BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION, JALANDHAR.
Complaint No.42 of 2022
Date of Instt. 09.02.2022
Date of Decision: 31.07.2023
Raj Kumar aged about 42 years son of Sh. Amar Nath resident of House No.15 D/2, Kamal Vihar, Jalandhar.
..........Complainant
Versus
1. HDFC ERGO General Insurance Company Ltd. IRDAI Registration. No.146 through its General Manager, Corporate Office: 1st Floor, HDFC House, 165/166, Backbay Reclamation, HT Parekh Marg, Church Gate, Mumbai-400020.
2. Regional Manager/Branch Head HDFC General Insurance Company Ltd. Eminent Mall, 3rd Floor, Near Guru Nanak Mission Chowk, Distt. Jalandhar.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Dr. Harveen Bhardwaj (President)
Smt. Jyotsna (Member)
Sh. Jaswant Singh Dhillon (Member)
Present: Sh. P. S. Dhillon, Adv. Counsel for the Complainant. Sh. V. K. Gupta, Adv. Counsel for OPs No.1 and 2.
Order
Dr. Harveen Bhardwaj (President)
1. This complaint has been filed by the complainant, wherein alleged that the complainant got issued a health insurance of his family vide policy no.2805203534156301 HDFC ERGO General Insurance Company Ltd. from the OPs on 28.01.2019, vide above said Health insurance policy no.2805203534156301, the OPs insured the complainant, his wife, Mrs. Pooja and sons of the complainant namely Mr. Yuvraj and Master Hitesh. The complainant got renewed the said policy within time and the said policy i.e. Health Insurance is valid upto April 2022. Unluckily the wife of the complainant namely Mrs. Pooja got ill and she took medicine from Dr. Jatinder Kumar, Jalandhar and who referred wife of the complainant namely Pooja to PGI on 30.01.2019. As per the advice of Dr. Jatinder Kumar, the complainant took his wife to PGI Chandigarh on 02.02.2019. The wife of the complainant was examined by the doctors of Department of Internal Medicine, PGI, Chandigarh vide OPD/CR no.201901446431 dated 02.02.2019. The concerned doctors of PGI, Chandigarh had medically examined and got conducted laboratory clinical test of the wife of the complainant and found that Mrs. Pooja is suffering from blood cancer. The complainant regularly got check up his wife from PGI Chandigarh. Unluckily the condition of wife of the complainant became deteriorated, which compelled the complainant got admitted his wife at Civil Hospital, Jalandhar on 21.06.2021 and she remained admitted for 05 days. On 14.07.2021 the condition of wife of the complainant again deteriorated, then the complainant brought his wife at PGI, Chandigarh and on 16.07.2021 the doctors of PGI Chandigarh has admitted Mrs. Pooja vide admission no. 2021 036331 and she remained under the medical treatment till 28.08.2021 but unluckily on 28.08.2021 the wife of the complainant expired. The cause of death of Mrs. Pooja was (a) Fungal Pneomonia with Type 1 respiratory failure (b) Chronic Lymphocytic Leukemia. The complainant has spent huge amount on the medical treatment of his wife namely Pooja. After the death of wife of the complainant namely Pooja, the complainant applied/ submitted to the opposite parties to pay the insured sum of Rs. 5 Lakhs to the complainant on the death of his wife alongwith medical expenditures to the tune of Rs.3 Lakhs. The complainant has fulfilled all the legal formalities/ requirements from time to time but the opposite parties have failed to pay the insured amount alongwith medical bills as per the insurance policy no. 2805203534156301. The complainant also served a legal notice dated 07.01.2022 upon the OPs through registered post, but all in vain. The act of the OPs is totally wrong, incorrect, illegal and unlawful, whereby the OPs have caused mental tension and harassment to the complainant and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay the insured amount to the tune of Rs.5,00,000/- on the account of the death of Mrs. Pooja the wife of the complainant alongwith medical expenditure to the tune of Rs.3,00,000/- and to compensation damages of Rs.5,00,000/- on account of harassment, mental suffering etc. and litigation expenses of Rs.55,000/- with intereset @ 18% as claimed above.
2. Notice of the complaint was given to the OPs, who filed its joint written reply, whereby contested the complaint by taking preliminary objections that the above complaint is not sustainable for the reasons the word ‘deficiency’ as defined in Section 2 (11) of the Consumer Protection Act, 2019, has no application in the facts and circumstance of the present Case. The Complainant having not revealed the material facts in the proposal from at 'Column 4. Medical and Life Style Information Section B, Which is crucial and relevant as far as underwriting the policy and assuming the risk is barred from filling the present Complaint alleging deficiency of service against the Respondent on this count the Complaint does not stand the test of law. Without prejudice to the foregoing contention, answering OPbeg to traverse the Complaint allegations in the ensuing paragraphs. It is further averred that as Section 11 of the Insurance act 1938, the policyholder shall furnish all information that is sought from him by the insurer and also any other information which the insurer considers as having a bearing on the risk to enable the latter to assess properly the risk sought to be covered by a policy. Thus it is evident that the Act and the regulations framed there under also impose a duty upon the policyholder/proposer/Applicant to disclose all the material facts to the insurer to enable them to assess the risk to be undertaken. The insurance is done on the basis of doctrine Uberrima Fides and there was no reason for answering OP to verify the correctness of the facts stated in the said application, more so since the Applicant has signed specific declaration to that effect. To this extent it can be said that material facts were not disclosed by the insured, and therefore the answering OP is entitled to declare the policy as null and void and repudiate the claim. It is further averred that at the very outset the answering OP deny all the allegations, facts and averments stated in the complaint filed by the complainants except to the extent it is expressly admitted therein. The non traversal of any paragraph should be read as categorical denial. It is further averred that the present complaint is frivolous, vexatious and devoid of merits and hence, the same is liable to be dismissed with heavy cost. The complainant has not approached this Forum with clean hands. The complainant has suppressed various material facts in the present complaint. Hence, the present complaint is liable to be dismissed on this ground only. It is further averred that there is no deficiency in service or negligence or unfair-trade practice on the part of answering OP which brings the present case adjudicable before this Forum under Consumer Protection Act. It is further averred that the present complaint filed by the complainant with the malafide intention and has not come before this Court with the clean hand, being litigation for the sake of litigation is liable to be dismissed with exemplary costs.
3. Rejoinder to the written statement filed by the complainant, whereby reasserted the entire facts as narrated in the complaint and denied the allegations raised in the written statement.
4. In order to prove their respective versions, both the parties have produced on the file their respective evidence.
5. We have heard the learned counsel for the respective parties and have also gone through the written arguments submitted by counsel for the complainant as well as case file very minutely.
6. It is admitted that the complainant took health insurance of his family from the OPs on 28.01.2019 and the same was renewed by the complainant and the same was vlaid upto April, 2022, which is evident from Ex.C-1. The complainant has alleged that his wife got ill and she took medicine from Dr. Jatinder Kumar, Jalandhar, who referred his wife to PGI, Chandigarh and the complainant took his wife to PGI, Chandigarh on 02.02.2019, where he came to know that his wife is suffering from blood cancer. The complainant regularly got checked up his wife from Chandigarh and also his wife remained admitted in Civil Hospital, Jalandhar for five days and then on 14.07.2021, when the condition of his wife deteriorated, then the complainant shifted his wife to PGI, Chandigarh and then on 28.08.2021, she expired. After her death, the complainant submitted a claim of Rs.5,00,000/- alongwith medical expenses of Rs.3,00,000/-, but the OPs failed to pay the same.
7. The contention of the OP is that the complainant had obtained health insurance policy from the OP which was valid from 28.01.2019 to 27.01.2020 and as per the medical records of wife of the complainant, she was ill and she was having medical history prior to one month and she was referred to PGI, Chandigarh just after two days of obtaining the insurance policy from the OP, as such the OP had demanded consultation papers prior to 28.01.2019 from the complainant, but the complainant failed to submit the same and then the OP closed the claim of the complainant. The OP has relied upon the letters written by the OP dated 24.12.2021 and 07.01.2022 to the complainant asking the complainant to provide the consultation papers relating to the ailment prior to 28.01.2019. These letters have been proved by the OP Ex.OP-6 and Ex.OP-7, whereas the complainant has alleged that he had provided all the documents and treatment record to the OP.
8. Perusal of the documents proved by the complainant Ex.C2 show that the wife of the complainant was referred to PGI, Chandigarh on 30.01.2019 and there is no reference of the fact that she was suffering from blood cancer in this prescription. She was taken to PGI, Chandigarh and as per Ex.C-3 she took the medicine and treatment from the PGI, Chandigarh continuously. Ex.C-4 is the medical certificate of cause of death. Perusal of this certificate shows that the immediate cause for the death of the wife of the complainant was Fungal Pneomonia with Type 1 Respiratory Failure and the Antecedent Cause was Chronic Lymphocytic Leukemia. From this document, it is clear that she died of Fungal Pneomonia and Blood Cancer was not the direct cause of her death. This has not been alleged by the OP that she was suffering from blood cancer since long and the complainant has also alleged that he came to know about the blood cancer only after he got his wife checked up from PGI, Chandigarh. The claim was not settled for want of documents. In such circumstances, the complainant is directed to supply the necessary required information/documents, if any with him, to the OPs, within 15 days from the date of receipt of the copy of the order and then the OPs will settle the claim of the complainant within 15 days from the date of receipt of the necessary documents/information, failing which the OPs will be liable to pay compensation of Rs.20,000/- to the complainant. It is further ordered that if the complainant is not satisfied with the settlement of the claim made by the OPs, then he is at liberty to file a fresh complaint. Original documents submitted alongwith the complaint be returned to the complainant for onward submission of the same to OPs for the settlement of the claim. Thus, this complaint is disposed of. This complaint could not be decided within stipulated time frame due to rush of work.
9. 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 Jaswant Singh Dhillon Jyotsna Dr. Harveen Bhardwaj
31.07.2023 Member Member President
