Chandigarh

DF-I

CC/528/2015

Rajdeep Sharma - Complainant(s)

Versus

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

Pradeep Bhanot

08 Sep 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I, U.T. CHANDIGARH

============

Consumer Complaint  No	:	CC/528/2015
Date  of  Institution	:	11/08/2016
Date   of   Decision	:	08/09/2016

 

 

 

 

 

Rajdeep Sharma, S/o Sh. Sansar Chand Sharma, R/o A-2 Pent House No.1 Nirmal Chhaya, Towers Penthouse No.1, VIP Road Nirmal Chhaya, Zirakpur - 180603.

  .. Complainant.

 

VERSUS

 

(1)  HDFC ERGO General Insurance Co. Limited, Stellar I.T Park, Tower-1, 5^th Floor, C-25, Sector 62, Noida – 201 301 through its Senior Vice President, Claims, Kumar Bikram Singh.

 

(2)  Kumar Bikram Singh, Senior Vice President, Claims, HDFC ERGO General Insurance Co. Limited, Stellar I.T. Park, Tower-1, 5^th Floor, C-25, Sector 62, Noida – 201 301.

 

(3)  M/s Eden Hospital, Plot No.115, Industrial Area, Phase-I, Near Elante Mall, adjoining City Emporium/ Autopace, Chandigarh – 160002, through its Manager.

 

(4)  Dr. Sukhchain Singh Bhullar, MBBS, ENT Specialist, (Consultant), C/o M/s Eden Hospital, Plot No.115, Industrial Area, Phase-I, Near Elante Mall, adjoining City Emporium/Autopace, Chandigarh – 160002.

 

(5)  Dr. H.S. Bath, Consultant, C/o M/s Eden Hospital, Plot No.115, Industrial Area, Phase-I, Near Elante Mall, adjoining City Emporium/Autopace, Chandigarh – 160002         (Deleted vide order dated 08.12.2015).

 

……………  Opposite Parties

BEFORE:    DR.MANJIT SINGH            PRESIDENT

           MRS.SURJEET KAUR           MEMBER

           SH.SURESH KUMAR SARDANA    MEMBER

 

For Complainant	:	Sh. Pradeep Bhanot, Advocate.
For Opposite Parties No.1 & 2	:	Sh. Vishal Aggarwal, Advocate.
For Opposite Party No.3	:	Sh. Sahil Khunger, Advocate.
For Opposite Party No.4	:	None
For Opposite Party No.5	:	Deleted

PER SURJEET KAUR, MEMBER

 

          The factual matrix in epigrammatic form of the present Complaint are that the Complainant, who was subscribed to Health Suraksha Policy (Silver Plan) Policy No.2825200938516800000, valid from 19.12.2014 to 18.12.2015, developed an acute infection in his larynx during March, 2015, and was referred Respondent Opposite Party No.5 (Dr.H.S. Batth) to Eden Hospital, where after being diagnosed by Opposite Party No.4 (Dr. S.S. Bhullar), bilateral tonsillectomy by dissection method was conducted on the Complainant, in emergency to avoid further infection to his pulmonary area. The Complainant was billed for Rs.41,410/-, which was submitted to Opposite Party No.1 by Opposite Party No.3. However, when even after doggedly corresponding with the Opposite Parties No.1 to 4, they failed to indemnify the Complainant with the aforesaid amount towards medical and hospitalization expenses, he got served a legal notice dated 06.04.2015 upon the Opposite Parties No.1 & 2, which also failed to fructify. With the cup of woes brimming, the Complainant has filed the instant consumer complaint, alleging that the aforesaid acts amount to deficiency in service and unfair trade practice on the part of the Opposite Parties.

 

2.      Notice of the complaint was sent to Opposite Parties seeking their version of the case.
3.      Opposite Parties No.1 & 2, in their joint reply, while admitting the basic facts of the case have pleaded that the treatment taken by the Complainant was not covered under the policy for the first two years  of the policy and therefore, the claim was rightly repudiated and the Complainant was duly informed of the same vide letter dated 24.03.2015. All other allegations made in the Complaint have been denied and pleading that there was no deficiency in service on their part, Opposite Parties No.1 & 2 have prayed for dismissal of the complaint.

 

4.      Opposite Party No.3, in its written statement, while admitting the key facts of the case has pleaded that the entire gamut of allegations in the Complaint relates to Opposite Parties No.1 & 2 and there was no alleged deficiency in service on its part. It has been asserted that the Complainant was referred by Dr.H.S. Bath to the answering Opposite Party. All other allegations made in the Complaint have been denied and pleading that there was no deficiency in service on its part, Opposite Party No.3 has prayed for dismissal of the complaint.

 

5.      Opposite Party No.4, in his written statement, while admitting the facts of the case has pleaded that the entire allegations made in the present Consumer Complaint relates to Opposite Parties No.1 & 2 alone and nothing has been alleged against him. It has been asserted that the answering Opposite Party conducted the Surgery regarding Quinsy (Tonsillectomy) in emergency crisis and submitted Discharge Summary dated 06.03.2015. All other material allegations made in the Complaint have been denied and pleading that there was no deficiency in service on his part, Opposite Party No.4 has prayed for dismissal of the complaint.

 

6.      In view of the endorsement made by the learned Counsel for the Complainant, on the Complaint itself, the name of Opposite Party No.5 was ordered to be deleted from the array of Opposite Parties, vide order dated 08.12.2015.

 

7.      The Complainant also filed separate replications to the respective written statements filed by the Opposite Parties No.1 & 2 and 3, wherein the averments as contained in the complaint have been reiterated and those as alleged in the written statement by the Opposite Parties No.1 & 2 and 3 have been controverted.

 

8.      Parties were permitted to place their respective evidence on record, in support of their contentions.

 

9.      We have heard the learned counsel for the parties and have perused the record with utmost care and circumspection.   

 

10.      Evidently, as per Annexure C-3, the Complainant purchased the Health Suraksha Policy (Silver Plan) from Opposite Parties No.1 & 2 for the period from 19.12.2014 to 18.12.2015, after paying the requisite premium of Rs.18,723/-. The case of the Complainant is that just after three months i.e. in March, 2015, he developed an acute infection in his larynx, and due to emergency, surgery was conducted upon him for bilateral tonsillectomy by dissection method. It has been contended that the Complainant had to pay Rs.41,410/- for the said treatment, but the Opposite Parties No.1 & 2, despite selling the aforesaid Policy to Complainant repudiate his claim vide letter dated 24.03.2015 Annexure C-5. Annexure  C-1 is the legal notice dated 06.04.2015 sent by the Complainant to the Opposite Parties to settle his claim for Rs.41,410/- spent by him on the aforesaid treatment/surgery. As per the Complainant, the exclusion clause is not applicable in his case, as he had to undergone the surgery in emergency crises. 

 

11.      The stand taken by Opposite Parties No.1 & 2 is that the Health Policy issued by them is subject to certain terms & conditions approved by the IRDA, which is binding upon both the Insurance Company as well as the Insured. It has been urged that as per Annexure R-1/1 all diseases are not covered from day one and exclusions does exists in the same. Meaning thereby, there is a gestation period wherein certain serious diseases including the disease of the Complainant are not covered and are with a waiting period of two years i.e. for the first two years the diseases mentioned in the Policy are not covered and in case of any expenses incurred on such treatment during the first two years, the Insurance Company is not liable to pay for the same.

 

12.      After carefully scanning the Health Suraksha Policy, placed on record by the Opposite Parties No.1 & 2 at Annexure R-1/1 (Pg. No.38 of the paper book), we are satisfied that Section 9 thereof, which deals with Exclusions, clearly specifies the list of diseases not covered for the first two years of the policy. Section 9 of the Policy ibid is reproduced hereinbelow for the sake of precision: - 

 

“A.  Waiting Period:-

 

All claims payable will be subject to the waiting periods specified below:

 

i. General waiting period of 30 days for all claims payable under the Policy except claims arising due to an Accident.

ii. A waiting period of 24 months shall apply to the treatment, whether medical or surgical, of the disease/ conditions mentioned below. Additionally the said 24 months waiting period shall be applicable to all surgical procedures mentioned under surgeries in the following table, irrespective of the disease/ condition for which the surgery is done, except claims payable due to the occurrence of cancer.

 

1. Illnesses: Internal Congenital diseases, non-infective arthritis; calculus diseases of gall bladder including cholecystitis and urogenital system e.g. Kidney stone, Urinary Bladder Stone; Pancreatitis, Ulcer and erosion of stomach and duodenum; Gastro Esophageal Reflux Disorder (GERD); All forms of Cirrhosis (Pls note: all forms of cirrhosis due to alcohol will be excluded); Perineal Abscesses; Perianal Abscesses; cataract; fissure/ fistula in anus, hemorrhoids, pilonidal sinus; gout and rheumatism; internal tumors, cysts, nodules, polyps including breast lumps (each of any kind unless malignant); osteoarthritis and osteoporosis; polycystic ovarian diseases; Fibroids (fibromyoma); sinusitis; Rhinitis; Tonsillitis and skin tumors unless malignant; Benign Hyperplasia of Prostate.

 

2. Treatments:adenoidectomy, mastoidectomy, tonsillectomy and tympanoplasty); dilatation and curettage (D&C); joint replacement; myomectomy for fibroids; surgery of genito urinary system unless necessitated by malignancy; surgery on prostate; cholecystectomy; surgery of hernia; surgery of hydrocele/ Rectocele; surgery for prolapsed inter vertebral disk; Joint replacement surgeries surgery of varicose veins and varicose ulcers; Surgery for Nasal septum deviation, nasal concha resection.

 

iii. 48 months waiting period for all Pre-existing Conditions declared and/or accepted at the time of application.”

 

          A perusal of afore-extracted Section makes it emphatically clear that in the list of illness/ diseases it has been lucidly mentioned that the tonsillectomy is not covered for a period of first two years. In the present case, it was the first year of the policy and during the same itself the Complainant had to face the problem. It being so, there was no question of the Opposite Parties to pay to the Complainant for the expenses incurred by him for the surgery. In these set of circumstances, we find that the whole gamut of facts and circumstances leans towards the side of the Opposite Parties. The case is lame of strength and therefore, liable to be dismissed.

13.      Taking into consideration all the facts and circumstances of the case, we have no hesitation to hold that the Complainant has failed to prove that there has been any deficiency in service on the part of the Opposite Parties or that the Opposite Parties adopted any unfair trade practice. As such, the Complaint is devoid of any merit and the same is hereby dismissed, leaving the parties to bear their own costs.
14.      Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced

08^th September, 2016                                              

Sd/-

[DR.MANJIT SINGH]

PRESIDENT

                                                Sd/-

[SURJEET KAUR]

MEMBER   

Sd/-                      

[SURESH KUMAR SARDANA]                                                                                                   

“Dutt”                                                                           MEMBER