Punjab

Sangrur

CC/766/2022

Ranjit Bhagria - Complainant(s)

Versus

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

Sh. Amit Goyal

21 Aug 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SANGRUR .

                                                                        Complaint No. 766

 Instituted on:   01.11.2022

                                                                        Decided on:     21.08.2024

Ranju Bhagria aged 51 years W/o Sh. Sukhpal Kumar R/O Adjoining Arora Dental Clinic, Club Road, Sangrur.

                                                         …. Complainant.     

                                                 Versus

1.             HDFC ERGO General Insurance Company Limited, Area Office: 1^st Floor, SCO 124-125, Sector 8-C, Madhya Marg, Chandigarh.

2.             HDFC ERGO General Insurance Co. Ltd. Regd. & Corporate Office: 1^st Floor, HDFC House, 165/166, Backbay Reclamation, HT Parekh Marg, Churchgate, Mumbai-400020 through its M.D.

                                                        ..Opposite parties.

 

For the complainant  :       Shri Amit Goyal, Adv.

For Opp.parties         :       Shri Jatinder Verma, Adv.

 

Quorum                                          

Jot Naranjan Singh Gill, President

Sarita Garg, Member

                        Kanwaljeet Singh, Member

 

ORDER

SARITA GARG, MEMBER

1.             Complainant has preferred the present complaint against the opposite parties  on the ground that complainant obtained a health insurance  policy bearing number 2805 2039 5112 4400 000 from the OPs for an amount of Rs.10,00,000/- by paying the requisite premium of Rs.21,939/- and the policy in question was valid for the period from 05.01.2021 to 04.01.2022 which was subsequently renewed for the period from 31.01.2022 to 30.01.2023.  Further case of complainant is that during the subsistence of the insurance policy the complainant for the very first time experienced the problem of acute shortness of breathing on 28.02.2021 while she alongwith her husband were on a family visit to Amritsar, as such upon the advice of relatives she was taken to Dr. PSP Memorial Janta Hospital, Amritsar, where upon clinical examination and other tests such as echo were performed and was diagnosed that she was having lungs congestion due to malfunctioning of left ventricle of heart called severe mitral valve stenosis and the complainant remained admitted in the hospital for the period from 28.02.2021 to 11.03.2021, where she spent an amount of Rs.92,007/-.  Further case of complainant is that thereafter she was admitted at Grecian Super Speciality Hospital Mohali  for the said problem on 24.03.2021 for surgery and replacement of her mitral valve stenosis and to repair the other one-tricuspid valve and accordingly pre-authorisation request was sent to the OPs by hospital authorities through TPA. It is further averred that during investigation her thyroid level was found to be on the higher side, so her surgery was deferred for the time being and the complainant was discharged from the hospital on 30.3.2021 and an amount of Rs.92,691/- was incurred on the treatment of complainant during her stay in the hospital.   Thereafter the complainant lodged both the claims i.e. Rs.92007/- and of Rs.92691/- of PSP Memorial Janta Hospital, Amritsar and Grecian Super Speciality Hospital Mohali, respectively with the OPs.  Further case of complainant is that due to severe second wave of corona pandemic, surgery of the complainant was postponed and ultimately it was decided to get the complainant operated at PGI Chandigarh.  Since cashless treatment was not available at PGI, so the OPs were informed vide e-mail dated 12.09.2021 about the admission of complainant at PGI for the treatment.  The complainant was admitted in PGI Hospital Chandigarh on 10.09.2021 and surgery was performed upon her on 16.09.2021 and she was discharged on 25.09.2021, where an amount of Rs.2,74,781/- including charges for surgery, medicines, tests etc. were incurred.

2.             Further case of complainant is that while processing these claims, OPs asked for a certificate from the treating doctor of PSP Memorial Janta Hospital, Amritsar about duration of the ailment in the format alongwith past consultation papers and treatment record, which was duly provided and intimated that the complainant experienced the symptoms of acute shortness of breathing for the first time on 28.02.2021 and was admitted at PSP Memorial Hospital, Amritsar.  It is further averred in the complaint that the OPs got conducted investigation at their own level as the representative sent by them visited the residence of complainant and collected copies of all the treatment record and certificates.  The complainant though sent all the documents to the OPs sought for by them, but despite all this the OPs vide their email dated 15.12.2021 illegally repudiated the genuine claim of the complainant pertaining to treatment taken at Dr. PSP Memorial Hospital, Amritsar for the reason that ‘hospitalisation was done before policy inception’. The remaining two claims were also repudiated by the OPs for the reason that as the date of inception of policy is 05.01.2021 and the symptoms of ailment were diagnosed one year back, the ailment is pre-existing in nature.  It is further averred in the complaint that neither the complainant was aware about the heart ailment prior to the inception of policy nor she took any treatment for the same. In fact the problem was for the first time diagnosed at Dr. PSP Memorial Hospital, Amritsar on 28.2.2021,  as such, repudiation of the claims is said to be totally illegal and without any basis. 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 the total claims amount of Rs.4,59,479/- alongwith with interest and further claimed compensation and litigation expenses.

3.             In reply filed by OPs, preliminary objections are taken up on the grounds that the complaint is false, malicious, incorrect and malafide and is an abuse of process of law, that the complainant has not come to this Commission with clean hands, that the complainant has no cause of action to file the present complaint, that the complainant was admitted in hospital for diagnosis of rheumatic heart disease and treated for the same, as such the claim has rightly been repudiated.  On merits, it is admitted that the complainant obtained the insurance policy in question for a sum of Rs.10,00,000/- for himself and his son. It is submitted that the policy was issued to the complainant as per his declaration in proposal form only and its duty of proposer to share correct facts in proposal form at the time of issuance of policy.  It is admitted that the complainant submitted three claims for Rs.92007/-, Rs.92,691/- and Rs.2,74,781/-. It is further averred that after reviewing the submitted documents by the complainant, it was found that the symptoms of the ailment were diagnosed one year back, as such it was stated that it was a pre-existing disease and the claim has rightly been repudiated under section 5A iii of policy terms and conditions (any pre-existing disease/illness/injury will not be covered until 36 months of continuous coverage have elapsed since inception of the policy with us). It is stated that the complainant concealed his earlier disease, as such the claim is said to has rightly been repudiated. The other allegations levelled in the complaint have been denied and prayed for dismissal of the complaint with costs.

4.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-41 copies of documents and affidavit and closed evidence. On the other hand, the learned counsel for the OPs has produced Ex.OPs/1 to Ex.OPs/4 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 son were insured with the OPs under the medical insurance policy in question, copy of which on record is Ex.C-2.  The learned counsel for the complainant has argued vehemently that during the subsistence of the insurance policy the complainant for the very first time experienced the problem of acute shortness of breathing on 28.02.2021 while she alongwith her husband were on a family visit to Amritsar, as such she was taken to Dr. PSP Memorial Janta Hospital, Amritsar, where upon clinical examination and other tests and echo were performed and was diagnosed that she was having lungs congestion due to malfunctioning of left ventricle of heart called severe mitral valve stenosis and the complainant remained admitted in the hospital for the period from 28.02.2021 to 11.03.2021, where she spent an amount of Rs.92,007/- as is evident from the copy of claim form with bills Ex.C-3 on record.  Further case of complainant is that thereafter she was admitted at Grecian Super Speciality Hospital Mohali  for the said problem on 24.03.2021 for surgery and replacement of her mitral valve stenosis and to repair the other one-tricuspid valve and accordingly pre-authorisation request was sent to the OPs by hospital authorities through TPA which was disallowed. It is further argued that during investigation her thyroid level was found to be on the higher side, so her surgery was deferred for the time being and the complainant was discharged from the hospital on 30.3.2021 and an amount of Rs.92,691/- was incurred on her treatment during stay in the hospital, as is evident from the copy of claim form alongwith bills Ex.C-4.   Thereafter the complainant lodged both the claims i.e. Rs.92007/- and of Rs.92691/- of PSP Memorial Janta Hospital, Amritsar and Grecian Super Speciality Hospital Mohali, respectively, with the OPs as is evident from the copy of claim form Ex.C-3 and Ex.C-4.  Further the learned counsel for complainant has argued that due to severe second wave of corona pandemic, surgery of the complainant was postponed and ultimately it was decided to get the complainant operated at PGI Chandigarh.  Since cashless treatment was not available at PGI, so the OPs were informed vide e-mail dated 12.09.2021 about the admission of complainant at PGI for the treatment.  The complainant was admitted in PGI Hospital Chandigarh on 10.09.2021 and surgery was performed upon her on 16.09.2021 and she was discharged on 25.09.2021, where an amount of Rs.2,74,781/- including charges for surgery, medicines, tests etc. were incurred and the complainant lodged the claim with the OPs vide claim form Ex.C-40.        Further  the learned counsel for complainant has argued that while processing these claims, OPs asked for a certificate from the treating doctor of PSP Memorial Janta Hospital, Amritsar about duration of the ailment in the format alongwith past consultation papers and treatment record, which was duly provided and intimated that the complainant experienced the symptoms of acute shortness of breathing for the first time on 28.02.2021 and was admitted at PSP Memorial Hospital, Amritsar.  It is further contended that the OPs got conducted investigation at their own level as the representative sent by them visited the residence of complainant and collected copies of all the treatment record and certificates.  The complainant though sent all the documents to the OPs sought for by them, but despite all this the OPs vide their email dated 15.12.2021 illegally repudiated the genuine claim of the complainant pertaining to treatment taken at Dr. PSP Memorial Hospital, Amritsar for the reason that ‘hospitalisation was done before policy inception’. The remaining two claims were also repudiated by the OPs for the reason that as the date of inception of policy is 05.01.2021 and the symptoms of ailment were diagnosed one year back, the ailment is pre-existing in nature.  It is further contended that neither the complainant was aware about the heart ailment prior to the inception of policy nor she took any treatment for the same. In fact the problem was for the first time diagnosed at Dr. PSP Memorial Hospital, Amritsar on 28.2.2021,  as such, repudiation of the claims is said to be totally illegal and without any basis.

7.             On the other hand, the learned counsel for the OPs has contended vehemently that the complainant had obtained the insurance policy in question for a sum of Rs.10,00,000/- for himself and his son. It is further contended that the policy was issued to the complainant as per his declaration in proposal form only and it is the duty of proposer to share correct facts in proposal form at the time of issuance of policy.  It is admitted that the complainant submitted three claims for Rs.92007/-, Rs.92,691/- and Rs.2,74,781/-. It is further contended that after reviewing the submitted documents by the complainant, it was found that the symptoms of the ailment were diagnosed one year back, as such it was stated that it was a pre-existing disease and the claim has rightly been repudiated under section 5A iii of policy terms and conditions (any pre-existing disease/illness/injury will not be covered until 36 months of continuous coverage have elapsed since inception of the policy with us). It is contended further that the complainant concealed his earlier disease, as such all the claims are said to have rightly been repudiated.

8.             It is an admitted fact that the complainant obtained the insurance policy in question from the Ops, a copy of which on record is Ex.C-2 and during the subsistence of the insurance policy the complainant suffered illness and as such was admitted

in Dr. PSP Memorial Janta Hospital, Amritsar, where upon clinical examination and other tests such as echo were performed and was diagnosed that she was having lungs congestion due to malfunctioning of left ventricle of heart called severe mitral valve stenosis and the complainant remained admitted in the hospital for the period from 28.02.2021 to 11.03.2021, thereafter she was admitted at Grecian Super Speciality Hospital Mohali  for the said problem on 24.03.2021 for surgery and replacement of her mitral valve stenosis and to repair the other one-tricuspid valve and accordingly pre-authorisation request was sent to the OPs by hospital authorities through TPA which was not allowed. Further case of complainant is that due to severe second wave of corona pandemic, surgery of the complainant was postponed and ultimately it was decided to get the complainant operated at PGI Chandigarh.  Since cashless treatment was not available at PGI, so the OPs were informed vide e-mail dated 12.09.2021 about the admission of complainant at PGI for the treatment.  The complainant was admitted in PGI Hospital Chandigarh on 10.09.2021 and surgery was performed upon her on 16.09.2021 and she was discharged on 25.09.2021, where an amount of Rs.2,74,781/- including charges for surgery, medicines, tests etc. were incurred and the complainant lodged all the claims with the OPs. But grievance of complainant is that all the claims were wrongly repudiated by the OPs vide letter dated 04.11.2022.  

9.             On the other hand, the stand of the OPs is that the claim has rightly been repudiated as the complainant was suffering from lungs congestion due to malfunctioning of left ventricles of heart called several mitral valve stenosis  problem which disease was not disclosed by him during the process of purchasing the insurance policy.  Now, the only question for determination before this Commission is whether the OPs have rightly been repudiated the claims of the complainant on the ground of complainant suffering from lungs congestion due to malfunctioning of left ventricles of heart called several mitral valve stenosis  problem not. Our answer to this question is that the claim is payable because the OPs have produced nothing on record to show that the complainant was suffering from the above said problem before the inception of the insurance policy.  The OPs have produced only copy of proposal form Ex.OPs/1, copy of policy schedule Ex.OPs/2, Copy of claim discharge summary Ex.OPs/3 and affidavit Ex.OPs/4. Though the stand of the OPs is that the claims have been repudiated on the ground that the complainant was suffering from pre existing disease such as lungs congestion due to malfunctioning of left ventricles of heart called several mitral valve stenosis  problem. But we may mention that the OPs have not produced iota of evidence to show that the complainant was suffering the above said problem before the inception of the insurance policy in question. As such, we are of the considered opinion that the claims of the complainant have been wrongly repudiated by the OPs.

10.           Now, coming to the quantum of compensation payable to the complainant. Admittedly, the insurance policy is for the sum insured of Rs.10,00,000/-.  The complainant has  claimed an amount of Rs.4,59,479/-. After perusal of the bills we find that as per claim form Ex.C-3 an amount of Rs.73,000/- was paid by the complainant to the hospital authorities and as per claim form Ex.C-4 relating to the claim of Grecian Super Speciality Hospital, an amount of Rs.90,842/- is payable. Further regarding the third claim i.e. of PGI Chandigarh, an amount of Rs.2,74,781/- is payable as is evident from the copies of various bills of medicine etc. appended with the claim form Ex.C-4. Now, we find that total amount of Rs.4,38,623/- for all the three claims (Rs.73000/- plus Rs.90842/- plus Rs.274781/-) is payable to the complainant. As  such, we find that the OPs are liable to pay to the complainant an amount of Rs.4,38,623/- which was 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 to pay to the complainant the claim amount of Rs.4,38,623/- alongwith interest @ 7% per annum from the date of filing of the present complaint i.e. 01.11.2022 till realisation. Further OPs 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.

 

                August 21, 2024.

 

 

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

                  Member                       Member                  President