Punjab

Moga

CC/17/3

Jagmohan Singh Randhawa - Complainant(s)

Versus

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

In person

26 Apr 2017

ORDER

THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MOGA.

 

 

                                                                                                CC No. 3 of 2017

                                                                                                Instituted on: 09.01.2017

                                                                                                Decided on: 26.04.2017

 

Jagmohan Singh Randhawa s/o Harbans Singh, R/o 374, Suraj Nagari, Ferozepur City, Punjab. Mob no.94176-04755

……… Complainant

 

Versus

1.       HDFC ERGO General Insurance Company Ltd. 5^th Floor, Tower 1, Steller IT Park, C-25, Sector 62, Noida- 201301.

 

2.       Moga Medicity Multispecialty Hospital, Dutt Road, Mandir Wali Gali, Moga-142001.  

 

                                                                           ……….. Opposite Parties

 

 

Complaint U/s 12 of the Consumer Protection Act, 1986.

 

 

Quorum:    Sh. Ajit Aggarwal,  President

                   Smt. Vinod Bala, Member

                   Smt. Bhupinder Kaur, Member

 

Present:       Sh. Jagmohan Singh Randhawa, complainant in person.

                   Sh. Ajay Gulati, Advocate Cl. for opposite party no.1.

                   Sh. Rajneesh Arora, Advocate Cl. for opposite party no.2.

.

 

ORDER :

(Per Ajit Aggarwal,  President)

 

1.                Complainant has filed the instant complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as the "Act") against HDFC ERGO General Insurance Company Ltd. 5^th Floor, Tower 1, Steller IT Park, C-25, Sector 62, Noida and others (hereinafter referred to as the opposite parties) directing them to pay Rs.62,060/- as claim amount to the complainant. Further opposite parties may be directed to pay Rs.3,92,940/- as compensation for causing mental agony, harassment and financial loss and Rs.43,500/- as litigation expenses to the complainant.

2.                Briefly stated the facts of the case are that the complainant took family medical insurance policy from opposite party no.1 vide policy no.51759755 and payment was done via online credit card. Unfortunately, the wife of the complainant got sick and admitted in the hospital of opposite party no.2 and remained admit there for the period 07.12.2014 to 13.12.2014 and intimation regarding the admission of wife of the complainant was given to opposite party no.1. After discharge, the complainant submitted the claim documents with opposite party no.1 for total claim amount of Rs.62,060/- (which includes Rs.33,500/- as hospital expenses, Rs.19,560/- for Medical bills and Rs.9000/- for HCB). The claim was registered vide reference no.RR-HS14-10266893. Thereafter the complainant received a query on 31.12.2014 from opposite party no.1, vide which, they demanded more documents and the complainant visited the hospital for getting such required documents, but the opposite party no.2 told that they have already been got verified all the documents to HDFC and provided him on letterhead regarding the same. The complainant again received another query on 23.01.2015 from opposite party no.1, vide which, they again demanded more documents and information. On it, the complainant approached opposite party no.2, who told that they cannot provide more document as the same has already been got verified by the investigator and the complainant informed the opposite party no.1 about this fact. Thereafter, the complainant applied, through RTI such information and documents, vide acknowledge dated 30.06.2015, but the complainant received reply from the RTI that this is a private sector and RTI is not applicable for private sector. After that the complainant received final reminder dated 28.03.2016 from opposite party no.1 with the remarks that "you are requested to submit these original documents within 15 days from the receipt of this letter, so that they can proceed further and process the claim. In case, we do not receive any reply from you within stipulated period, claim will be deemed as closed, but the opposite party no.1 closed the claim on 31.03.2016 before the stipulated period provided by them. After that he confirmed from HDFC Ergo Customer Care officer that his documents have been received late on 9 April, but his claim has already been closed. The complainant requested the opposite party no.1 to open his claim, as they closed his claim before 15 days, but to no effect. Due to the acts of opposite parties, the complainant has suffered mental tension and harassment. Hence this complaint.

3.                Upon notice, opposite party no.1 appeared through counsel and filed written reply taking certain preliminary objections that the complaint being pre-mature is not maintainable. The complaint being false, self contradictory, frivolous, vague and vexatious is liable to be dismissed with compensatory costs; that the complainant has not come with clean hands. He has not disclosed the entire true facts. The complainant has also suppressed the material facts from this Forum as well as from the answering opposite party; that no deficient services have been rendered to the complainant as alleged in the complaint. The claim of the complainant has been duly entertained and is pending in want of documents/clarification as required by this opposite party; that the complainant got himself alongwith his wife and son insured from answering opposite party under the Health Suraksha Policy having policy no.51759754 for the period from 20.12.2013 to 19.12.2014. The policy alongwith the terms and conditions were duly dispatched to the complainant, which was never disputed by him. After receiving the claim intimation the answering opposite party duly proceed the claim and in pursuance to the same, the answering opposite party sent a letter to the complainant seeking the submission of the relevant documents for the process of claim. The answering opposite parties sent repeated reminders vide letters dated 23.01.2015, 15.01.2015, 21.02.2015, 08.03.2015, 23.03.2015, 08.04.2015, 02.07.2015, 17.07.2015, 23.07.2015, 25.08.2015, 18.09.2015, 03.10.2015, 26.10.2015, 10.11.2015, 25.11.2015, 25.12.2015, 12.01.2016, 29.01.2016, 05.02.2016, 21.02.2016, 10.03.2016 & 28.03.2016 to the complainant seeking the submission of documents. But on the contrary the complainant had not submitted the relevant documents and thus the answering opposite party in the absence of documents is not able to verify and process the claim, as the authenticity of the claim cannot be decided in the absence of the relevant documents asked for. The complainant failed to supply the said documents on account of which, the claim of the complainant could not be settled. The claimant is supposed to supply documents as envisaged under section 7 (f) of the terms and conditions of the policy. The documents asked for were as follows:-

a.         Written clarification from the treating Dr on his/her letter head duly signed and stamped bearing his/her registration number to confirm on treatment alongwith period of hospitalization.

b.         Complete and readable medicines purchase invoices for all the medicines utilized during this hospitalization from the hospital/pharmacy shop bearing their batch number with expiry date alongwith the Name, Address & contact number of the whole-seller/supplier on the Hospital letter head.

c.         Authority letter on the official letter head of the hospital to verify medicine purchase invoices from the distributor.

d.         Provide the necessary documents/agreement that the Pathologist is/was associated with the hospital along with the salary slips with respective bank statement for having paid the salary for the working period.

e.         Certificate from the Pathologist having conducted and examined the lab reports of the patient along with his/her sign and seal bearing his/her registration no. for confirmation.

f.          The contact details and a copy registration certificate of the Pathologist.

g.         The schedule of visit of Pathologist at the hospital alongwith the period of his association with the hospital, so that we can meet him/her and verify the details.

h.         In case, if no pathologist is associated, provide the name & contact details of the Lab technician along with copy of his valid degree for lab technician & registration certificate.

i.          Copy of admission/IPD register of the hospital.

j.          Copy of the bill book entry of the hospital.

k.         Copy of pathology lab register of the hospital.

 

                   Thus, in the want of above mentioned documents, the answering opposite party was forced not to process the claim; that the complainant is estopped to file the present complaint by his own act and conduct. The complainant himself has not been cooperating with the answering opposite party no.1, as the complainant did not furnish the required information, record and documents etc. with the answering opposite party no.1 for the successful processing of the claim in question, inspite of repeated requests made by opposite party no.1 ultimately the alleged claim file has been closed in the absence of original documents; that the complaint is time barred, as the present complaint has been filed after 2 years of alleged hospitalization. The hospitalization of the insured wife was on 7.12.14, who got discharged on 13.12.2014; that this Forum has got no jurisdiction to try and entertain the present complaint. On merits, it is admitted that the complainant intimated and lodged the claim before the answering opposite party and they registered the same with the given claim number. Further submitted that the answering opposite party had sent a bunch of reminders/letters to the complainant seeking the submission of documents. But, on the contrary the complainant has not submitted the relevant documents and thus, the answering opposite party in the want of documents is not able to settle the claim. All other allegations made in the complaint have been denied and a prayer for dismissal of the complaint with costs has been made.

4.                Whereas, opposite party no.2 filed written reply taking certain preliminary objections that the present complaint is not maintainable against opposite party no.2. Moreover, the complainant did not demand any relief against opposite party no.2. There is no negligence or deficiency in service of opposite party no.2. So, it cannot be liable to pay any claim to the complainant; that the complainant has no locus standi to file the present complaint; that the complainant has stopped by his own act and conduct; that the complainant has not come to this Forum with clean hands and concealed the true facts from this Forum. All the allegations levelled by the complainant against the opposite party no.2 are false and frivolous. Whatever, the treatment was given to the patient Asha Rani wife of Jagmohan Singh Randhawa i.e. complainant as per the need of circumstances. Regarding the above said treatment all the bills, discharge summary has already been provided to the complainant. But he made some illegal demands through RTI from opposite party no.2 regarding the private information of doctors, pathologist like their salaries, their bank statements etc. which could not be given at any cost to any person under any law. Moreover, the officers of the opposite party no.1 rushed at the hospital of opposite party no.2 on 14.01.2015 and verified all the bills and other documents regarding the treatment of patient Asha Rani wife of complainant and they were fully satisfied regarding the same. The actual dispute is between the Jagmohan Singh Randhawa complainant and opposite party no.1 insurance company, but the complainant intentionally dragged the opposite party no.2 without any rhyme or reason only to grab the huge money from opposite party no.2. On merits, it is admitted correct upto the extent that Asha Rani Randhawa was got admitted in the hospital of opposite party no.2. All other allegations made in the complaint have been denied and a prayer for dismissal of the complaint has been made.

5.                In order to prove the case, complainant tendered in evidence his duly sworn affidavit Ex. C-1, additional affidavits Ex.C-2 & Ex.C-3 alongwith copies of documents Ex.C-4 to Ex.C-41 and closed the evidence. 

6.                On the other hand, opposite party no.1 tendered in evidence affidavit of Sh. Pankaj Kumar, Legal Manager, HDFC Ergo General Ins. Co. Ex.OP-1/1 alongwith copies of documents Ex.OP-1/2 to Ex.OP-1/14 and closed the evidence. Whereas, ld. opposite party no.2 tendered in evidence affidavit of Sh. Ajmer Singh Kalra, Director, Moga Medicity Multispecialty Hospital Ex.OP-2/1 and closed the evidence.

7.                We have heard ld. counsel for the parties and have very carefully gone through record placed on file.

8.                The case of the complainant is that he purchased a medical insurance policy from opposite party no.1 covering himself, his wife and son. During the period of insurance his wife Smt. Asha Rani Randhawa got some health problem and admitted in the hospital of opposite party no.2. She remained admit in the said hospital for the period 07.12.2014 to 13.12.2014. The complainant gave due intimation regarding it to opposite party no.1. After discharge of his wife, the complainant submitted the claim documents alongwith discharge summary, medical bills, test reports and other required documents with opposite party no.1, as demanded by them. The opposite party no.1 further demanded some documents which were also supplied by the complainant to opposite party no.1. Then opposite party no.1 sent another query and need more information. On it, the complainant approached opposite party no.2, who refused to provide that information on the ground that investigator of opposite party no.1 already verified all the documents from opposite party no.2 and they cannot provide further information to him. He duly informed regarding it to opposite party no.1, but opposite party no.1 wrongly and illegally closed the claim of the complainant and did not pay anything to him.

9.                On the other hand, opposite party no.1 admitted that the complainant alongwith his wife and son insured with opposite party no.1 under Health Suraksha Policy  valid for the period from 20.12.2013 to 19.12.2014 and during the period of insurance his wife admitted in hospital of opposite party no.2 and hospitalized for the period 07.12.2014 to 13.12.2014. He admitted that complainant lodged the claim with them and submitted claim documents to them. He argued that after receipt of claim intimation, opposite parties duly processed the claim and in pursuance to which, the opposite party no.1 sent a letter to complainant seeking the submission of the relevant documents for the process of claim, which are as follows:-

a.         Written clarification from the treating Dr on his/her letter head duly signed and stamped bearing his/her registration number to confirm on treatment alongwith period of hospitalization.

b.         Complete and readable medicines purchase invoices for all the medicines utilized during this hospitalization from the hospital/pharmacy shop bearing their batch number with expiry date alongwith the Name, Address & contact number of the whole-seller/supplier on the Hospital letter head.

c.         Authority letter on the official letter head of the hospital to verify medicine purchase invoices from the distributor.

d.         Provide the necessary documents/agreement that the Pathologist is/was associated with the hospital along with the salary slips with respective bank statement for having paid the salary for the working period.

e.         Certificate from the Pathologist having conducted and examined the lab reports of the patient along with his/her sign and seal bearing his/her registration no. for confirmation.

f.          The contact details and a copy registration certificate of the Pathologist.

g.         The schedule of visit of Pathologist at the hospital alongwith the period of his association with the hospital, so that we can meet him/her and verify the details.

h.         In case, if no pathologist is associated, provide the name & contact details of the Lab technician along with copy of his valid degree for lab technician & registration certificate.

i.          Copy of admission/IPD register of the hospital.

j.          Copy of the bill book entry of the hospital.

k.         Copy of pathology lab register of the hospital.

                        But the complainant failed to provide said required documents. They issued repeated reminders to complainant, but the complainant till date have not submitted these documents with them and in the absence of these documents opposite party no.1 is unable to verify and process the claim. The authenticity of the claim cannot be decided in the absence of relevant documents asked for. So, they rightly closed the claim of the complainant.

10.              Now, the question arises, whether the documents which were demanded by the opposite parties are necessary or not? The opposite parties demanded the documents at serial no. (a) that written clarification from the treating doctor on his/her letter head duly signed and stamped bearing his/her registration number to confirm on treatment alongwith period of hospitalization. The complainant has already submitted the discharge summary and other relevant documents alongwith bills of medicines with opposite party no.1. Moreover the investigator of the insurance company already verified all these documents by visiting the hospital of opposite party no.2. The other documents alleged to be required at serial no. (b) are that complete and readable medicines purchase invoices for all the medicines utilized during this hospitalization  from the hospital/pharmacy shop bearing their batch no. with expiry date alongwith the Name, Address & contract number of the whole/seller/supplier on the Hospital letter head and authority letter on the official letter head of the hospital to verify medicines purchase invoices from the distributor and necessary documents/agreement of the Pathologist, which is associated with the hospital alongwith salary slips, bank statement regarding payment of salaries, registration certificate of pathologist, schedule of visit of pathologist at the hospital alongwith period of association with the hospital, copy of the degree of Lab technician and its registration certificate, copy of admission registration of hospital, bill book and entry of hospital, which are not required for the settlement of the claim and these documents are not in the possession of the complainant, even the hospital of opposite party no.2 refused to provide these documents and gave certificate to this effect that the information regarding salary and registration number of their doctors cannot be provided as per the agreement with the doctors. Moreover, the official of opposite party no.1 visited the hospital on 14.01.2015 and verified all the contents regarding the treatment of patient Smt. Asha Rani, copy of the certificate is Ex.C-27. These documents are not required for the settlement of the claim of the complainant and opposite party no.1 are demanding these documents only to avoid payment of genuine claim of the complainant on one ground or the other. Ld. counsel for opposite party no.2 argued that they gave treatment to Smt. Asha Rani as per the need of circumstances. Regarding the treatment all the bills, discharge summary had already been provided to complainant and official of opposite party no.1 also visited the hospital of opposite party no.2 and verified all the bills and other documents regarding the treatment of patient Asha Rani and they were fully satisfied with all these documents. They cannot provide personal information regarding their doctors, pathologists and other staff regarding their salaries and bank statement and technical degrees at any costs to any person under any law. The complainant argued that opposite party no.1 only to grab of payment of genuine claim are making lame excuses and demanding unnecessary documents from him only to reject the claim. On this point, our Apex Court in case titled as M/s Modern Insulators Ltd. Vs The Oriental Insurance Company Ltd - 2000(1) CPR 93 (Supreme Court) 242 held that clauses which are not explained to complainant are not binding upon the Insured and are required to be ignored. Furthermore, it is generally seen that Insurance Companies are only interested in earning the premiums and find ways and means to decline the claims. Further our Hon’ble Punjab & Haryana High Court in case titled as New India Assurance company Ltd Vs Smt Usha Yadav & Others - 2008(3) R.C.R. (Civil) Page 111 held that it seems that Insurance Companies are only interested in earning premiums and find ways and means to decline the claims. The conditions, which generally are hidden need to be simplified so that these are easily understood by a person at the time of buying any Policy. The Insurance Companies in such cases, rely upon the clauses of agreement which a person is generally made to sign on dotted lines at the time of obtaining the policy.

11.              From the above discussion and in the light of the case earlier decided by our Hon'ble Apex Court and High Court, we are fully satisfied with the version of complainant. The complainant has already submitted all the required documents like discharge summary, tests reports of hospital and bills of medicines to opposite party no.1 for the settlement of his claim. The documents allegedly demanded by opposite party no.1 from the complainant are not necessary for the settlement of his claim and they are demanding these documents only to harass the complainant and to avoid the payment of claim amount, which amounts to deficiency in service and trade mal practice on the part of opposite party no.1. Hence the present complaint is allowed against opposite party no.1 and it is directed to pay the amount of Rs.62,060/- to the complainant as medical claim of his wife Smt. Asha Rani Randhawa with interest @ 9% per annum from the day, when it closed the claim of the complainant as 'no claim' till final realization. Opposite party no.1 is further directed to pay Rs.10,000/-(Ten thousand only) as compensation for mental, tension and harassment suffered by complainant and Rs.2000/-(Two thousand only) as litigation expenses to the complainant. Complaint against opposite party no.2 stands dismissed. Compliance of the order be made within 30 days of receipt of the copy of order, failing which, complainant shall be entitled to initiate proceedings against opposite party no.1 under section 25 & 27 of the Consumer Protection Act. Copy of the order be sent to the parties, free of costs. File be consigned to record room.

Announced in Open Forum

Dated : 26.04.2017

                               (Bupinder Kaur)           (Vinod Bala)                     (Ajit Aggarwal)

                                     Member                     Member                             President