Chandigarh

DF-I

CC/339/2023

AMANDEEP SHARMA - Complainant(s)

Versus

HDFC ERGO GENERAL INSURANCE COMPANY LTD. - Opp.Party(s)

VARUN BHARDWAJ

02 Jan 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/339/2023
Date of Institution	:	20/7/2023
Date of Decision	:	2/1 /2024

 

Amandeep Sharma son of Sh. Suresh Kumar Sharma, SCO 178, First floor, Sector 38-C,  Chandigarh.

… Complainant(s)

V E R S U S

1.     HDFC ERGO General Insurance Company Ltd. through its Regional Manager SCO No.124-125, Madhya Marg, Sector 8, Chandigarh.

2.     The Regional Manager, HDFC ERGO General Insurance Company Ltd. SCO No.124-125, Madhya Marg, Sector 8, Chandigarh.  

… Opposite Parties

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER

                                                                               

ARGUED BY	:	Sh. Varun Bhardwaj, Advocate for complainant
	:	Sh. Nitesh Singhi, Advocate for OPs

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by the complainant under Section 35 of the Consumer Protection Act 2019 against the opposite parties  (hereinafter referred to as the OPs). The brief facts of the case are as under :-

1. It transpires from the averments as projected in the consumer complaint that the complainant had purchased one Optima Secure Policy Exhibit C-1  from the OPs valid w.e.f. 7.4.2022 to 6.4.2023. On 18.11.2022, the complainant was admitted in Global Hospital Zirakpur due to complaint of High Grade fever, cough, generalized weakness, burning micturition, Nausea, vomiting and loose Motions and treated for the same. The complainant was discharged on 22.11.2022. Copy of discharge summary is annexed as Exhibit C-2. The aforesaid hospital raised bill of Rs.1,50,187/- and the copies of bills and claim form are annexed as Exhibit C-3(colly) and Exhibit C-4. However, vide repudiation letter Exhibit C-5 dated 29.3.2023,  the OPs have repudiated the claim of the complainant on the ground that the complainant has not submitted the requisite document asked by the OPs i.e. treating doctor’s certificate, medicine purchase invoice, and certificate from pathologist. The documents asked by the Ops had already been submitted by the complainant alongwith reply to the queries. Copy of query and reply is annexed as  Exhibit C-6(colly).  It is alleged that the  claim of the complainant has been wrongly denied by the OPs. The aforesaid act amounts to deficiency in service and unfair trade practice on the part of 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 written version, inter alia, taking preliminary objections of maintainability, cause of action, locus standi , concealment of fact and jurisdiction and also on the ground that the complainant has not approached this Commission with clean hands. It is further alleged that all the pathology reports do not seem to be genuine  as no pathologist has authenticated the reports. On merits, the facts as stated in the preliminary objections have been re-iterated. It is further alleged that the claim of the complainant was closed for want of requisite documents as asked by the OPs The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. Complainant chose not file rejoinder.

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.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant had obtained the subject policy from OPs which was valid w.e.f. 7.4.2022 to 6.4.2023 with sum insured of Rs.5,00,000/- as is evident from  Exhibit C-1 copy of policy and during the currency of the subject policy the complainant was admitted at Global Hospital, Zirakpur and was discharged on 22.11.2022 and the claim of the complainant was repudiated by the OPs vide Exhibit C-5 on the ground of non submission of requisite documents by the complainant with the OPs,  the case is reduced to a narrow compass as it is to be determined if  the OPs are unjustified in repudiating the claim  of the complainant and the complainant  is entitled for the relief as prayed for or if the OPs are justified in repudiating the claim of the complainant on the ground of non-submission of requisite documents  for the settlement of the claim  and the complaint being not maintainable is liable to be dismissed as is the defence of the OPs.
   2. In the back drop of the foregoing admitted and disputed facts on record, one thing is clear that  the documentary evidence led by  both parties i.e. copy  of subject policy, medical record and repudiation letter having been relied upon by both the parties, required to be scanned carefully in order to determine the real controversy between the parties.
   3. Perusal of Exhibit C-1 clearly indicates that  Optima Secure Policy Annexure C-1  was issued by the OPs to the  complainant by charging total premium amount of Rs.3379.81 and the subject policy was valid w.e.f. 7.4.2022 to 6.4.2023.  with a sum of  insured to the tune of Rs.5,00,000/-. Exhibit C-2  is the discharge summary which clearly indicates that the complainant was hospitalized with Global Hospital where he remained admitted w.e.f. 18.11.2022 to 22.11.2022 and was diagnosed with septicemia with urethritis with diarrhea with stomach flu and the relevant portion of the discharge summary is as under:-

 

 

 

 

 

 

 

 

 

4. Exhibit C-3  is the final bill clearly indicates that  bill of Rs.1,50,187/- was raised by the  treating hospital and the same was paid by the complainant  which is also evident from the receipt annexed with the final bill.  Exhibit C-4 is the claim form submitted by the complainant with the OPs.  Exhibit C-5 is the claim closer letter issued by Ops on 29.3.2023 to the complainant and the relevant portion of the same is reproduced as under:-

 

 

 

5. Exhibit C-6(colly) is the query reply sent by hospital during hospitalization, which clearly indicates that the detailed reply to the three queries put by OPs were admittedly replied by the treating hospital and relevant portion of the same is as under:-

 

 

 

 

 

Alongwith the reply the certificate issued by the treating doctor is also proved by the complainant and the relevant portion of the same is as under:-

 

Alongwith Annexure C-6  details of medicines purchased and the laboratory tests conducted by the pathologist are annexed and in addition to that
doctor Aditya Negi has also issued laboratory  declaration   which is available at page 34 of the paperbook of the complaint certifying that  he was   pathologist at the relevant time when the laboratory test of the complainant was conducted.

6. The sole ground on which the OPs resisted the complaint of the complainant is that as the complainant has failed to submit requisite documents for the settlement of the claim, the claim of the complainant was closed by the OPs, is concerned there is no evidence on record from the OPs side to prove this fact  that the complainant had failed to submit relevant documents.
7. Moreover,  when vide query  reply Annexure C-6  submitted by the treating hospital to the queries of the OPs were categorically answered in details and also annexed the documents as asked by the OPs including medical bills qua the medicines as well as the amount spent on the investigation i.e. laboratory tests and further that the doctor Aditya Negi has issued laboratory declaration  indicating that he was pathologist at the relevant time, it is clear on record that the claim of the complainant was closed on flimsy grounds by the OPs without applying their mind for the settlement of the genuine claim of the complainant despite of the fact that all the documents i.e.  medical record including discharge summary were submitted by the complainant to the OPs and the aforesaid act of OPs amounts to deficiency in service and unfair trade practice on their part.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OPs are directed as under :-

1. to pay ₹1,50,187/- to the complainant alongwith interest @ 9% per annum from the date closur of the claim i.e. 29.3.2023 till onwards.
2. to pay an amount of ₹10,000/- to the complainantas compensation for causing mental agony and harassment to him;
3. to pay ₹10,000/- to the complainant as costs of litigation.

 

5. This order be complied with by the OPs within 45 days from the date of receipt of its certified copy, failing which, they shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
6. Pending miscellaneous application(s), if any, also stands disposed off.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

Announced 2/1/2024 mp			Sd/- [Pawanjit Singh] President
			Sd/-
			[Surjeet Kaur] Member