DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.
Complaint Case No: CC/183/2022
Date of Institution: 02.08.2022
Date of Decision: 15.07.2024
Rupinder Singh aged about 36 years son of Ravinder Singh, resident of H.No. BV-X/204, Ward No. 13, Ahata Narain Singh, Barnala, District Barnala, Punjab (India) 148101.
…Complainant
Versus
1. HDFC ERGO General Insurance Company Ltd. Regd. & Corporate Office- 1st Floor, HDFC House, 165/166, Backbay Reclamation. H.T. Parekh Marg, Churchgate, Mumabi-400020 through its Director;
2. HDFC ERGO General Insurance Company Ltd. Stellar IT Park, Tower-1, 5th Floor, C-25, Noida, Sector-62, Pin-201301 through its Authorized Signatory;
3. HDFC ERGO, Health Insurance Ltd. 2nd Floor, SCO-146, Feroze Gandhi Market, Ludhiana- 141001, through its Authorized Signatory.
…Opposite Parties
Complaint Under Section 35 of the Consumer Protection Act, 2019.
Present: Sh. Ramandeep Rajput Adv counsel for complainant.
Sh. Anuj Mohan Gupta Adv counsel for opposite parties.
Quorum.-
1. Sh. Ashish Kumar Grover: President
2. Sh. Navdeep Kumar Garg: Member
(ORDER BY ASHISH KUMAR GROVER PRESIDENT):
The complainant has filed the present complaint under Section 35 of the Consumer Protection Act 2019 against HDFC ERGO General Insurance Company Ltd. Regd. & Corporate Office- 1st Floor, HDFC House, 165/166, Backbay Reclamation. H.T. Parekh Marg, Churchgate, Mumabi-400020 through its Director & others (in short the opposite parties).
2. The facts leading to the present complaint are that on 4.12.2019 the complainant purchased one Apollo Manich Health Insurance Policy-Optima Restore Floater, vide policy No. 110600/11121/AA01272306 issued on 4.12.2019 valid upto 3.12.2020 for himself, alongwith his wife Gurleen Kaur and his son Samarjit Singh, for total sum insured of Rs. 5,00,000/- in consideration of gross premium of Rs. 13,470/-. It is alleged that the above said Apollo Manich Health Insurance merged into the HDFC ERGO General Insurance Co. Ltd. and the above said policy was renewed by opposite parties vide policy No. 2805 2035 1707 4301 000, for the period 4.12.2020 to 3.12.2021 for an insured sum of Rs. 7,50,000/- for the complainant himself, alongwith his wife & child. It is further alleged that the above said policy again renewed vide policy No. 2805 2035 1707 4302 000, for the period 4.12.2021 to 3.12.2022 in consideration of Gross premium of Rs. 14,143/- for an insured sum of Rs. 5,00,000/- for the complainant himself, alongwith his wife & child. The complainant’s son Samarjit Singh suffered from abdominal problem as mentioned in the medical record and admitted on 7.10.2020 in Indraprashta Apollo Hospital, Sarita Vihar, Delhi and after treatment discharged on 28.10.2020 and an amount of more than six lacs approx. was expended on his treatment. The reimbursement claim was filed with the opposite parties which was approved by the opposite parties for Rs. 4,65,304/- and paid by the opposite parties vide RR-HS20-12327437/-. All the medical record in original along with original medical bills, In-Patient Bill, including certificate by doctor and consultation papers, were submitted to the opposite parties at the time of lodging the claim. However, the only copy of discharge summary available with the complainant. It is further alleged that the son of the complainant again admitted in the Indraprashta Apollo Hospital, Sarita Vihar, Delhi on 21.6.2021 for above mentioned same abdominal problem and after treatment discharged on 6.7.2021 and an amount of Rs. 5,57,236/- has been expended on his treatment. The reimbursement claim for Rs. 5,57,236/- along with expenditure on follow up treatment was filed with the opposite parties alongwith original medical bills, discharge summary, and other required documents as per rules and regulations of the policy. It is alleged that the opposite parties with malafide intention issued a letter to complainant on 5.11.2021 under subject Additional document requirement for RR-HS21-12572826 (CCN) and raised the baseless objection that “treated doctor certificate for exact duration of the Ailment in DD/MM/YYYY format along with past consultation papers and treatment records. As per submitted documents, complaints since nov. 2019. Kindly provide first consultation papers” and requested to submit the documents within 15 days from the receipt of this letter. It is submitted that the opposite parties were well known the fact that they have already approved the Reimbursement Claim No. RR-HS20-12327437 for hospitalization the complainant’s son for same problem for the period 7.10.2020 to 28.10.2020 in which the presently required documents had already been submitted in original, as such the demand of the opposite parties is baseless, without any reason and just to harass the complainant. The opposite parties have already issued a letter dated 24.5.2021 regarding the previous claim approval. It is further alleged that in continuation of the follow up treatment the complainant visited the hospital on 21.3.2022 for follow up treatment and paid Rs. 120/- as professional fee of doctor Chaudhary Surjit Kumar and issued a receipt in this regard. The complainant is entitled to get the claim filed with the opposite parties alongwith the follow up treatment expenditures for his son and opposite parties are bound to pay the same. The opposite parties have closed the above said claim on 9.2.2022 vide its letter dated 9.2.2022 which is against law and facts. As such, the act and conduct of the opposite parties comes within the definition of deficiency in service and unfair trade practice. Hence, the present complaint is filed for seeking the following reliefs.-
- The opposite parties may be directed to pay the claim of complainant already submitted with the opposite parties for an amount of Rs. 5,57,236/- alongwith further follow up claim alongwith interest @ 12% per annum.
- To pay Rs. 2,00,000/- as compensation as physical and mental pain, agony and harassment.
- Further, to pay Rs. 22,000/- as litigation expenses.
3. Upon notice of this complaint, the opposite parties appeared and filed written version by taking preliminary submissions and objections interalia on the grounds that insurance company received a duly filled PF bearing No. 200VQ1SJ3P from the proposer, Mr. Rupinder Singh on 04.12.2019 for availing health insurance Policy seeking to cover himself and his family members. It is further submitted that Apollo Munich Health Insurance Co. Ltd. which is now merged with HDFC Ergo General Insurance Co. Ltd. and policy no. 110600/11121/AA01272306 was issued to the complainant and the inception date of the said policy was 04/12/2019 up to 03/12/2020 and then renewed vide policy no. 2805 2035 1707 4301 000 for the period 04/12/2020 to 03/12/2021 and then vide policy no. 2805 2035 1707 4302 000 for the period 04/12/2021 to 03/12/2022 and the insured persons under the said policy are Rupinder Singh, Gurleen Kaur and Samarjit Singh. It is further submitted that the terms and conditions were read and explained to the complainant in the language best known to him and on the basis of the information furnished in the enrolment form, the same was processed by the opposite parties and thereafter the said certificate of insurance along with the terms and conditions were issued to the complainant. It is further alleged that on 22.06.2021 Cashless request was received for complainant/hospital for Samarjit Singh who got admitted in Indraprasth Apollo Hospital, with date of admission 21.06.2021, with complaints of Hirschsprung's disease and post scrutiny of documents query was raised for;- (1) Investigation reports (Pathological/Radiological) supporting diagnosis. (2) Treating certificate for exact duration of the ailment in DD/MM/YYYY format along with past consultation papers and treatment records. (3) Treating doctor's certificate (4) Please mentioning underline cause/ etiology of presenting ailment. forward the First consultation prescription related to diagnosis and after reviewing replied documents it was noted that submitted documents was not sufficient to process/decide the claim, hence cashless request was repudiated under below wordings as:-
“As per the available documents, Possibility of the present ailment being Pre- Existing (as per policy terms & conditions) could not be ruled out i.e. Constipation has possibility of being pre-existing from the inception of the policy. Hence cashless approval would not be possible at this juncture."
It is further alleged that after cashless denial claim was received from the complainant for reimbursement of expenses with date of admission 21.06.2021 and date of discharge 06.07.2021 with diagnosis of Hirschsprung's disease, for claimed amount Rs. 5,57,236/-. It is further submitted that case was investigated and noted in progress note and discharge summary that insured has similar kind of pain since Nov 2019 before policy inception, hence, further, query was raised for TDC of duration for current ailment with first consultation paper. However, no reply with this regards was then received even after several reminders hence claim got closed under non submission vide letter dated 09/02/2022. It is further alleged that the present complaint is bad for non-joinder and mis-joinder of parties as Indraprastha Apollo Hospitals, New Delhi has not been impleaded as party which is a necessary party to adjudicate the claim. The opposite parties deny all the allegations, facts and averments stated in the complaint filed by the complainant. On merits, the opposite parties reiterated the averments as mentioned in the preliminary submissions and objections and denied all other allegations and prayed for the dismissal of complaint.
4. Ld. Counsel for complainant filed rejoinder to the written version of opposite parties and denied the averments as mentioned in the written version.
5. To prove the case the complainant tendered into evidence copy of Aadhar Card Ex.C-1, copy of Apollo Manich Health Insurance Policy Ex.C-2 containing two pages, copy of policy No. 2805203517074301000 Ex.C-3, copy of renewal letter dated 1.12.2020 Ex.C-4 containing three pages, copy of policy No. 2805203517074302000 containing two pages Ex.C-5, copy of renewal letter dated 29.11.2021 Ex.C-6, copy of discharge summary for period of treatment from 7.10.2020 to 28.10.2020 containing seven pages Ex.C-7, copy of discharge summary for period of treatment from 21.6.2021 to 6.7.2021 containing four pages Ex.C-8, copy of In patient final bill containing six pages Ex.C-9, copy of other medical record Ex.C-10 to Ex.C-21, copy of follow up treatment bills Ex.C-22 to Ex.C-24, copy of letter dated 5.11.2021 Ex.C-25, copy of letter dated 24.5.2021 Ex.C-26, copy of letter dated 9.2.2022 Ex.C-27, copy of office copy of legal notice dated 13.5.2022 Ex.C-28, postal receipts Ex.C-29 to Ex.C-31 and affidavit of complainant Ex.C-32 and closed the evidence.
6. To rebut the case the opposite parties tendered into evidence affidavit of Manoj Kumar as Ex.OPS-1, copy of proposal form as Ex.OPS-2 (containing 10 pages), copy of policy schedule as Ex.OPs-3 (containing 6 pages), copy of terms and conditions as Ex.OPs-4 (containing 33 pages), copy of request for cashless as Ex.OPS-5 (containing 4 pages), copy of letter dated 22.06.2021 as Ex.OPs-6, copy of procedure report alongwith medical record as Ex.OPs-7 (containing 17 pages), copy of denial letter as Ex.OPs-8, copy of discharge summary alongwith medical record as Ex.OPS-9 (containing 16 pages), copies of reminder letter dated 25.12.2021, 02.01.2022, 08.01.2022, 17.01.2022, 24.01.2022, 01.02.2022, 05.11.2021 are Ex.OPs-10 to OPs-16 respectively and closed the evidence.
7. We have heard the learned counsel for the parties and have gone through the record on the file. Written arguments filed by the parties.
8. It is admitted case of the opposite parties that Apollo Munich Health Insurance Co. Ltd. which is now merged with HDFC Ergo General Insurance Co. Ltd. and policy no. 110600/11121/AA01272306 was issued to the complainant and the inception date of the said policy was 04/12/2019 up to 03/12/2020 (as per Ex.C-1) and then renewed vide policy no. 2805 2035 1707 4301 000 for the period 04/12/2020 to 03/12/2021 (as per Ex.C-3) and then vide policy no. 2805 2035 1707 4302 000 for the period 04/12/2021 to 03/12/2022 (as per Ex.C-5) and the insured persons under the said policy are Rupinder Singh, Gurleen Kaur and Samarjit Singh. It is also admitted case of the opposite parties that the complainant’s son Samarjit Singh suffered from abdominal problem as mentioned in the medical record and admitted on 7.10.2020 in Indraprashta Apollo Hospital, Sarita Vihar, Delhi and after treatment discharged on 28.10.2020 (as per Ex.C-7) and an amount of more than six lacs approx. was expended on his treatment and the reimbursement claim was filed with the opposite parties which was approved by the opposite parties for Rs. 4,65,304/- and paid by the opposite parties vide RR-HS20-12327437/-.
9. The case of the complainant is that the son of the complainant again admitted in the Indraprashta Apollo Hospital, Sarita Vihar, Delhi on 21.6.2021 for above mentioned same abdominal problem and after treatment discharged on 6.7.2021 (as per Ex.C-8) and an amount of Rs. 5,57,236/- has been expended on his treatment (as per Ex.C-9). Ld. Counsel for the complainant argued that the reimbursement claim for Rs. 5,57,236/- along with expenditure on follow up treatment was filed with the opposite parties alongwith original medical bills, discharge summary, and other required documents as per rules and regulations of the policy. It is argued that the opposite parties with malafide intention issued a letter to complainant on 5.11.2021 (Ex.C-25) under subject Additional document requirement for RR-HS21-12572826 (CCN) and raised the baseless objection that “treated doctor certificate for exact duration of the Ailment in DD/MM/YYYY format along with past consultation papers and treatment records. As per submitted documents, complaints since nov. 2019. Kindly provide first consultation papers” and requested to submit the documents within 15 days from the receipt of this letter. It is further argued that the complainant is entitled to get the claim filed with the opposite parties alongwith the follow up treatment expenditures for his son and opposite parties are bound to pay the same but the opposite parties have closed the above said claim on 9.2.2022 vide its letter dated 9.2.2022 which is against law and facts.
10. Ld. Counsel for the opposite parties argued that on 22.06.2021 (as per Ex.O.Ps-6) cashless request was received for complainant/hospital for Samarjit Singh who got admitted in Indraprasth Apollo Hospital, with date of admission 21.06.2021, with complaints of Hirschsprung's disease and post scrutiny of documents query was raised for;- (1) Investigation reports (Pathological/Radiological) supporting diagnosis. (2) Treating certificate for exact duration of the ailment in DD/MM/YYYY format along with past consultation papers and treatment records. (3) Treating doctor's certificate (4) Please mentioning underline cause/ etiology of presenting ailment. forward the First consultation prescription related to diagnosis and after reviewing replied documents it was noted that submitted documents was not sufficient to process/decide the claim, hence cashless request was repudiated as mentioned in the written reply. It is further alleged that after cashless denial claim was received from the complainant for reimbursement of expenses with date of admission 21.06.2021 and date of discharge 06.07.2021 with diagnosis of Hirschsprung's disease, for claimed amount Rs. 5,57,236/-. It is further argued that case was investigated and noted in progress note and discharge summary that insured has similar kind of pain since Nov 2019 before policy inception, hence, further, query was raised for TDC of duration for current ailment with first consultation paper, however no reply with this regards was then received even after several reminders hence claim got closed under non submission vide letter dated 09/02/2022.
11. The opposite parties rejected/repudiated the claim of the complainant on the basis of discharge summary Ex.O.Ps-9 vide which it is mentioned in the column of History of Present Illness it is mentioned that “Mr. Smarjit Singh a 4 years old child presented with history of recurrent abdominal distension associated with constipation since Nov/2019. He was evaluated and was on follow up elsewhere in Ludhiana. He often needed laxatives for relief”
12. We have also gone through the earlier discharge summary of patient Samarjit Singh i.e. Ex.C-7 and found that earlier the patient was got admitted for same problem as mentioned in Ex.O.Ps-9. But the doctor nowhere mentioned that it is pre-existing disease. Ld. Counsel for the complainant further argued that earlier the complainant’s son Samarjit Singh was suffered from same abdominal problem as mentioned in the medical record and admitted on 7.10.2020 in Indraprashta Apollo Hospital, Sarita Vihar, Delhi and after treatment discharged on 28.10.2020 and the opposite parties approved Rs. 4,65,304/- and paid the same vide RR-HS20-12327437/- (as per Ex.C-26) and this fact is also admitted by the opposite parties in their written version. It is further argued by the Ld. Counsel for the complainant that at that time all the medical record in original along with original medical bills, In-Patient Bill, including certificate by doctor and consultation papers, were submitted to the opposite parties at the time of lodging the claim. It is also argued that the presently required documents had already been submitted in original, as such the demand of the opposite parties is baseless, without any reason, unjustified and just to harass the complainant. On the other hand, apart from the Ex.O.Ps-9 the opposite parties have failed to place on record any cogent evidence to prove the fact that they have rightly repudiate the genuine claim of the complainant and the insured/patient had pre-existing disease. The complainant in order to prove his case has placed on record copy of In Patient Bill Ex.C-9 which shows the total bill amount as Rs. 5,37,236/- and the from the perusal of copy of insurance policy Ex.C-3 it is established that the complainant alongwith his family members was insured for total sum insured of Rs. 7,50,000/-.
13. We are of the view that it was in the hands of insurance company to see and not to issue/or renewed the policy again where person is not entitled to claim on account of treatment of Pre-existing disease. But in the present case the opposite parties have renewed the insurance policy again which proves from Ex.C-3 & Ex.C-5. Moreover, there is nothing on record from the side of opposite parties that they have conducted the medical examination/investigation of the complainant and his family members at the time when Apollo Manich Health Insurance merged into the HDFC ERGO General Insurance Co. Ltd., or at the time of renewed the policy in question. Moreover, we are of the view that the opposite parties cannot escape from their liability as for the same disease the opposite parties had paid the claim to the complainant in the year 2020. Further, from the perusal of the file it is also clear that policy in question is continued from the year 2019. The Principal of estoppel is applicable on the opposite parties as opposite parties had already paid the claim in the year 2020 for problem of same treatment.
14. Ld. Counsel for the complainant relied upon the judgment of the Hon’ble Supreme Court of India, Division Bench in case titled Om Prakash Ahuja Vs Reliance General Insurance Co. Ltd. ETC in Civil Appeal Nos. 2769-2770 of 2023 vide which the Hon’ble Supreme Court held that “Health Insurance Policy- Once there is a valid insurance policy available in favour, the claim made for reimbursement of the expenses incurred is justifiable and deserves to be paid to him”. The learned counsel for the complainant also relied upon the judgment of the Hon'ble Punjab and Haryana High Court (DB) 2012 (1) RCR (Civil)-901 in which the Hon'ble High Court held that “Claim of the petitioner denied on the ground that he was suffering from the disease prior to taking of the policy and was therefore covered under the exclusion clause of the policy. Single judge allowed the claim on the ground that it was for Insurance Company to see and not to issue policy where person is not entitled to claim on account of treatment of existing disease. No interference called for in the order of Single Judge. Held the pre-existing condition existed in the year 2002 which was five years prior to acquiring Insurance Policy. Claim cannot be denied. Ld. Counsel for the complainant further relied upon the Judgment in New India Assurance Company Ltd., Vs Usha Yadav and others (2008) 151 PLR 313 Punjab and Haryana High Court, Chandigarh, vide which it is held that it seems that the insurance companies are only interested in earning the premiums, which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance Companies make the effected people to fight for getting their genuine claims.
15. From the above discussion, it is proved that the claim of the complainant was repudiated by the opposite parties on unreasonable and unjustified grounds and there is clear cut deficiency in service and unfair trade practice on the part of opposite parties.
16. In view of the above discussion, the present complaint is allowed and the opposite parties are directed to pay an amount of Rs. 5,37,236/- alongwith interest @ 7% per annum from the date of filing the present complaint till its actual realization to the complainant. The opposite party No. 1 is further directed to pay Rs. 10,000/- on account of compensation for causing mental torture, agony and harassment suffered by the complainant and Rs. 5,000/- as litigation expenses to the complainant. Compliance of this order be made within the period of 45 days from the date of the receipt of the copy of this order. Copy of the order be supplied to the parties free of costs. File be consigned to the records after its due compliance.
ANNOUNCED IN THE OPEN COMMISSION:
15th Day of July, 2024
(Ashish Kumar Grover)
President
(Navdeep Kumar Garg)
Member
