Chandigarh

DF-I

CC/752/2019

Divesh Kumar - Complainant(s)

Versus

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

Devinder Kumar Adv.

29 Nov 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/752/2019
Date of Institution	:	26/07/2019
Date of Decision	:	29/11/2022

Divesh Kumar son of Sh. Ashok Kumar, aged about 32 years, r/o H.No.11, Parshant Vihar, Near Shiv Mandir, Baltana, Zirakpur, District : SAS Nagar.

… Complainant

V E R S U S

1. HDFC Ergo General Insurance Company Limited, SCO No.124-125, First Floor, Madhya Marg, Sector 8-C, Chandigarh through its Branch Manager.
2. HDFC Ergo General Insurance Company Limited, Regd. & Corporate Office : 1^st Floor, 165-166, Backbay Reclamation, H.T. Parekh Mart, Churchgate, Mumbai 400020 through its Managing Director.
3. HDFC Bank Limited, SCO No.153-155, Madhya Marg, Sector 8-C, Chandigarh through its Branch Manager.

… Opposite Parties

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER

 

                       

ARGUED BY	:	Sh. Devinder Kumar, Counsel for complainant
	:	Sh. Nitesh Singhi, Counsel for OPs 1 & 2
	:	Ms. Neetu Singh, Counsel for OP-3

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Sh.Divesh Kumar, complainant against the opposite parties (hereinafter referred to as the OPs).  The brief facts of the case are as under :-

1. It transpires from the allegations as projected in the consumer complaint that on the assurance of OP-3, complainant and his brother Sh. Mohan Kumar had purchased Home Suraksha Plus Insurance Policy (hereinafter referred to as the “aforesaid policy”) from OPs 1 & 2 as OP-3 had sanctioned the loan of ₹15.00 lacs in favour of them. The said policy was valid w.e.f. 19.9.2017 to 18.9.2022 for which complainant and his brother had paid premium of ₹31,508/- to OPs 1 & 2.  The brother of the complainant died on 23.11.2017 and information about his death was given to the OPs and the complainant called the Customercare of OPs and demanded the policy documents, which were never supplied. OPs only provided the insurance policy containing five pages on the email address of Mohan Kumar on 29.11.2017.  On 12/13.9.2018, when the complainant was suffering from abdominal pain, he visited the Civil Hospital, Manimajra for treatment.  On the next day, when the complainant faced the same problem, he visited Govt. Hospital, Sector 16, Chandigarh and after check-up, doctor referred him to GMCH, Sector 32, Chandigarh and thereafter he was discharged.  However, when the complainant did not get any relief from the said pain, he visited Malhotra Nursing Home, Sector 7, Panchkula for better treatment on 16.9.2018 and after conducting tests, he was advised bed rest.  On 17.9.2018, when the complainant again faced the same problem, he was brought to Healing Hospital, Sector 34, Chandigarh by his family members.  On the very next day i.e. 18.9.2018, the complainant again felt abdominal pain and he became unconscious. Thereafter, complainant’s neighbour Mr.Varun Kumar took him to Global Health Care Clinic, Sector 21, Chandigarh, where he was operated in emergency on the same day.  The complainant remained admitted and he was discharged on 21.9.2018.  On his treatment, complainant had spent an amount of ₹1,29,394/- and as per the advice of the doctor, he remained on bed rest till December, 2018.  Subsequently, complainant submitted two claim forms (Annexure C-8 & C-9) – one for operation and another for pre and post hospital expenses including medical charges – to the OPs with the request to release the insurance claim, but, with no result.  Thereafter, the complainant sent emails on 22.2.2019 and 25.2.2019 requesting the OPs to resolve the issue, but, with no response, rather vide email dated 26.2.2019, OPs 1 & 2 had conveyed rejection of the claim of the complainant on the ground that hospitalisation is not covered under the policy.  Averred, OPs had assured that major illness and procedures are covered under the policy, but, later on by relying upon the terms and conditions of the policy, which were never supplied to the complainant, claim of the complainant was wrongly repudiated, which amounts to deficiency in service and unfair trade practice on the part of the OPs. OPs were requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. OPs resisted the consumer complaint and filed their separate written statement/reply. In their written statement, OPs 1 & 2 took preliminary objections of maintainability, concealment of facts, cause of action and locus standi. On merits, admitted that the aforesaid Policy was obtained by the complainant and his brother which was valid from 19.9.2017 to 18.9.2022 and also admitted that the complainant had lodged claim with the answering OPs, but, denied that complete policy documents were not received by the complainant.  It is further alleged that even the brother of the complainant had filed complaint against the OPs by relying upon the same insurance policy which was dismissed and the present consumer complaint filed by the complainant is also not maintainable since as per the terms and conditions of the policy, expenses for hospitalisation of the complainant are not covered and the present consumer complaint of the complainant is liable to be dismissed. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. In its written reply, OP-3 took the preliminary objections of maintainability and also that there is no deficiency in service on the part of the answering OP.  On merits, admitted that the aforesaid Policy was purchased by the complainant from OPs 1 & 2 and the answering OP cannot act in any manner whatsoever so as to look into the grievance of the complainant. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
4. In replication to the written statement of OPs 1 & 2, complainant re-asserted his claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.

2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the parties and also gone through the file carefully, including the written arguments.
4. Close scrutiny of the entire evidence on record of the case file, rival contentions of the learned counsel for the parties, are discussed as under:-

1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant and his brother had purchased the aforesaid Policy from OPs 1 & 2 which was valid w.e.f. 19.9.2017 to 18.9.2022 on payment of premium of ₹31,508/-, as is evident from Annexure C-3 and corresponding copy of which is Annexure R-1/1, and also that the complainant had taken the treatment in several hospitals due to the abdominal pain w.e.f. 12/13.9.2018 and was operated upon for “burst appendix with peritonitis” at Global Health Care Clinic and had spent an amount of ₹1,29,394/- for his medical treatment and thereafter the complainant has lodged claim for the aforesaid amount with OPs 1 & 2, the case is reduced to a narrow compass as it is to be determined if OPs 1 & 2 have not been justified in repudiating the claim of the complainant, as is the case of the complainant, or if they have been justified in repudiating the claim of the complainant as per terms and conditions of aforesaid insurance policy, as is the defence of the OPs.
2. As per the case of the complainant, only five pages policy documents were issued to the deceased brother of the complainant Sh. Mohan Kumar on 29.11.2017 when OPs 1 & 2 were informed about the death of Sh.Mohan Kumar and the said Policy documents were received through email (Annexure C-2) and except these documents since other documents containing the preamble and terms and conditions of the policy, which are now attached by OPs 1 & 2 with Annexure R-1/1 with internal pages 22 to 53, were never supplied to the complainant, OPs 1 & 2 cannot take advantage of these documents, especially when the same were never supplied to the complainant or his brother at the time of issuance of the aforesaid insurance policy and the repudiation of the claim of the complainant, by giving reference of exclusion clause by OPs 1 & 2 is not justified and the complainant is entitled for the genuine claim which has been lodged by him.  On the other hand, the claim of the complainant is resisted by OPs 1 & 2 on the ground that as the expenses borne by the insured in hospitalisation are not covered under the Policy, OPs 1 & 2 have rightly repudiated the claim of the complainant and the consumer complaint of the complainant be dismissed with costs.   In the light of the aforesaid facts, it would be worth that the entire Policy, having been relied upon by both the parties, be scanned carefully in order to determine the real controversy between the parties.
3. As per the case of the complainant, since he had received only five pages of the Policy (Annexure C-2) and the remaining pages of the policy containing the terms and conditions were never sent to the complainant by the OPs, OPs cannot take benefit of the said terms and conditions which were never sent to the complainant and further when no treatment to the patient can be given without hospitalisation, the defence of the OPs is without merit and the complainant is entitled for the claim, as prayed for.  In order to determine this fact if the complainant was aware of the coverage details and sum insured in the policy after payment of premium to the OPs and also if in the absence of the terms and conditions, which the complainant has denied that from pages 22 to 52, complainant has been able to prove his claim as set up in the consumer complaint and for that purpose Annexure C-3 (containing 5 pages) which admittedly has been received by the complainant and having been relied upon by him, is required to be scanned carefully.  The second page of Annexure C-3 gives the coverage details and the sum insured in the tabulated form and the same is reproduced as under :-

Section No.	Coverage Details	Sum insured	Maximum Deductible	Section No.	Coverage Details	Sum Insured	Maximum deductible
I	FIRE AND ALLIED PERILS, EARTHQUAKE AND TERRORISM		NIL	III	MAJOR MEDICAL ILLNESS AND PROCEDURES	1006480	Nil
	(A) Building	1006479		IV	PERSONAL ACCIDENT		Nil
	(B)Contents	251620			(A) Accidental death	1006480	Nil
II	BURGLARY, HOUSEBREAKING, THEFT		1000		(B) Permanent Total Disablement	1006480	Nil
	(A) Contents	251620			(C) Dependent Child Education Benefit (Max 2 child)	50000/Per Child	Nil
				V	LOSS OF JOB (No. of EMIs)	3	Nil

On the foot of the table, major medical illness and procedure is further explained.   The illnesses covered under sub head III and the same is further reproduced as under for convenience :-

“In case of co-applicant, benefits under Section III & IV (Major Medical Illness and Procedure & Personal Accident) are limited to 50% of Sum Insured for each insured.  Benefit under Section V (Loss of Job) is payable only to the insured(s) who pays the EMI.  In the event both Insured pay EMI the benefit shall be limited to the extent of the EMI, paid towards the loan by each insured.  Under Major Medical Illnesses & Procedures Section following illnesses are covered : (1) Cancer (2) End Stage Renal Failure (3) Multiple Scierosis (4) Major Organ Transplant (5) Heart Valve Replacement (6) Coronary Artery Bypass Graft (7) Stroke (8) Paralysis (9) Myocardial Infarction.  In the Policy wordings the list of Major Medical Illnesses and Procedures enlisted under Section III has 18 illnesses/procedures.   However, please note that the coverage provided to You under this Policy is restricted only to the above mentioned 9 Major Medical Illnesses and Procedures.

Fixed SI basis : In the event of Sum Insured opted by the Insured is less than the loan amount and if the claim is payable under Section V (Loss of Job), the claim shall be calculated under this Section on pro-rata basis of the principal outstanding loan amount.”

Thus, one thing is clear from policy (Annexure C-3) that the same was purchased by the complainant and his brother Home Suraksha Plus Policy as both the complainant and his brother had taken loan from the bank and in order to secure that loan, said policy was purchased by them and the said policy was not a mediclaim policy, rather the same had provided protection to the loanee till the clearance of the loan. The complainant has set up his case under Section III (head III) i.e. Major Medical illness and procedures for which the sum insured was 1006480 with nil deduction.  As the aforesaid major medical illness and procedures have further been explained in the second page of the policy (Annexure C-3), receipt of which has also not been disputed by the complainant, it is clear that the complainant was well aware of the fact about the illnesses which were covered under the Policy and even if the remaining portion of the Policy (Annexure R-1/1) has not been received by the complainant, same is not going to give any benefit to the complainant, especially when it is the case of complainant that he was taking treatment of abdomen pain and was operated upon due to bursting of appendix with peritonitis, which is not covered under the above mentioned diseases i.e. under major medical illness and procedure.

5. In view of foregoing discussion, the complainant has not been to prove any deficiency in service or unfair trade practice on the part of the OPs and the present consumer complaint deserves to fail.
6. In the light of the aforesaid discussion, the present consumer complaint, being devoid of any merit, is hereby dismissed leaving the parties to bear their own costs.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

Announced 29/11/2022 hg			Sd/- [Pawanjit Singh] President
			Sd/- [Surjeet Kaur] Member