and the same may be dismissed.
5. In order to prove the case of the complainant, the counsel for the complainant tendered into evidence two affidavits Ex.CA and Ex.CB along with some documents Ex.C-1 to Ex.C-43 and then closed the evidence.
6. Similarly, counsel for the OP No.1 and 2 tendered into evidence affidavit of Sh. Pankaj Kumar, Manager Legal as Ex.OP/A along with some documents Ex.O-1 to Ex.O-7 and closed the evidence.
7. We bestowed our thoughtful consideration to the submissions made by learned counsel for the respective parties and also gone through the case file very minutely.
8. From the over all circumstances as put before us by the counsel for the parties, it reveals that the OP has admitted that the complainant purchased an insurance policy of Health Suraksha and Sarv Suraksha policy accident and premium of both the policies was also paid respectively Rs.7823/- and Rs.1573/- and insured amount of both the insurance policy is Rs.3,00,000/- and Rs.1,00,000/- and it is also admitted that the complainant submitted a medical insurance claim, but the same was found improper and therefore, the same was repudiated by the OP, vide repudiation letter dated 21.06.2016 and photostat copy of the same is Ex.O-7. In this case, the main issue is to see whether the claim of the complainant has been rightly repudiated on a solid ground or not, for that purpose, we are of the opinion that the reason mentioned in the repudiation letter is very much necessary to discuss here, for reference sake we reproduced the same as under :-
“As per the documents submitted, the claim was found to be misrepresented. As per the policy terms and conditions, if any claim is in any manner dishonest or fraudulent or is supported by any dishonest or fraudulent means or devices, whether by insured person or anyone acting on behalf of an insured person, then this policy shall be void and all benefits paid under it shall be forfeited. Hence, this claim is being repudiated under Section 10”.
9. Further, in order to prove that as per the terms and conditions of Section-10, the repudiation of the claim is genuine, for that purpose, the OP has also brought on the file a photostat copy of the terms and conditions, which is Ex.O-2. We have analyzed Section 10 of the terms and conditions as well as wording of the repudiation letter and find that the main plea of the OP is only that the complainant has distorted the facts and documents by disclosing two dates of accident, in the claim form dated 03.01.2016 Ex.O-3, the complainant mentioned the date of accident as 03.01.2016, whereas the complainant remained admitted in hospital from 04.01.2016 to 20.01.2016 and the complainant alleged even in his complaint that he met with an accident on 04.01.2016, whereas the date of accident mentioned in the claim form Ex.O-3 is 03.01.2016 and as such, there is dishonest statement, which is a fraud committed by the complainant with the OP and by taking into account this date, the claim of the complainant had been repudiated by the OP.
10. We have considered the above facts that whether simply mentioning a wrong date i.e. 03.01.2016 instead of 04.01.2016 in the claim form is alone sufficient to discard the entire claim of the complainant, the answer is in negative form because it might be a typographically mistake, slip of pen and simply on this ground, the claim cannot be repudiated. Upon this observation, we like to take advantage to refer a pronouncement of the Hon'ble Chhatisgarh State Consumer Disputes Redressal Commission, Raipur, cited in 2004 (2) CLT 162, titled as “Lalit Kumar Oswal Vs. National Insurance Co. Ltd.”, wherein his Lordship held that “ground of mentioning a wrong date of accident is not sufficient to consider that there was no accident.”
11. If, we see the case of the complainant in the light of above pronouncement of Hon'ble State Commission, Chhatisgarh, then we can say without any hesitation that the claim of the complainant has been wrongly repudiated by the OPs. The complainant has produced on the file sufficient evidence to establish that he got injury due to accident and remained admitted in the hospital from 04.01.2016 to 20.01.2016 and also produced the bills of hospital as well as the medicines purchased by him, which are Ex.C-5 to Ex.C-43 and further the complainant fortified his version by placing on the file his own affidavit Ex.CA and supplementary affidavit Ex.CB and insurance policy Ex.C-2.
12. From the above detailed discussion, it has emerged that the complainant is able to prove his case, therefore, the same is partly accepted and OPs are directed to pay medical claim amount of Rs.1,03,841/- with interest @ 12% per annum from the date of repudiation 21.06.2016, till realization and further OPs are directed to pay compensation for mental harassment to the complainant, to the tune of Rs.15,000/- and litigation expenses of Rs.5000/-. The entire compliance be made within one month from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.
13. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Harvimal Dogra Karnail Singh
10.07.2018 Member President
