Haryana

Karnal

CC/250/2019

Rohan Mehendiratta - Complainant(s)

Versus

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

16 Mar 2020

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

 

                                                          Complaint No. 250 of 2019

                                                          Date of instt.06.05.2019

                                                          Date of Decision 16.03.2020.

 

Rohan Mehendiratta son of Vipin Kumar, resident of House no.2-A, Shanti Nagar, Panipat, through her mother Savita Mehendiratta.

 

                                                 …….Complainant.

                                              Versus

 

1. H.D.F.C. Ergo General Insurance Company Ltd. Stellar I.T. Park Tower-1, 5^th floor, C-25, Sector-62, Noida-201301, U.P. through its M.D./ General Manager.

2. HDFC Ergo General Insurance Company Ltd. Regd. & Corporate office HDFC House, 1^st floor, 165-166, Backbay Reclamation H.T. Parekh Marg, Church Gate, Mumbai- 400 020 through its M.D./General Manager.

3. HDFC Ergo Insurance Company through its branch Manager address is SCO 778,779, 1^st floor, Narayan Plaza, Kunjpura Road, Dayal Singh Colony, Karnal Haryana 132001.

                                                                         …..Opposite Parties.

 

           Complaint u/s 12 of the Consumer Protection Act. 

 

Before    Sh. Jaswant Singh……President. 

                Sh. Vineet Kaushik……Member   

                Dr. Rekha Chaudhary…….Member

 

 Present:  Ms.Sarita Advocate for complainant.

                   Shri Sanjeev Vohra Advocate for opposite parties.

                 

                   (Jaswant Singh President)

ORDER:                    

 

                        This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act 1986 on the averments that complainant purchased a Family Floater Policy/Health Suraksha Policy Silver Plan bearing no.2952201377133700000/1 from the OP on 20.04.2016 for two years having its branch office in Karnal i.e. 19.04.2018 for the sum assured of Rs.3,00,000/- and the premium of Rs.19,665/- for the same. The said policy was cashless policy. The said policy was for Vipin Kumar father of complainant, Savita mother of the complainant, the complainant himself and Chahat Mehendiratta sister of the complainant. The complainant has extended the policy by giving amount Rs.14,870/- . The complainant fell ill and was admitted in Dr. Ravindra Hospital, Model Town, Panipat and the complainant diagnosed suffering from Idiopethic Pancreatitis. The complainant remained under treatment and admitted in the said hospital from 14.03.2018 to 21.03.2018. The said hospital sent the intimation to the OP regarding the illness of complainant qua the said policy but OP sent the letter dated 20.03.2018 ‘Denial of cashless claim facility’ alleging that as per Section 9-A.ii.a, of policy, a waiting period of two years is applicable for the said ailment, hence the clam is repudiated. Complainant spent Rs.71,548/-on his treatment. OPs repudiated the claim of the complainant on the false and baseless ground. Complainant requested the OPs so many times to reimbursement the claim amount but OPs did not do so. In this way there was deficiency in service on the part of the OPs. Hence complainant filed the present complaint.

2.             Notice of the complaint was given to the OPs, who appeared and filed written version stating therein that complaint is liable to be dismissed being premature. The cashless claim of the complainant was denied by the OP. After the denial of cashless facility the complainant never approached the OP for reimbursement of claim. During denial of cashless facility it was denial of cashless does not imply denial of treatment and does not in any way prevent the insured from seeking necessary medical attention or hospitalization/claiming for reimbursement but complainant never lodged any claim for reimbursement of the amount after discharge from the hospital. Therefore, the present complaint is premature. It is further stated that the insured suffered from illness of ‘idiopathic Pancreatitis’ and further was managed medically, as per terms and conditions of the policy, the treatment related to illness of Pancreatitis is covered only after 2 years. As per section 9 A ii a, 2 years waiting period is applicable to the illness related to Pancreatitis. It is further pleaded that complaint pertains to hospitalization claim of insured who is also one of the insured under the policy, pertaining to Health Suraksha Policy having policy vide no.2952201377133700000, for the period from 20.04.2016 to 19.04.2018. The policy was first incepted on 20.04.2016 and the illness started on 14.03.2018, which the policy was in 2 year. Therefore, the claim falls under 9 A ii a, clause. Further, accordingly, the cashless claim was denied and a letter dated 20.03.2018 was sent to the hospital. Therefore, the present complaint is not maintainable and is liable to the dismissed. There is no deficiency in service on the part of the OPs. The other allegations made in the complaint have  been denied and prayed for dismissal of the complaint.

3.             Complainant tendered into evidence his affidavit Ex.CW1/A and documents Ex.C1 to Ex.C28 and closed the evidence on 19.09.2019.

4.             On the other hand, OP tendered into evidence affidavit of Shweta Pokhriyal Ex.RW1/A and documents Ex.R1 and Ex.R2 and closed the evidence on 03.03.2020.

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

6.             The case of the complainant, in brief, is that he purchased a Family Floater Policy/Health Suraksha Policy Silver Plan bearing no.2952201377133700000/1 from the OP on 20.04.2016 for two years for the sum assured of Rs.3,00,000/-.  The said policy was cashless policy. The complainant fell ill and was admitted in Dr. Ravindra Hospital, Model Town, Panipat and the complainant diagnosed suffering from Idiopethic Pancreatitis. The complainant remained under treatment and admitted in the said hospital from 14.03.2018 to 21.03.2018. The said hospital sent the intimation to the OP regarding the illness of complainant qua the said policy but OP sent the letter dated 20.03.2018 ‘Denial of cashless claim facility’ alleging that as per Section 9-A.ii.a, of policy, a waiting period of two years is applicable for the said ailment, hence the clam is repudiated. Complainant spent Rs.71,548/-on his treatment. OPs repudiated the claim of the complainant on the false and baseless ground.

7.             On the other hand, the case of the OPs, in brief, is that the cashless claim of the complainant was denied by the OP. After the denial of cashless facility the complainant never approached the OP for reimbursement of claim. Complainant never lodged any claim for reimbursement of the amount after discharge from the hospital. Therefore, the present complaint is premature.

8.             During the pendency of the complaint the complainant has supplied the documents on 19.09.2019 at the time of evidence as required by the OPs and OPs had sought 30 days time for settlement of the claim.  Now near about six months has been expired but OPs failed to settle the claim of the complainant. Thus, the act of OPs amounts to deficiency in service and unfair trade practice.

9.             The complainant incurred Rs.71,548/- for his treatment which is proved from the bills Ex.C2 to Ex.C13. Thus, the complainant is entitled for the same alongwith compensation for harassment and litigation expenses.

10.            Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.71,548/- to the complainant with interest @ 9% per annum from the date of filing the complaint till its realization. We further direct the OPs to pay Rs.20,000/- to the complainant on account of mental agony and harassment suffered by him and for the litigation expense  This order shall be complied within 30 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated: 16.03.2020

                                                                   President,

                                                           District Consumer Disputes

                                                           Redressal Forum, Karnal.

 

 

             (Vineet Kaushik)         (Dr. Rekha Chaudhary) 

                     Member                          Member