Haryana

Karnal

CC/625/2020

Angrej Singh - Complainant(s)

Versus

HDFC ERGO General Insurance Company Limited - Opp.Party(s)

27 Sep 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

                                                      Complaint No. 625 of 2020

                                                      Date of instt.31.12.2020

                                                      Date of Decision:27.09.2023

 

Angrej Singh son of Shri Maman Singh resident of village Kutail, Tehsil Gharaunda, District Karnal. Mobile no.9813677965.

 

                                               …….Complainant.

                                              Versus

 

1. HDFC ERGO General Insurance Company Limited, corresponding office: Stellar IT Park Tower-1, 5^th floor, C-25, Sector-62, Noida-201301 through authorized signatory.

 

2. HDFC ERGO General Insurance Company Limited, Registred & Corporate office: first floor, 165-166, Backbay Reclamation, H.T. Parekh Marg, Charchgate, Mumbai-400020 through Authorized Signatory.

 

…..Opposite Parties.

       

Complaint Under Section 35 of Consumer Protection Act, 2019.

 

 

Before   Shri Jaswant Singh……President.

              Shri Vineet Kaushik…….Member

              Dr. Rekha Chaudhary……Member

          

Argued by:  Shri Jasbir Jain, counsel for the complainant.

                    Shri Sanjeev Vohra, counsel for the OPs.

 

                    (Jaswant Singh, President)

ORDER:                     

          

                 The complainant has filed the present complaint Under Section 35 of Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that in the year 2019,  complainant purchased a health Surksha insurance policy from the OPs and the same was renewed, bearing policy no.2828100771431500, valid from 15.04.2020 to 14.04.2021. Complainant paid the premium through online. At the time of taking the policy, OP assured the complainant that all the disease are covered under the policy. In the month of October, 2020, complainant suffered from fever and he was taken to P.R.P. Multi  Specialty Hospital, Karnal for check-up. After check-up, complainant found was suffering from Dengu and he got admitted in the said hospital from 04.10.2020 to 10.10.2020. Complainant spent Rs.83327/- on his treatment. After discharge from the hospital, complainant lodged the claim with the OPs for reimbursement of the said amount and submitted all the required documents as demanded by OPs. Thereafter, OPs appointed an investigator to investigate the matter. The investigator enquired about the matter and assured the complainant that his claim will be passed. On 11.12.2020, complainant received an email from the OPs, vide which the claim of the complainant has been denied by the OPs on the false and frivolous ground. In this there is deficiency in service and unfair trade practice on the part of the OPs. Hence this complaint.

2.             On notice, OPs appeared and filed its written version raising preliminary objections with regard to maintainability and concealment of true and material facts. On merits, it is pleaded that complainant has taken the My-Health Surksha Policy bearing no. 2828100771431500, valid from 15.04.2020 to 14.04.2021. As alleged by the insured, he was admitted in P.R.P. Multi Specialty Hospital, Karnal from 04.10.2020 to 10.10.2020 with complaints of Dengue. Insured paid total Rs.83327/- and thereafter a claim was lodged with the OPs seeking reimbursement for the expenses incurred during the hospitalization. After receiving the claim, an independent investigator was appointed in order to verify the genuineness and veracity of the facts. During investigation, the following observations were made:-

.       Insured confirmed no any blood/platelets transfusion was done during whole treatment period while hospital is presenting it was done and Rs.22000/- is added in bill by hospital as Apharesis charges.

.       As per insured only time per day pulse, BP and T was checked but in vital chart it is found 10-12 times.

.       As per insured he was in general ward but hospital is presenting in private room, as per insured monitor, pulse oxymeter was applied but no such history found.

.       As per insured stool test was done but in ICPS/Lab records no such history found.

.       As per insured USG was not done but hospital prepared a fake report of USG which is attested by Treating doctor.

Since there were major discrepancies/misrepresentations in the documents submitted by the complainant, the OPs were constrained to repudiate the claim of the complainant, vide the repudiation letter dated 11.12.2020, in view of section G clause 8 of the terms and conditions of the policy Section-G: General conditions

8. Fraud

If any claim made by the insured person, is in any respect fraudulent, or if any false statement, or declaration is made or used in support thereof, or if any fraudulent means or devices are used by the insured person or anyone acting on his/her behalf to obtain any benefit under this policy, all benefits under this policy and the premium paid shall be forfeited.

 

Therefore, the claim of the complainant has been rightly repudiated by the OPs. There is no deficiency in service and unfair trade practice on the part of the OPs. The other allegations made in the complaint have been denied by the OPs and prayed for dismissal of the complaint.

3.             Parties then led their respective evidence.

4.             Complainant has tendered into evidence his affidavit Ex.CW1/A, copy of final bill Ex.C1, copy of deficiency letter dated 29.10.2020 Ex.C2, copy of confirmation letter dated 15.04.2019 Ex.C3, copy of insurance policy Ex.C4, copy of identity card Ex.C5, copy of proposal form Ex.C6, copy of repudiation letter dated 11.12.2020 Ex.C7, copy of bill dated 10.10.2020 Ex.C8, copies of medical bills Ex.C9 to Ex.C24, copy of application by complainant to OP Ex.C25, copies of receipts Ex.C26 and Ex.C27 and closed the evidence on 01.02.2022 by suffering separate statement.

5.             On the other hand, learned counsel for the OPs has tendered into evidence affidavit of Manoj Kumar Prajapati, Manager Ex.RW1/A, copy of investigation report Ex.R1, copy of claim form/statement of complainant Ex.R2, copy deficiency letter dated 29.10.2020 Ex.R3, copy of treatment record Ex.R4, copy of repudiation letter dated 11.12.2020 Ex.R5 and closed the evidence on 17.04.2023 by suffering separate statement.

6.             We have heard the learned counsel of the parties and perused the case file carefully and have also gone through the evidence led by the parties.

7.             Learned counsel for complainant, while reiterating the contents of complaint, has vehemently argued that complainant had purchased a Health Surksha Insurance policy from the OPs, which continued from the year 2019 to 2021. On 04.10.2020, complainant suffered from fever and he was taken P.R.P. Multi Specialty Hospital, Karnal where doctor examined the complainant and found he was suffering from Dengu. Complainant has taken the treatment for the said disease and spent Rs.83,327/- on his treatment. After discharge from the hospital, complainant lodged his claim with the OPs for reimbursement of the said amounts but OPs did not pay the claim and denied the same on the false and frivolous ground and prayed for allowing the complaint.

8.             Per contra, learned counsel for OPs, while reiterating the contents of the written version, has vehemently argued that complainant lodged a claim with the OPs seeking reimbursement for the expenses incurred during the hospitalization. After receiving the claim, an independent investigator was appointed in order to verify the genuineness of the claim. During investigation, there were major discrepancies/misrepresentations in the documents submitted by the complainant. Thus, the claim of the complainant has been rightly repudiated by the OPs, vide letter dated 11.12.2020 and prayed for dismissal of the complaint.

9.             We have duly considered the rival contentions of the parties.

10.           Admittedly, complainant purchased a Health Surksha Insurance Policy from the OPs. It is also admitted that during the subsistence of the insurance policy, complainant was hospitalized in P.R.P. Multispecialty Hospital, Karnal and spent Rs.83,327/- on his treatment.

11.           The claim of the complainant has been repudiated by the OPs, vide repudiation letter dated 11.12.2020 Ex.C7/Ex.R5 on the grounds, which is reproduced as under:-

“We have received your request for reimbursement of claim for the above mentioned hospitalization. We have verified the same with respect to the coverage terms and conditions under the insurance policy plan. And on primary scrutiny of the submitted documents, we regret to inform that your claim is not payable due to following reasons:

As per the documents submitted, the claim was found to be misrepresented. As per the policy terms and conditions, if any, claim is in any manner dishonest or fraudulent, or is supported by any dishonest or fraudulent means or devices, whether by insured person or anyone acting on behalf of an insured person, then this policy shall be void and all benefits paid under it shall be forfeited. Hence this claim is being repudiated under section G-B of policy terms and conditions. Furthermore, as the policy is under process of cancellation, no further claim will be entertain.

While expressing our inability to pay this claim due to the above-mentioned rationale, we reiterate our obligation to pay all admissible claims fairly and promptly”

12.           The claim of the complainant has been repudiated by the OPs on the abovementioned ground. OP has alleged that during investigation, as per insured his BP, temperature and pulse were checked only once and only for one day during the whole hospitalization but as per case sheet same were checked 10-12 times in a day and was checked every day (daily) during the hospitalization. How a fever patient can be managed without temperature check. As per insured he was admitted in General ward during the hospitalization but same was charged for private room in final bill. Hence bill inflation has been done. Insured did not know how many times his blood, urine, stool and x-ray tests were done during the hospitalization and he also did not know the dates on which his blood, urine, stool and x-ray tests were done during the hospitalization. As per insured blood or platelets Apheresis were not given to him during the hospitalization but same was charged for Rs.22000/- in final bill. Hence bill inflation has been done and charged could not be justified.

13.           Complainant has taken the My Health Surksha Policy from the OPs. Complainant was admitted in P.R.P. Multispecialty Hospital, Karnal from 04.10.2020 to 10.11.2020 with the complaints of Dengue and paid total Rs.83,327/-. The claim of the complainant has been rejected by the OPs on the ground of discrepancies/misrepresentation in the treatment record. In the said record, if there are any discrepancies, it is the treated hospital which is responsible for such type of discrepancies and why should the complainant suffer for that.

 14.          Further,  Hon’ble Punjab and Haryana High Court in case titled as New India Assurance Company Ltd. Versus Smt. Usha Yadav & others 2008 (3) RCR (Civil) 111, has held as under:-

“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. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy”.

15.           Keeping in view, the ratio of the law laid down in aforesaid judgments, facts and circumstances of the present complaint, we are of the considered view that act of the OPs while repudiating the claim of the complainant amounts to deficiency, which is otherwise proved as genuine one. 

16.           The complainant claimed Rs.83,327/- and in this regard he has submitted the medical bills  on record Ex.C8 to Ex.C24. The said bills have not been rebutted by the OPs. The sum insured in the policy is Rs.5,00,000/-. Hence, the complainant is entitled for the said amount alongwith interest, compensation for mental harassment and litigation expenses etc.

17.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.83,327/- (Rs.eighty three thousand three hundred twenty seven only) to the complainant alongwith interest @ 9% per annum from the date of repudiation of claim i.e. 11.12.2020 till its realization. We further direct the OPs to pay Rs.20,000/- to the complainant on account of mental agony and harassment and Rs.5500/- towards the litigation expenses.  This order shall be complied with within 45 days from the receipt of copy of this order. However, OPs are at liberty to recover the awarded amount from the concerned hospital who has committed discrepancies in the treatment record.  The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated: 27.09.2023

                                                                President,

                                                      District Consumer Disputes

                                                      Redressal Commission, Karnal.

 

             (Vineet Kaushik)     (Dr. Rekha Chaudhary) 

                   Member                  Member