Chandigarh

DF-II

CC/573/2017

Arvind Sharma - Complainant(s)

Versus

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

In Person

19 Dec 2017

ORDER

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

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Consumer Complaint  No	:	573 of 2017
Date  of  Institution	:	27.07.2017
Date   of   Decision	:	19.12.2017

 

 

 

 

Arvind Sharma son of Sh.Amar Nath Sharma, resident of H.No.1416/12, Phase-XI, SAS Nagar, Mohali (Near Punjab Mandi Board Building, Mohali), Punjab 160062    

             …..Complainant

Versus

1]  HDFC Ergo General Insurance Company Limited, SCO 124-125, Madhya Marg, Sector 8, Chandigarh

2]  HDFC Ergo General Insurance Company Limited, Steller, I.T. Park Tower No.1, 5^th Floor, C-25, Sector 62, NOIDAS 201301 U.P.

3]  HDFC Ergo General Insurance Company Limited, Registered and Corporate Office HDFC House, 1^st Floor, 165-166, Backbay Reclamation, H.T. Parekh Marg, Churchgate Mumbai 1400020

 

….. Opposite Parties 

 

 

BEFORE:  SH.RAJAN DEWAN                 PRESIDENT

         MRS.PRITI MALHOTRA             MEMBER

                               

 

 

For complainant(s)      : Complainant in person. 

 

For Opposite Party(s)   : Sh.Nitish Singhi, Adv. for OPs NO.1 & 2.

  Opposite Party No.3 exparte.

 

 

PER PRITI MALHOTRA, MEMBER

 

          As per the case, the complainant purchased Health Insurance Policy (Ann.C-1) from OP Company whereby the complainant and his wife Asha Devi were covered for a sum insured of Rs.3.00 lakh and it was valid from 14.11.2014 to 13.11.2018.  It is averred that the wife of the complainant, an insured, under gone treatment at Laser Eye Clinic, Sector 22A, Chandigarh.  It is further averred that as she was diagnosed to be effected from problem of Cataract RE, thus was operated for surgery of Cataract with Multifocal IOL, RE (Ann.C-II).  Averred that on the said treatment of Asha Devi (insured) an amount of Rs.66,736/- was incurred (Ann.C-III).  However, against the claim lodged with the OPs, they paid only an amount of Rs.40,425/- against claim of Rs.66,736/-. It is also averred that the complainant represented to the Opposite Parties for making payment of the balance amount of Rs.26,321/-, but the same was repudiated by them vide letter Ann.C-V. Alleging the said repudiation as illegal and deficiency in service, hence this complaint has been filed.

 

2]       The OPs NO.1 & 2 have filed joint reply and while admitting the factual matrix of the case, stated that the complainant himself admitted that he had received an amount of Rs.40,415/-. It is stated that the OPs had already passed the amount under the policy for which the complainant/policyholder was entitled and the complainant is not entitled for any other amount, which is over and above the terms & conditions of the policy and thus, the claim of the complainant was rightly repudiated vide letter dated 28.6.2017 (Ann.R-4). It is also stated that the complainant is not entitled for any other amount, what has already been paid to him, as per policy.  Pleading no deficiency in service and denying rest of the allegations, the OPs No.1 & 2 have prayed for dismissal of the complaint. 

         Opposite Party No.3 did not turn up despite service of notice sent through regd. post on 6.9.2017, hence it was proceeded exparte vide order dated 16.10.2017.

 

3]       Parties led evidence in support of their contentions.

 

4]       We have heard the complainant in person, ld.Counsel for the OPs No.1 & 2 and have also perused the entire record.

 

5]       The present complaint is admitted to the extent that the complainant purchased Health Insurance Policy (Ann.C-1) from Opposite Party Insurance Company whereby the complainant and his wife Asha Devi were covered for a sum insured of Rs.3.00 lakhs which was valid from 14.11.2014 to 13.11.2018 (Ann.C-1).  The treatment availed by the wife of the complainant (insured) and payment of Rs.40,425/- made by the OPs against the claim of Rs.66,736/- incurred by the complainant on the treatment of his wife during the policy period is also admitted.  

 

6]       The dispute in the present complaint pertains to the less settlement of the claim than the actual amount incurred on the treatment of Mrs.Asha Devi (insured).  It is necessary to reproduce the stand of the OPs whereby it refused to make the balance payment:-

    “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 submitted documents, patient was admitted on 18/05/2017 with the diagnosis of Cataract-right eye & was managed surgically with Phaco IOL (multifocal lens).  The main claim was paid to the claimant as per hospitals agreed tariff for Unifocal lens with us. The multifocal lens are used for correction of refractive errors of eyes which remain post Cataract surgery.  This case is hence being repudiated under Section 9C xxvi. As per which any treatment or part of a treatment that is not of a reasonable change or not medically necessary is not covered.”

 

7]       After considering the contentions, as reproduced above and keeping in view the arguments submitted by the parties, we firmly believe that the complainant in the present complaint is fully entitled for the balance payment, which the OPs withheld taking recourse to the clause 9(c)(xxvi) of terms & conditions of the policy in question. The OPs in order to justify their stand have not brought forward any expert opinion.  Admittedly the OPs paid to the complainant as per hospitals agreed tariff for unifocal lens but not brought forward any opinion of medical expert in order to counter that the complainant’s case was not fit to be treated with multifocal lens. As a matter of fact and common prudence, it is only the doctor concerned/treating doctor, who is the best judge to decide which way the patient is to be treated considering his/her medical status. In the absence of any substantial evidence, the denial of legitimate claim is unjustified and not legal. It is observed that if the genuine claims are to be considered with such perverse minds, then definitely it would shatter the faith of the common man in the insurance industry. The deficiency in service on the part of the OPs is writ large.

 

8]       In view of the above findings, the complaint is allowed against Opposite Parties with direction to jointly & severally pay the balance amount of Rs.26,321/- to the complainant, along with compensation of Rs.10,000/- for causing harassment due to their deficient services and also to pay litigation cost of Rs.5,000/- within a period of 30 days from the date of receipt of copy of this order, failing which they shall also be liable to pay additional cost of Rs.10,000/-, apart from the above awarded relief.

 

         The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

19^th December, 2017                                                              Sd/-                                                                                                  

(RAJAN DEWAN)

PRESIDENT

 

Sd/-

 (PRITI MALHOTRA)

MEMBER