Chandigarh

DF-I

CC/592/2021

SI Mohinder Kumar - Complainant(s)

Versus

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

In Person

01 Aug 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/592/2021
Date of Institution	:	19/08/2021
Date of Decision	:	01/08/2023

 

SI Mohinder Kumar s/o Sh. Jamna Das r/o 468, Sector 22-A, Chandigarh.

… Complainant

V E R S U S

1. HDFC ERGO General Insurance Co. Ltd. through its Branch Manager, SCO 124-125, Sector 8-C, Madhya Marg, Chandigarh.
2. HDFC ERGO General Insurance Co. Ltd., through its Managing Director, Stellar 17 Park, Tower-1, 5^th Floor, C-25, Sector-62, Noida – 201301.

… Opposite Parties

 

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	SHRI SURESH KUMAR SARDANA	MEMBER

 

                                                                               

ARGUED BY	:	Sh. A.S. Salar, Vice Counsel for Sh. S.S. Salar, Counsel for complainant
	:	Sh. Nitesh Singhi, Counsel for OPs

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Sh. SI Mohinder Kumar, complainant against the opposite parties (hereinafter referred to as the OPs).  The brief facts of the case are as under :-

1. It transpires from the allegations as projected in the consumer complaint that the complainant had purchased a Health Suraksha Family Policy (hereinafter referred to as “subject policy”) from the OPs for himself, his wife (Smt.Anukampa Behal) and daughter (Tiana) which was valid w.e.f. 1.2.2018 to 31.1.2020.  In the month of June 2019, complainant and his wife got appointment from Arya Vaidya Sala Kottakkal Ayurvedic Hospital & Research Centre, Mallappuram, Kerala (hereinafter referred to as “subject hospital”) for general/routine check-up where they were diagnosed and got treatment of Vathavyadhi and osteoarthritis respectively. Both the complainant and his wife were admitted on 5.6.2019 and were discharged on 25.6.2019 from the subject hospital. After that, complainant and his wife had lodged medi-claim with the OPs, but, surprisingly the genuine claim of the complainant was repudiated by OPs vide letter dated 21.9.2019 (Annexure C-6) whereas that of his wife was repudiated vide letter dated 13.1.2020 (Annexure C-7) on the ground that the complainant and his wife were suffering from pre-existing disease and for the said treatment, they were not covered under the subject policy until 48 months of the continuous coverage have elapsed.  It is also alleged that the complainant was having history of four years of pre-existing disease knowing this fact that Vathavyadhi is not a disease, rather the same is a disorder.  Moreover, the wife of the complainant was not having any previous history of osteoarthritis treatment. Complainant also sent legal notice dated 10.8.2020 (Annexure C-1), but, to no avail.  In this manner, OPs have wrongly repudiated the claims of the complainant and his wife and the said act of the OPs amounts to deficiency in service on their part. OPs were requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. OPs resisted the consumer complaint and filed their written version, inter alia, taking preliminary objections of maintainability and concealment of facts. It is alleged that even the medical record produced by the complainant clearly indicates that the complainant and his wife were suffering from pre-existing disease and their claim was rightly repudiated, especially when the pre-existing disease was specifically excluded from being covered under the policy until 48 months of continuous coverage have elapsed.  The discharge summaries of both the complainant and his wife further make it clear that they were suffering from pre-existing diseases which they have not disclosed at the time of obtaining the subject policy.  On merits, the facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. The complainant chose not to file the rejoinder.

2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the parties and also gone through the file carefully.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant, his wife (Smt.Anukampa Behal) and daughter (Tiana) were covered under the subject policy, which was valid w.e.f. 1.2.2018 to 31.1.2020, and both the complainant and his wife had taken treatment from the subject hospital where they remained admitted w.e.f. 5.6.2019 to 25.6.2019 and their respective claims were repudiated by the OPs, being not covered under the subject policy, as is also evident from Annexure C-6 & Annexure C-7, the case is reduced to a narrow compass as it is to be determined if the OPs are unjustified in repudiating the genuine claim of the complainant and his wife and the complainant is entitled for the reliefs prayed for in the consumer complaint, as is the case of the complainant, or if OPs are justified in repudiating the claim of complainant and the consumer complaint of complainant, being false and frivolous, is liable to be dismissed, as is the defence of OPs.
   2. Perusal of the discharge summary (Annexure C-4) of the complainant clearly indicates that he was diagnosed by the subject hospital with following health problem :-

       “Reduced memory, Giddiness, Dust allergy, Reddish patches all over body, Stiffness in low back and right shoulder, Recurrent cold attacks, cough, sorethroat, Dyslipidemia, Snoring, Acidity, Bloating of abdomen, Frequent urination, Reduced vision, Hypertension.”

 

The past history of the patient/complainant has also been mentioned as “H/O Vertigo H/O Fatty liver.”

3. Similarly, another certificate dated 20.8.2019 (Annexure F/OP-6 at page 31) produced by the OPs also indicate that the complainant was found suffering from Vathavyadhi (Vertigo and dust allergy since 4 years, stiffness in low back and right shoulder since 6 months). Further opinion of the doctor was that these complaints started gradually due to stressful job.
4. The claim of the complainant has been repudiated by the OPs vide repudiation letter (Annexure C-6) and relevant portion of same is reproduced as under :-

        “As per the submitted documents, the patient was admitted on 05/06/2019 with the diagnosis of Vatavyadhi and was treated for same. As the date of inception of policy is 01/02/2018 and there is history of 4 years; the ailment is pre-existing in nature.  Hence, this claim is being repudiated under section 9.a.iii of policy terms and conditions (any pre-existing disease/illness/injury will not be covered until 48 months of continuous coverage have elapsed since inception of the first Health Suraksha policy with us).”

 

5. Thus, one thing is clear from the discharge summary as well as the certificate (Annexure F/OP-6) that the complainant was having previous history of Vathavyadhi Vertigo and dust allergy which cannot be otherwise considered as pre-existing disease, rather the same is a tantra as per dictionary meaning which runs the machine of our body and controls the mind, senses and perception. 
6. In this manner, it is safe to hold that the OPs are unjustified in repudiating the claim of the complainant on the ground that the complainant was suffering from pre-existing ailment for which he had taken treatment for the last more than four years. 
7. While taking up the case of Smt. Anukampa Behal, wife of the complainant, the relevant documents pertaining to her treatment and repudiation of the claim are required to be scanned carefully.  Annexure C-5 is copy of her discharge summary and the relevant portion of same reads as under :-

        “Multi joint pain, K/C/O Fibromyalagia, Stiffness on joints, Occasional headache, Tingling sensation and weakness of left side of body.”

The past history of the patient has also been mentioned as “H/O Dengue fever – 2015.”

8. Annexure C-7 is the copy of repudiation letter dated 13.1.2020 and the relevant portion of the same reads as under :-

        “As per the submitted documents, patient was admitted on 05/06/2019 with the diagnosis of Osteoarthritis and was treated for same. As per section 9.A.iia of policy, a waiting period of 2 years is applicable for the said ailment.  As date of inception of policy is 01/02/2018, the policy is in (second) year. Hence, the claim is repudiated under the above mentioned section of the policy terms and conditions.”

      

9. It is clear from the discharge summary of the insured, Smt. Anukampa Behal that she had been found past history of dengue fever back in the year 2015.  In addition to that, she had only complained of multi joint pain, stiffness of joints, occasional headache etc. at the time of her admission in the hospital.  As per the repudiation letter, since the insured Smt. Anukampa Behal was diagnosed of Osteoarthritis and she was treated for the same in the in the hospital and a period of two years is applicable for the said ailment, the claim of the complainant was rightly repudiated by the OPs.  The defence of the OPs is that as Smt. Anukampa Behal was diagnosed with Osteoarthritis by the hospital within two years of the issuance of the subject policy, hence her claim was rightly repudiated by the OPs under Section 9.A.iia of the policy.  However, nothing has come on record that she was diagnosed with Osteoarthritis, though in the discharge summary it has been mentioned as multi joint pain etc. Moreover, even the ailment with which the insured/Smt.Anukampa Behal was diagnosed by the hospital as per discharge summary (Annexure C-5), the same is not covered under the exclusion clause of the subject policy which nowhere excludes a patient diagnosed with joint pains etc. by the hospital.
10. In view of the foregoing discussion it is safe to hold that OPs are unjustified in repudiating the genuine claim of the complainant and the said act amounts to deficiency in service on their part and the present consumer complaint deserves to be allowed. 
11. Now coming to the quantum of compensation, as the complainant has proved the medical bills (Annexure C-8 and Annexure C-9), through which he spent an amount of ₹58,682/- and ₹1,18,250/- for the treatment of himself and his wife, therefore, the OPs are liable to reimburse the said amount to him alongwith interest and compensation etc. for the harassment suffered by him and his wife.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OPs are directed as under :-

1. to pay ₹58,682/- and ₹1,18,250/- to the complainant alongwith interest @ 9% per annum from the respective dates of repudiation of the claim i.e. 21.9.2019 and 13.1.2020, till realization of the same.
2. to pay an amount of ₹20,000/- to the complainant as compensation for causing mental agony and harassment to him and his wife;
3. to pay ₹10,000/- to the complainant as costs of litigation.

5. 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.
6. Certified copies of this order be sent to the parties free of charge. The file be consigned.

Announced 01/08/2023 hg			Sd/- [Pawanjit Singh] President
			Sd/- [Suresh Kumar Sardana] Member