Chandigarh

DF-II

CC/11/2024

AJAY GOYAL - Complainant(s)

Versus

HDFC ERGO GENERAL INSURANCE COMPANY LIMITED - Opp.Party(s)

ATUL GOYAL

02 May 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II

U.T. CHANDIGARH

 

 

Consumer Complaint No.	:	11/2024
Date of Institution	:	08.01.2024
Date of Decision	:	02.05.2024

 

                                       

 

 

Ajay Goyal aged about 44 years s/o Sh.Mohan Lal r/o H.No.387, Sector 32-A, Chandigarh.

…..Complainant

Versus

HDFC ERGO General Insurance Company Limited having office at SCO No.124. 125, Madhya Marg, Sector 8-C, Chandigarh through Authorized Representative/Signatory.

...Opposite Party

 

BEFORE:
	SHRI AMRINDER SINGH SIDHU,	PRESIDENT
	SHRI B.M.SHARMA	MEMBER
Present:-
	Sh.Atul Goyal, Counsel for complainant Sh.Nitin Thathai & Ms.Monika Thathai, Counsel for OP.

 

ORDER BY AMRINDER SINGH SIDHU, M.A.(Eng.),LLM,PRESIDENT

1.         The complainant has filed the present complaint pleading therein that he took the policy from Apollo Munich for himself and his family which was later on taken over by the OP and at the time of renewal issued Optima Restore Floater Two Year Policy and the same was renewed from time to time and the latest policy was issued for the period from 19.06.2022 to 18.06.2024 for sum assured of Rs.20.00 lakhs.  He was diagnosed with the disease of diabetes in April, 2021 and the same was informed to the OP vide email dated 05.05.2021 requesting to endorse diabetes in its policy. The OP vide reply dated 07.06.2021 admitted that the medical disclosure was noted and considered.  On 25.10.2023, he was admitted in Healing Super Speciality Hospital and diagnosed with dengue. He was discharged  on 27.10.2023 and incurred Rs.75,053/- on his treatment. The OP was informed about the admission and they also raised the pre-authorization request with the hospital.  He submitted the claim along with the requisite documents for reimbursement vide e-mail dated 21.11.2023 but the said claim has not been settled till date.  Alleging that the aforesaid acts of omission and commission on the part of the OP amount to deficiency in service and unfair trade practice, the complainant has filed the instant complaint seeking directions to the OP to reimburse the claim along with interest, compensation for mental agony and physical harassment as well as litigation expenses.
2.         In its written version, the OP while admitting the factual matrix of the case has stated that no such email dated 21.11.2023 was ever received and as such no claim was lodged with the OP and without going into the merits o the controversy, the OP requested  that the complainant be directed to supply the following documents in original to the OP for processing the claim:-

1. Discharge summary.
2. Original final bill with detailed breakup
3. Original payment receipts
4. All investigation reports
5. ICP’s
6. KYC documents as the claim was cashless.

                The remaining allegations have been denied, being false. Pleading that there is no deficiency in service or unfair trade practice on their part, the OP has prayed that the complaint be disposed with a direction to the complainant to submit the aforesaid documents.

3.         We have heard the Counsel for the contesting parties  and have gone through the documents on record, including written submissions.
4.         From the submissions of the parties and the documentary evidence on record, it is observed that the complainant has alleged to have submitted the claim with requisite documents through e-mail with the OP. However, the OP has denied the receipt of the said e-mail and the documents. Under these circumstances, it will be just and proper if the OP is afforded an opportunity to decide the claim as per the terms and conditions of the policy. Accordingly, the complainant is directed to submit the requisite documents to the OP as stated in the written version, the detail of which is as under:-

1. Discharge summary.
2. Original final bill with detailed breakup
3. Original payment receipts
4. All investigation reports
5. ICP’s
6. KYC documents as the claim was cashless.

5.         In this view of the matter, the complaint is disposed with a direction to the complainant to submit the documents aforesaid to the OP. The OP is also directed to process and decide the claim as per the terms and conditions of the policy within 45 days from the receipt of the aforesaid documents. However, the complainant is at liberty to file a fresh complaint, if he aggrieves with the decision of the OP.
6.         The pending application(s) if any, stands disposed of accordingly.
7.         Certified copy of this order be communicated to the parties, as per rules. After compliance file be consigned to record room.

Announced in open Commission 02.05.2024
	Sd/- (AMRINDER SINGH SIDHU) PRESIDENT
	Sd/- (B.M.SHARMA) MEMBER