Punjab

Sangrur

CC/27/2021

Balraj Singh - Complainant(s)

Versus

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

Sh. Tribhuvan Singh

02 Jul 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SANGRUR .

                                                                         Complaint No. 27

 Instituted on:   06.01.2021

                                                                         Decided on:     02.07.2024

 

Balraj Singh Gill aged about 39 years son of Sh. Baljinder Singh, resident of H.No.5, Village Bhadalwad, Tehsil Dhuri, District Sangrur.

                                                         …. Complainant.     

                                                 Versus

1.             HDFC ERGO General Insurance Company Limited, Branch Office: 1^st Floor, SCO No.11, Chhoti Baradari, Patiala 147001 through its Branch Manager.

2.             HDFC ERGO General Insurance Company Limited, Stellar IT Park, Tower-1, 5^th Floor, C-25, Sector-62, Noida (UP) through its Regional Manager.

3.             HDFC Bank Limited, Branch Office: New Mandi Road, Dhuri, Tehsil Dhuri, Distt. Sangrur through its Branch Manager.

                                                        ..Opposite parties.

 

For the complainant  :       Shri Uday Goyal, Adv.

For Opp.parties 1&2  :      Shri Vinay Jindal, Adv.

For Opp.party 3                :       Exparte.

 

Quorum                                          

Jot Naranjan Singh Gill, President

Sarita Garg, Member

                             Kanwaljeet Singh, Member

ORDER

JOT NARANJAN SINGH GILL, PRESIDENT.

1.             Complainant has preferred the present complaint against the opposite parties  on the ground that the complainant is having a saving bank account with the OP number 3 as such the complainant through OP number 3 took a mediclaim insurance policy i.e. Health Suraksha Policy for the period from 20.04.2020 to 19.04.2021 bearing number 2825-1007-7302-9500-000 for himself and his daughter from OPs number 1 and 2. The policy was never sent by the opposite parties. The grievance of complainant is that unfortunately on 17.09.2020, the daughter of the complainant namely Rashneet Kaur suffered acute abdominal pain and burning, as such was immediately taken to Deep Nursing Home Dhuri, where the doctor prescribed certain medicines and tests, but did not get much relief. Thereafter she was taken to Balian Hospital and Heart Centre, Dhuri and after check the doctor referred her to surgical doctor for treatment, as such she was taken to Dayanand Medical College and Hospital, Ludhiana. The complainant showed the policy number, but the hospital authorities asked the complainant to show the policy. The complainant then approached the opposite party No. 3 and requested to send the policy documents. Thereafter, the opposite party No. 3 sent the PDF copy of the policy schedule and the complainant showed his insurance policy to the hospital authorities, who sent the request to OP number 3 for cashless treatment, but cashless treatment vide letter dated 19.09.2020 was rejected on the ground that there is a history of ovarian cyst since February, 2020.  The complainant spent an amount of Rs.60,000/- on the treatment of his daughter and was discharged from the hospital on 22.09.2020. Further case of complainant is that after discharge from the hospital, the complainant approached the OPs for reimbursement of the medical treatment expenses, but the Ops flatly refused to pay the claim amount on the ground that the history of ovarian cyst was not disclosed at the time of proposing the policy. The complainant told that at the time of proposing the policy nothing was put to him regarding any previous ailment/treatment, only the address and age was confirmed. Thus, alleging deficiency in service on the part of the OPs, the complainant has prayed that the OPs be directed to pay to the complainant claim amount of Rs.60,000/- alongwith interest @ 18% per annum and further to restore the policy and further to pay compensation and litigation expenses.

2.             In reply filed by OPs number 1 and 2, legal objections are taken up on the ground that the complaint is not maintainable being pre-mature. The cashless claim of the complainant was denied. After denial of cashless facility the complainant never approached the OPs for reimbursement of claim, the claim of the complainant was repudiated on the ground of non-disclosure of material fact as the complainant never disclosed the fact that his daughter had a history of ovarian cyst and was admitted for treatment of ovarian cyst in February 2020 i.e. before the inception of the insurance policy. It is admitted that the complainant took the insurance policy in question for 20.4.2020 to 19.04.2021. The OPs number 1 and 2 also took preliminary objections that the complaint is bad for non joinder and misjoinder of parties, that the complainant filed by the complainant does not fall  within the definition of consumer dispute and that the complainant has got no cause of action and locus standi to file the present complaint. On merits, it is admitted that the complainant had taken the insurance policy in question for the period from 20.04.2020 to 19.04.2021 under which the complainant and his daughter were insured. It is admitted that the OPs had received pre-authorisation request form of Rashneet Kaur Gill from DMC Ludhiana. Thereafter the OPs number 1 and 2 vide letter dated 19.09.2020 requested to provide treating doctor’s certificate for exact duration of the right ovarian cyst in DD/MM/YYYY format alongwith past consultation papers and treatment record, treating doctor’s certificate mentioning underline cause/etiology of presenting ailment, confirm the final diagnosis. Further case of the OPs is that as per the documents submitted, patient is admitted on 18.09.2020 for the treatment of ovarian cyst with pain in abdomen. Patient is a known case of ovarian cyst before the first inception of the policy. There is history of ovarian cyst since February 2020. Insured had not disclosed the ailment while purchasing the policy, hence there is non disclosure of material facts and thus this claim was repudiated. The other allegations levelled in the complaint have been denied. Lastly, OPs number 1 and 2 have prayed that the complaint be dismissed with costs.

3.             Record shows that the OP number 3 did not appear despite service, as such was proceeded against exparte.

4.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-8 copies of documents and affidavit and closed evidence. On the other hand, the learned counsel for the OPs number 1 and 2 has produced Ex.OP1&2/1 to Ex.OP1&2/12 copies of documents and affidavit and closed evidence.

5.             We have gone through the pleadings put in by  the parties along with their supporting documents with their valuable assistance. 

6.             It is an admitted fact between the parties that complainant and his daughter were insured with the OPs under the medical insurance policy in question, copy of which on record is Ex.C-2. The contention of the complainant is that during the subsistence of the insurance policy in question, Rashneet Kaur was admitted in Deep Nursing Home Dhuri on 17.09.2020 where some tests were conducted, as is evident from the copy of prescription slip Ex.C-3, Ex.C-4 is the copy of laboratory test report, Ex.C-5 is the copy of prescription slip of Balian Hospital and Heart Centre, Ex.C-6 is the report of X-ray abdomen standing view and report of ultrasonography (whole abdomen). Ex.C-7 is the copy of in patient final bill of Dayanand Medical College & Hospital Managing Society, which shows that admission date is 18.09.2020 and discharge date is 22.09.2020, which shows that the complainant paid a total amount of Rs.22856/- for the treatment. Except that the complainant also spent an amount of Rs.5, 339/- minus Rs. 807/- (as mentioned in Refund Memo dated 22.9.2020 of DMCH Pharmacy) which comes to Rs. 4,532/- on medicines which is evident from the copies of the various medicine bills produced on record by the complainant. Ex.C-8 is the copy of rejection of cashless claim facility.

 7.            On the other hand, the learned counsel for the OPs number 1 and 2 has contended vehemently that the daughter of the complainant had a history of ovarian cyst and was admitted for treatment of ovarian cyst in February 2020 i.e. before the inception of the insurance policy. It is further contended that the complainant took the insurance policy in question for 20.4.2020 to 19.04.2021 under which the complainant and his daughter were insured. It is admitted that the OPs had received pre-authorisation request form of Rashneet Kaur Gill from DMC Ludhiana. Thereafter the OPs number 1 and 2 vide letter dated 19.09.2020 requested to provide treating doctor’s certificate for exact duration of the right ovarian cyst in DD/MM/YYYY format alongwith past consultation papers and treatment record, treating doctor’s certificate mentioning underline cause/etiology of presenting ailment, confirm the final diagnosis. Further learned counsel for OPs has contended that as per the documents submitted, patient is admitted on 18.09.2020 for the treatment of ovarian cyst with pain in abdomen. Patient is a known case of ovarian cyst before the first inception of the policy. There is history of ovarian cyst since February 2020, which was not disclosed at the time of getting the insurance policy, as such it is contended that the claim has rightly been repudiated by the OPs.

8.             After perusal of the whole case file as well as evidence and hearing the arguments advanced by the learned counsel for the parties, we find that the only question determination for this Commission is that whether the OPs have rightly repudiated the claim of the complainant on the ground of non disclosure of previous ailment of ovarian cyst or not.

9.             We have perused the copy of discharge on request document dated 22.09.2020 Ex.C-7 wherein in the column Reasons for Admission it is mentioned “Abdominal Pain X 3 days Burning micturition X 2 days”. Further, in the column of Diagnosis it has been mentioned “SUB ACUTE INTENSTINAL OBSTRUCTION”. Further, in the column of Hospital Course it has been mentioned “child was admitted with above mentioned complaints. After history and examination patient was diagnosed as a case of sub acute intestinal obstruction for which patient was managed conservatively. Paediatric consult under Dr. paediatric unit 2 was taken and advice was followed. Patient was taking orally and passing stool and flatus. Now patient is being discharged in stable condition.   It clearly reveals that the daughter of complainant was admitted in the DMC Hospital Ludhiana  for sub acute intestinal obstruction and not for ovarian cyst as contended by the learned counsel for the OPs number 1 and 2.  The OPs number 1 and 2 have drawn our attention towards the copy of certificate issued by Dayanand Medical College and Hospital Ludhiana, which is Ex.OP1&2/2 wherein it has been mentioned that patient has H/o right ovarian cyst diagnosed on 23.2.2020 managed conservatively and discharged on 28.02.2020. Currently patient has presented with intestinal obstruction & UTI. Underlying course of intestinal obstruction is unknown and patient is being managed conservatively.  Under the circumstances now the fact remains that Rashneet Kaur was not treated for Ovarian Cyst in the DMC Hospital, Ludhiana on 18.9.2020, on the basis of which the OPs cannot repudiate the rightful claim of the complainant. Further it reveals that Ovarian Cyst  was not having any connection with the present ailment i.e. Sub Acute Intestinal Obstruction and the OPs have wrongly repudiated the claim of the complainant. To support this contention, the learned counsel for the complainant has cited the judgment dated 12.03.2020 rendered by Hon’ble National Commission in Revision Petition NO.54 of 2018: Life Insurance Corporation of India vs. Sunita and others reported in 2020(3) CPR (NC) 301, the death of the life assured was due to cardiac arrest and the deceased –assured was suffering from diabetes mellitus and chronic liver disease, when he was brought to hospital. It was held by the Hon’ble National Commission that cause of death of the life assured was nowhere connected to his pre-existing disease. Further, The Oriental Insurance Company Limited versus Dr. Ujagar Singh Sachdev and other First Appeal No.125/2020 decided on 09.01.2023 (State Commission, Uttarakhand, Dehradun), it was held that we are of the considered opinion that the alleged pre-existing disease of the insured is not co-related with the treatment of retinal detachment, for which he was hospitalized and claim was submitted before the insurance company. The appeal being devoid of any merits, is liable to be dismissed. According to the facts and circumstances of this case, evidence available on record and law laid down by the Hon’ble National Commission (Supra), we are of the considered opinion that OPs number 1 and 2 are liable for deficiency in service.  

10.           Now, coming to the quantum of compensation payable to the complainant. Admittedly, the insurance policy is for the sum insured of Rs. 3,00,000/-. The complainant has though claimed an amount of Rs.60,000/-, but the complainant has produced hospital bill Ex.C-7 for Rs.22856/-. Further the complainant has spent an amount of Rs. 4,532/- on medicines a total of which comes to Rs.27,388/-. As such, we find that the OPs are liable to pay to the complainant an amount of Rs.27,388/- which were illegally and wrongly withheld by the Ops. 

11.           The insurance companies are in the habit to take these type of projections to save themselves from paying the insurance claim. The insurance companies are only interested in earning the premiums and find ways and means to decline claims. The above said view was taken by the Hon’ble Justice Ranjit Singh of Punjab and Haryana High Court in case titled as New India Assurance Company Limited versus Smt. Usha Yadav and others 2008(3) R.C.R. 9 Civil) 111.

12.           Accordingly, in view of our above discussion, we allow the complaint and direct OPs number 1 and 2 to pay to the complainant the claim amount of Rs.27,388/- alongwith interest @ 7% per annum from the date of filing of the present complaint i.e. 06.01.2021 till realisation. Further they are directed to pay to the complainant an amount of Rs.5000/- as compensation for mental tension, agony and harassment and further an amount of Rs.5000/- on account of litigation expenses. This order be complied with within a period of sixty days of receipt of copy of this order.

13.           The complaint could not be decided within the statutory time period due to heavy pendency of cases.

14.           Copy of this order be supplied to the parties free of cost. File be consigned to the records after its due compliance.      

                        Pronounced.

                July 2, 2024.

 

           (Kanwaljeet Singh)  (Sarita Garg) (Jot Naranjan Singh Gill)

                  Member                       Member                  President