Chandigarh

DF-II

CC/393/2016

Om Parkash - Complainant(s)

Versus

HDFC Ergo General Insurance Company Limited, SCO 124-125, Firts Floor, madhya Marg, Sector-8, Chandi - Opp.Party(s)

Sh. Wazir Singh Adv.

07 Jun 2017

ORDER

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

======

Consumer Complaint  No	:	393 of 2016
Date  of  Institution	:	02.06.2016
Date   of   Decision	:	07.06.2017

 

 

 

 

Om Parkash s/o Sh.Nathu Ram, R/o 788, Sector 8, Urban Estate, Kurukshetra.

             …..Complainant

Versus

1]  H.D.F.C. Ergo General Insurance Company Limited, SCO 124-125, First Floor, Madhya Marg, Sector 8, Chandigarh through its Branch Manager.

2]  H.D.F.C. Ergo General Insurance Company Limited, 6^th Floor Lila Business Park Andheri Kurla Road, Andheri East, Mumbai, through authorised/Constituted Authority/Managing Director/Chairman.   

                               ….. Opposite Parties

 

BEFORE:  SH.RAJAN DEWAN                 PRESIDENT

         MRS.PRITI MALHOTRA             MEMBER

                                SH.RAVINDER SINGH              MEMBER 

 

Argued by: Sh.Wazir Singh, Counsel for complainant

 Ms.Neeru, Proxy counsel for Sh.Sandep Suri,         Counsel for OPs

 

 

PER PRITI MALHOTRA, MEMBER

 

 

          Briefly stated, the complainant is holding Credit Card No.5452261000115501 of HDFC Bank and is also holder of saving account in the said bank (OP No.1).  It is averred that the complainant was issued ‘Health Suraksha Policy’ effective from 18.11.2010 to 17.11.2011 by the OPs against the premium of Rs.9607/-, deducted by the OPs from his credit card account.  The said policy was also renewed by the OPs w.e.f. 18.11.2011 to 17.11.2012.  Unfortunately, the complainant while suffering from breathlessness and chest congestion on 17.12.2011, rushed to B.S.Heart Care, Multi Specialist Hospital, Kurukshetra, where the doctor referred him to PGI. Then the  complainant was  admitted in PGI on 17.12.2011 and after conducting several tests including angiography etc., it was diagnosed that the complainant was suffering from Coronary Artery disease with acute inferior wall Myocardial Infraction with blockage upto 90% and later three stents were implanted.  The complainant was discharged on 23.12.2011 and the total expenses incurred on the said treatment was Rs.1,30,310/- including cost of stents, hospitalization charges and medicines during hospitalization. Thereafter, the complainant lodged claim with the OPs and submitted all requisite documents, but still the OPs vide letter dated 12.2.2012 informed the complainant that the claim was not payable since inspite of repeated reminders, the required documents were not submitted by the complainant, whereas the complainant had submitted all requisite documents (Ann.C-7).  It is pleaded that original bills regarding all tests have already been sent to the OPs, therefore, the rejection of the claim of the complainant is absolutely unlawful, null, void and amounts to deficiency in service. Hence, this complaint has been filed.

 

2]       The Opposite Parties have filed reply stating that neither is the policy taken from Chandigarh nor the premium paid here nor the claim raised here nor there is any communication addressed to or from Chandigarh, hence this Forum at Chandigarh does not have the territorial jurisdiction to decide the complaint as no cause of action has taken place here.  On merits, while admitting the factual matrix, it is stated that the claim has been ‘closed’ on account of the failure of the complainant to provide the necessary documents in order to enable the Opposite Parties to take a decision as to whether the claim is payable or not.  It is denied that all documents have been provided by the complainant.  It is submitted that in case the complainant provides the documents, the OPs shall forthwith and within a period of four weeks, thereafter, decide the claim by reopening the same and in case the amount is payable shall inform the complainant accordingly or if, the same is not payable as per the policy terms and conditions, the same shall also be intimated to the complainant. Pleading no deficiency in service and denying rest of the allegations, the OPs have prayed for dismissal of the complaint.

 

3]       Replication has also been filed by the complainant thereby reiterating the assertions as made in the complaint and controverting that of the reply filed by OPs.

 

4]       Parties led evidence in support of their contentions.

 

5]       We have heard the ld.Counsel for the parties and have also perused the entire record.

 

6]       At the outset, it is worth to decide the preliminary objection raised by the OPs regarding jurisdiction.

 

7]       In our considered view, the objection is not tenable since the complainant underwent his complete treatment at PGI, situated at Chandigarh only and the OPs are also having branch Office at Chandigarh and further, Section 11 of the Consumer Protection Act, 1986 stipulates as under-:

“11.        Jurisdiction of the District Forum.—

(1) xxxxx

(2)  A complaint shall be instituted in a District Forum within the local limits of whose jurisdiction,—

(a)     the opposite party or each of the opposite parties, where there are more than one, at the time of the institution of the complaint, actually and voluntarily resides or carries on business or has a branch office or personally works for gain, or

(b)     any of the opposite parties, where there are more than one, at the time of the institution of the complaint, actually and voluntarily resides, or carries on business or has a branch office, or personally works for gain, provided that in such case either the permission of the District Forum is given, or the opposite parties who do not reside, or carry on business or have a branch office, or personally work for gain, as the case may be, acquiesce in such institution;”

 

8]        Since the complainant incurred the expenses for the treatment taken at Chandigarh and the claim lodged for reimbursement of the expenses incurred on the treatment at Chandigarh, were not paid by the OPs, thus, the complainant is duly entitled to file the complaint with this Forum as part of cause of action arose within the jurisdiction of this Forum and the OPs have a branch office at Chandigarh i.e. within the jurisdiction of this Forum.  

 

9]       It is pertinent to mention here that the complainant had earlier filed a complaint with District Forum, Kurukshetra (Haryana) bearing Complaint No.68 of 2013, decided on 6.5.2016, which was dismissed for want of territorial jurisdiction, with liberty that the complainant would be entitled to the benefit of the Provisions of Section14(2) of Limitation Act for the period during which proceedings before this Forum took place, in case the complainant approaches the court of competent jurisdiction/tribunal to resolve the controversy involved in this case.

 

10]      Annexure C-7 is the letter issued by the OPs declaring that the claim lodged by the complainant has been closed, which forms the basis of the present complaint.  The perusal of the said letter reveals that the OPs closed the claim of the complainant for want of certain documents as not supplied by the complainant and relied upon Clause No.5 General Conditions (h), which is reproduced as under:-

Clause Description: We shall be under no obligation to make any payment under this Policy unless we have been provided with the documentation and information We or Our TPA has requested to establish the circumstances of the claim, its quantum or Our liability for it, and unless the Insured Person has complied with his obligations under this Policy i) We will only make payment to or at Your direction, if an Insured Person submits the requisite claim documents and information along with a declaration in a format acceptable to Us of having incurred the expenses, this person will be deemed to be authorised by You to receive the concerned payment. In the event of the death of Your or an Insured Person, We will make payment to the Nominee (as named in the Schedule).

 

11]      In our considered opinion, the demand raised by the OPs regarding documents, as mentioned in the said letter, is only a tactic to delay the payment of the genuine claim of the complainant.  It is very well established on record that the whole of the treatment record of the complainant is part of this judicial record, which has also been handed over/submitted to the OPs. Despite obtaining the whole treatment record of the complainant, the OPs afresh demand for the documents, is highly absurd.  This demand of the OPs only reflects that the OPs are merely shunning their responsibility to properly scrutinize the matter at their own level which further reveals that the OPs in their turn failed to investigate the genuineness of the claim raised by the complainant by conducting an investigation at their own end.

 

12]      In our opinion, the onus to prove any pre-existing disease of the complainant, if any, completely lies on the shoulders of the OPs and until & unless they prove so, the burden is not discharged.  It is pertinent to mention that during the pendency of the complaint, the ld.Counsel for the OPs stated that the OPs wants to verify certain facts from the PGI, Chandigarh and the applicant was allowed to do so vide order dated 29.3.2017.  Thereafter, the OPs moved an application for grant of more time to investigate the matter, which keeping in view the circumstances of the present case need not be granted.

 

13]      The pattern adopted by the OPs to dealt with the claim as in the present complaint, is completely unethical and is not acceptable. In our considered opinion, the OPs are not only liable to reimburse the whole medical claim of the complainant, but are also liable to compensate the complainant for their failure to render proper service as well as liable for resorting to unfair trade practice, for delaying the matter for such a long period adding misery to the sufferance of the complainant.

 

14]      In view of the foregoing discussion, we are of the opinion that the complaint deserves to be allowed.  Accordingly, the complaint is allowed against OPs.  The Opposite Parties are jointly & severally directed as under:-

1. To reimburse amount of Rs.1,30,310/- to the complainant, along with interest @9% p.a. from the date of repudiation i.e. 12.4.2012 (Ann.C-7) till realization;
2. To pay an amount of Rs.15,000/- to the complainant as compensation for causing him mental & physical harassment for deficiency in service and adopting unfair trade practice;
3. To pay litigation expenses of Rs.7000/-

         This order shall be complied with by the OPs within a period of 30 days from the date of receipt of copy of this order, failing which the OPs shall also be liable to pay interest @9% p.a. on the compensation amount from the date of filing complaint till realization, apart from complying with the directions as at sub-para (i) & (iii) above.

        Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced

7^th June, 2017              

 

                                                                                      Sd/-

                                                                   (RAJAN DEWAN)

PRESIDENT

 

 

Sd/-

 (PRITI MALHOTRA)

MEMBER

 

Sd/-

(RAVINDER SINGH)

MEMBER