Haryana

Karnal

CC/298/2018

Seema - Complainant(s)

Versus

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

Manish Kumar Saluja

18 Dec 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

 

                                                          Complaint No. 298 of 2018

                                                          Date of instt. 02.11.2018

                                                          Date of Decision 18.12.2019

 

Seema aged about 43 years wife of Shri Vikram, resident of House no.91, Ward no.2, Indri, District Karnal.

                                                …….Complainant

                                        Versus

 

1. HDFC ERGO General Insurance Company Ltd. # SCO no.237, 2^nd floor, Sector-12, opp. Mini Secretariat, Karnal, through its Branch Manager/Authorized Signatory.

2. HDFC ERGO General Insurance Company Ltd. # HDFC House, First floor, 165-166, Black Bay-Reclamation H.T. Parekh Marg, Church Gate, Mumbai, through its MD/CEO/Authorized signatory.

                                                                       

…..Opposite Parties.

 

           Complaint u/s 12 of the Consumer Protection Act. 

 

Before    Sh. Jaswant Singh……President. 

                Dr. Rekha Chaudhary…….Member

 

 Present:  Shri Manish Kumar 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 had purchased a Health Suraksha policy (Silver Plan) from the OPs bearing  policy no.2825100183670800000, valid from 16.03.2017 to 15.03.2018. The sum assured was Rs.5,00,000/. As per the terms and conditions of the said policy, all the family members of the complainant including herself, her husband Vikram and son Akash were covered under the said insurance policy. On 09.02.2018 husband of complainant had suffered acute pain in his stomach and then the complainant alongwith her husband immediately rushed towards Dr. Ajay Gupta’s Sarvodaya Multispecialty Hospital, Meerut Road, Karnal where Doctor admitted the husband of complainant and started the treatment. During treatment, when the conditions were not under control of concerned doctor then on 12.02.2018 the husband of complainant was referred by the concerned doctor to another superior hospital/higher centre for further treatment. Thereafter, the complainant got admitted her husband at Sir Ganga Ram Hospital, New Delhi on 12.02.2018 where the concerned doctor treated the husband of complainant upto 22.02.2018 and thereafter discharged him. During the treatment of her husband, son of the complainant namely Chand Uppal had submitted claim forms Part-A and Part-B, KYC Application form, Pre-Authorization Request forms before both the above mentioned hospital authorities, as per prescribed formats of the company of the OPs. The policy was cashless, so the amounts of bills of both the above mentioned hospital during indoor treatment of husband of complainant was required to be paid by the OPs but OPs have not paid said amount to both the hospitals, resultantly the complainant under compelling circumstances has paid entire bill amount including medicines, test, hospitalization charges etc. to both the hospitals from her own pocket. The complainant spent total Rs.3,66,700/- on the treatment of her husband in both the hospitals. Thereafter, complainant lodged the claim with the OPs for reimbursement of the abovesaid amount and submitted all the required documents with the OPs but OPs did not pay the claim and lingered the matter on one pretext or the other and lastly repudiated the same, vide letter dated 27.07.2018 on the ground that the complainant has not supplied the past medical history of her husband, whereas the complainant number of times has already informed to the representative of company of OP no.1 that there is no previous past history of husband of the complainant regarding any disease and other relevant treatment record has already been obtained by the company of the OPs from the concerned hospital directly, but even than the OPs have repudiated the claim of the complainant without any cogent and reliable reason. Then complainant sent a legal notice to the OPs in this regard through his counsel but it also did not yield any result. 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 there were two claims lodged  by the insured under Health Suraksha Policy having policy no.2825100183670800000 subject to its terms and conditions and both the claim are separately processed. The policy was first incepted on 16.03.2017. The details of both the claims are as under:

Claim no.RR-HS17-10521922: That the claim was lodged against alleged hospitalization of insured Vikram at Sarvodya Multispecialty Hospital for the period from 10.02.2018 to 12.02.2018. On admission, the insured was diagnosed with Perforation Peritonitis and underwent conservative treatment for the same.

It is further stated that as per the documents submitted by the complainant, it was revealed that the patient was diagnosed with Perforation Peritonotis (Peptic ulcer) and was treated for same. It is further stated that the Referal Slip of Sarvodaya Hospital that the patient had history of NSAID (non-steroidal anti inflammatory drugs). The OP was also enlightened with the fact from the perusal of treatment note and P.A.C. Form of the Sarvodaya Hospital that the patient had history of Alcoholic abuse. It is further stated that the ailment (Peptic Ulcer) as suffered by the patient under the hospitalization was due to the use and abuse of the NSAID (Non-steroidal anti inflammatory drugs), as the main cause of Peptic Ulcer is due to the use of ingestion of Non-steroidal anti inflammatory drugs. It is further stated that going to the abovementioned facts, the claim of the complainant was rightly repudiated under the preview of section 9 A.ii.a, whereby, 2 years waiting period is applicable for all the ailment related to Ulcer. As per the policy term and condition the illness related to Ulcer is not covered for the first two years of the policy. In the present case as the first policy inception date was 16.03.2017, and the date of admission was 10.02.2018, which clearly demonstrate that the policy was in first year, thus the same falls under the waiting period of 2 years under section 9(A)(ii)(a).  Further, the claim was repudiated on the ground of abuse of intoxicants or hallucinogenic substances, as it was evident from the medical documents that the patient had history of NSAID (Non-steroidal anti inflammatory drugs). Thus, the claim was also repudiated under section 9 c iv of the policy.

Claim no.RR-HS17-10521925: That this claim was lodged against alleged hospitalization of insured (Vikram) at Sir Ganga Hospital for the period from 12.02.2018 to 22.02.2018. The insured was admitted and was diagnosed with Duodenal Perforation Peritonitis.

It is further stated that after scrutinizing the claim form and papers submitted, the OPs found that the documents submitted were insufficient to settle the claim amount and thus specific query was raised against the complainant so that the claim may be decided on merits. Therefore, letter dated 06.04.2018, 28.05.2018, 27.06.2018 and 12.07.2018 were issued to the complainant and request was made to submit the documents but she failed to produce the same till date and thus the claim was closed. Even after repeated reminders letter sent by OPs to the complainant regarding the submission of the documents, the complainant has failed to furnish require documents. Therefore, ultimately with no option to left, OPs had to close the claim on the ground of non-submission of documents vide letter dated 12.07.2018 which was duly supplied to the complainant. 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, affidavit of Vikram Ex.CW2/A and documents Ex.C1 to Ex.C38 and closed the evidence on 23.04.2019.

4.             On the other hand, OPs tendered into evidence affidavit of Shweta Pokhriyal Ex.RW1/A and documents Ex.R1 to Ex.R12 and closed the evidence on 10.10.2019.

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 she purchased Health Suraksha Policy (Silver Plan) from the OPs for the period from 16.03.2017 to 15.03.2018, covering herself, her husband and her son Akash and the sum insured of Rs.5,00,000/-. On 9.02.2018 husband of complainant suddenly suffered acute pain in his stomach and he immediately taken to the hospital of Ajay Gupta’s Sarvodya Multispecialty where he treated but on 12.12.2018 the husband of complainant was shifted to another Superior Hospital for treatment. The husband of complainant got admitted in Sir Ganga Ram Hospital New Delhi on 12.02.2018 and discharged on 22.02.2018. Complainant spent Rs.3,66,700/- on the treatment of her husband in both the abovementioned hospital. The complainant lodged the claim with the OPs for reimbursement of the amount spent by her on the treatment of her husband alongwith all the relevant documents but OPs repudiated the claim of the complainant on the false ground.

7.             On the other hand, the case of the OPs, in brief, is that the complainant submitted for reimbursement of medical expenses of Rs.3,66,700/- only. The claim of the insured has been repudiated by the OP on the ground that as per the submitted documents, the patient was admitted on 10.02.2018 with the diagnosis of Perforation Peritonitis (a complication of Peptic Ulcer Perforation) and was treated for same. As per section 9(A)(ii)(a), a waiting period of 2 years is applicable for the said ailment (Peptic Ulcer). As the date of inception of policy is 16.03.2017, the policy is in first year. Hence this claim is being repudiated. Moreover, this claim is also being repudiated under section 9(A)(ii)(a) of policy which excludes any treatment from the coverage which arises due to abuse or the consequences of the abuse of intoxicants or hallucinogenic substances such as drugs and alcohol, including smoking cessation programs and the treatment of nicotine addiction or any other substance abuse treatment or services, or supplies. While expressing our inability to pay this claim due to the abovementioned rationale, we reiterate our obligation to pay all admissible claims fairly and promptly. Hence, claim is rightly repudiated.

8.             Admittedly, the complainant purchased a Health Suraksha Policy from the OPs and the husband of the complainant namely Vikram was insured under the policy, with the sum assured of Rs.5,00,000/-. It is also admitted that insured Vikram had lodged two claims, first for admission at Sarvodaya Multispecialty Hospital Karnal  from 10.02.2018 to 12.02.2018 and spent Rs.30,000/-, it has been proved from bills Ex.C4 to Ex.C8 and Ex.C10 to Ex.C14. The claim of the insured has been repudiated by the OPs, vide letter Ex.R1 dated 07.07.2018, on the grounds that the insured has Diagnosis of Perforation Peritonitis (Peptic Ulcer) and as per section 9(A)(ii)(a), a waiting period of 2 years is applicable for the said ailment.

9.             The OPs have relied upon the referral slip Ex.R2, issued by Dr. Ajay Gupta, Sarvodaya Multispecialty Hospital Karnal. As per the said slip, Diagnosis Perforation Peritonitis has been questioned marked by the concerned doctors, meaning, thereby Doctor was not confirmed with regard the disease, when the disease has not been confirmed then terms and conditions mentioned at page no.3 of Insurance Policy Ex.R12 does not apply.

10.            As per instructions issued by Insurance Regulatory & Development Authority of India (IRDA), it was duty of the OP to put the husband of the complainant thorough medical examination. In the case of National Insurance Company Ltd. Versus Harbirinder Singh appeal no.220 of 2016 decided on 30.09.2016. State Commission U.T. Chandigarh has nothing abovesaid fact and failure on the part of the insurance company to get thorough medical examination of the insured before issuance of mediclaim insurance policy, dismissed appeal filed by the insurance company by observing as under:-

        “To deny claim raised by the complainant, reliance has been placed upon self declaration form R-2 (page 74 of the original paper book). The said declaration form has been signed by Saranbir Kaur on 5.2.2013. There is nothing on record to show that policy was issued to the complainant and his wife on the said date, by believing above document. The policy infact was issued on 13.02.2013. The appellants have failed to co-relate the said declaration form with the policy (C2) referred above. A note is appended on the said declaration form that it needs to be filled up if the age of the member is above 45 years. The complainant and his wife both are older than the said age. There is nothing on record to show that before insurance policy was issued to them, the appellants got them medically examined, which as per instructions issued by Insurance Regularly & Development Authority of India (IRDA) is must in such like cases. 

11.            Similar view was taken by Hon’ble Chandigarh State Commission in case of M/s Max Bupa Health Insurance Co.Ltd. Vs. Rakesh Walia, appeal no.191 of 2016 decided on 18.08.2016  wherein it was also stated that if contrary to the instructions issued by IRDA, an insured above the age of 45 years, was not put to through medical examination, claim raised after issuance of insurance of policy cannot be rejected on account of non-disclosure of the fact of pre-existing disease when policy was obtained.

12.            As per policy Ex.C2, the date of birth of the insured is 25.09.1971 and date of inception of policy i.e.16.03.2017. Thus, at the time of purchasing the policy age of the insured was more than 45 years.

13.            Learned counsel for the OP further argued that main cause of Peptic Ulcer is due to use of Non-steroidal anti inflammatory drugs (NSAID) and alcohol. As per referral slip Ex.R3, issued by Dr. Ajay Gupta Sarvodaya Multispecialty Hospital, Karnal, patient having H/O Alcoholic Abuse and thus insured has violated the terms and conditions of the policy Ex.R12.

14.            Pre-contra, learned counsel for the complainant argued that no quantity of Alcohol has been mentioned by the Doctor. Moreover, insured has not H/O Alcohol. No report of blood and urine of the insured to ascertain the H/O Alcoholic has been placed on record by the OPs. Doctor who has mentioned the history of the patient, neither examined nor tendered his affidavit by the OPs.

15.            The second claim of the insured has been declared by the OPs as ‘No Claim’ due to non-submission of documents.

16.            OP has wrote a letter Ex.R5 dated 06.04.2018 Ex.R6 dated 28.05.2018 Ex.R6 dated 27.06.2018, Ex.R7 dated 12.07.2018 and Ex.R8 dated 02.07.2018 to the complainant. In all letters, OP demanded the past treatment record when the insured has no past history of treatment then from where he could submitted the past treatment. When it was in the knowledge of the OP about the name of the hospital for past treatment, then OP could have obtained the demanded record from the said hospital. In view of the above facts and circumstances of the case, we are of the considered view that the act of the OPs amounts to deficiency in service and unfair trade practice. Hence complainant is entitled for amount which was spent on the treatment of her husband. The abovementioned authorities are fully applicable to the present case.

17.            The complainant has spent Rs.30,000/- on the treatment of her husband in Sarvodaya Multispecialty Hospital, Karnal and Rs.3,36,700/- in Sir Ganga Ram Hospital, New Delhi. Hence she is entitled for the said amount.

18.            Thus, as a sequel to above discussion, we allow the present complaint and direct the OPs to pay Rs.3,66,700/- to the complainant with interest @ 9% per annum from the date of repudiation/closed of the claims234 till its realization. We further direct the OPs to pay Rs.25,000/- to the complainant on account of mental agony and harassment suffered by her and Rs.11,000/- towards 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:18.12.2019                                                                       

                                                                         President,

                                                                District Consumer Disputes

                                                                Redressal Forum, Karnal.

 

 

                        (Dr. Rekha Chaudhary)

                              Member