Chandigarh

DF-II

CC/282/2019

Mr. Lalit Malik - Complainant(s)

Versus

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

Nikita Garg Adv. & Ishan Malhotra Adv.

13 Jul 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II,

U.T. CHANDIGARH

 

Consumer Complaint  No	:	282 of 2019
Date  of  Institution	:	08.05.2019
Date   of   Decision	:	13.07.2023

 

 

 

 

 

Lalit Malik s/o Sh.Harish Kumar, R/o 118, Old Indra Colony, Manimajra, Chandigarh 160101

 

            …..Complainant

 

Versus

 

1]  HDFC Ergo General Insurance Company Ltd., SCO 124-125, Sector 8, Madhya Marg, Chandigarh 160008

    Head Office at : HDFC Ergo General Insurance Company Limited, 1^st Floor, 165-166, Backbay Reclamation, H.T. Parekh Marg, Churchgate, Mumbai 400020

 

2]  Policy Bazaar.com, Plot NO.119, Sector 44, Gurugram, Haryana 122001

 

 

     ….. Opposite Parties

 

BEFORE:  MR.AMRINDER SINGH SIDHU       PRESIDENT

        MR.B.M.SHARMA                 MEMBER

                               

Argued by   :  Complainant in person

    Sh.Nitesh Singhi, Counsel of OP No.1.

    None for OP NO.2

 

ORDER BY AMRINDER SINGH SIDHU, M.A.(Eng.),LLM, PRESIDENT

 

1]      The complainant filed present complaint pleading that he has bought an insurance policy on 29.7.2018 from Policybazaar.com after going through an advertisement of the OP No.2 for the same.  The Policy No.2864100336978600000 was issued and the sum insured was Rs.3 lacs only.  An amount of Rs.3683/- was paid as premium and the policy was issued in the name of the complainant.  The complainant further pleaded that he was suffering from fever and cold on 18.8.2018 due to which he visited Civil Hospital, Sector 16, Chandigarh.  The complainant undergone certain tests as per the advise of the doctors and the reports of the tests were declared on 28.8.2018.  As per test reports, the complainant was completely fit and he was taking the treatment for normal cold & fever.  Feeling unwell, the complainant again admitted in IVY Hospital on 3.9.2018 and the hospital conducted various tests on the same day and on 4.9.2018 it was diagnosed that the complainant is suffering from ‘Antineutrophil Cytoplasmis Antibodies’.  In the meantime, the family of the complainant applied for cashless claim which was rejected by OPNo.1 on 4.9.2018 vide HDFC Ergo ID No.ER1804162615-01E.  After getting discharged, the complainant paid a bill of Rs.63,290/- to the Hospital.   The OP declined the claim of the complainant under Clause D2 of the policy which states that a general waiting period of 30 days is applicable for all claims payable under the policy.  The complainant alleged that the above repudiation  is on the wrong ground as the tests dated 28.8.2018 and 9.8.2018 proves that the chest of the complainant was quite fine and the complainant was taking treatment for fever and cough only.  The complainant thereafter got admitted in the Govt. Hospital by the name of Nehru Hospital Postgraduate Institute of Medical Education and Research, Chandigarh (herein referred as PGI, Chandigarh) on 6.8.2019 to save a bit of money as he knew that if he took the facility of private hospital, it would cause financial crisis to the complainant. The complainant got discharged from the hospital 0n 16.9.2018 and submitted the claim for refund with the OP NO.1 but the same was rejected vide letter dated 6.11.2018 and the reason given is as follows:-     

    “As per the submitted documents.  Patient was hospitalized on 05.09.2018 with the diagnosis of Antineutrophil Cytoplasmis Antibodies associated Vasculitis, Pulmonary Renal Syndrome and is taking conservative treatment for the same. Patient developed symptoms 1 month prior the date of hospitalization which falls within 30 days from the date of first inception of policy 29.07.2018.  The claim is being repudiated under D2 which states that a general waiting period of 30 days is applicable for all claims payable under the policy except those arising due to accidents.”

 

        The complainant alleged that the OP No.1 rejected the claim wrongfully and illegally as in the present case, the disease was never contracted during the waiting period, which is proved by the reports of tests which are conducted during the waiting period. The complainant again requested the OP No.1 to reimburse the amount of claim but the same was  again rejected by the OP No.1 vide its letter dated 21.11.2018 giving the same reason as before. The complainant alleged that the OPs have wrongly repudiated the claim of the complainant which amounts to deficiency in service as well as unfair trade practice on the part of OPs.  Lastly the complainant prayed for the acceptance of the complainant alogwith compensation and litigation expenses.

 

2]      After the service of notice, the OP No.1 appeared before this Commission and filed its written version taking preliminary objection that the complainant was suffering from fever & cold since 18.8.2018. It is submitted that as per Discharge Summary of Ivy Hospital, the complainant was suffering from law grade fever on and off since 25 days.  Moreover, the Discharge Summary also mentions that the complainant was admitted with provisional diagnosis of Cavitating Pneumonia Vasculitis.  As per Discharge Summary of PGIMER, Chandigarh the complainant was admitted from 5.9.2018 to 15.9.2018 having history of high grade fever and cough since 25 days. It is also alleged that the OP NO.1 rightly repudiated the claim of the complainant as per exclusion Clause D of the Policy, which is reproduce for ready reference:-

“D.    EXCLUSIONS

The Company shall not be liable to make any payment for any claim directly or indirectly caused by, based on, arising out of or howsoever attributable to any of the following:

2.     Any disease contracted and/or medical expenses incurred in respect of any disease/illness by the Insured/Insured Person during the first 30 days from the commencement date of the Policy except in case of accidental injuries. This exclusion doesn't apply for Insured/Insured Person having any health insurance indemnity policy in India at least for 1 year prior to taking this Policy as well as for subsequent renewals with the Company without a break.”

        The OP No.1 denied all the allegations made against it in the complainant and lastly prayed for dismissal of the complaint with costs.

3]      The OP No.2-Policy Bazaar.com has also filed its written version stating that the complainant visited the website of answering OP and out of his own volition, opted insurance policy from OP No.1.  It is stated that the complainant never paid any amount to answering OP No.2. It is also stated that the complainant paid the premium amount of the policy to OP No.1 and the terms & conditions of the policy were agreed upon between complainant and OP No.1.  Denying other allegation, OP NO.2 prayed for dismissal of the complaint qua it.

 

4]      Parties led evidence in support of their contentions.

 

5]      We have heard the ld.Counsel for the contesting parties and have perused the entire record including written arguments. 

 

6]      In views of the rival contentions of the parties, the main question which arise for the disposal of this Commission is whether the OP NO.1 has repudiated the claim of the complainant wrongly & arbitrarily or not ?

 

7]      In order to find out the answer to this question, it is necessary to find out whether ‘any disease contracted i.e.      Antineutrophil Cytoplasmis Antibodies (ACA) and/or medical expenses incurred in respect of any disease/illness i.e. Antineutrophil Cytoplasmis Antibodies (ACA) by insured person i.e. complainant namely Lalit Malik during the first 30 days from the commencement date of the policy.   

8]      Admittedly the complainant purchased the policy of OP No.1 on 29.7.2018. Though the complainant was suffering from fever and cold since 18.8.2018 yet as per medical records of the complainant, the reports of the complainant reveal that there is no abnormality in the tests conducted by the labs. Ann.C-4 in its report reveals Impression reported “Normal study”. Even the Out Patient Card of Govt. Multi Speciality Hospital, Sector 16, Chandigarh (Ann.C-3) mentions that the complainant was suffering from fever for the last 10 days and various tests were recommended to be conducted.  The result of the aforesaid tests shows no symptoms of the concerned disease i.e. Antineutrophil Cytoplasmis Antibodies (ACA).  Later on when more tests were conducted, then it was revealed that he is suffering from ‘Antineutrophil Cytoplasmis Antibodies associated Vasculitis, Pulmonary Renal Syndrome’.  In the Follow-up Card of PGI, Chandigarh (Ann.C-10 Page 48), it is clearly mentioned that there is no “Past History : No history of bronchial asthma T2DM, Pulmonary TB”. 

 

9]      The OP No.1 has repudiated the claim of the complainant under Exclusion Clause D 2 by stating that the patient was hospitalized on 5.9.2018 with the diagnosis of Antineutrophil Cytoplasmic Antibodies (ANCA) associated Vasculitis, Pulmonary Renal Syndrome and is taking conservative treatment for the same.  The patient developed the symptoms 1 months prior to the date of hospitalization which falls within 30 days from the date of first inception of policy dated 29.7.2018. The claim was repudiated under Clause D2 Exclusions of the policy, which states that ‘a general waiting period of 30 days is applicable for all claims payable under the policy except those arising due to accidents.’

 

10]     Though the OP No.1 alleged that the complainant was suffering from Antineutrophil Cytoplasmic Antibodies within 30 days from the date of inception of policy, but yet it failed to prove the same as neither any reliable evidence is given to this effect nor the concerned doctor was examined on oath by the OP No.1 to prove this fact.  In the absence of evidence, mere presumption cannot take the place of proof.  Therefore, it is held that the OP No.1 has wrongly and arbitrarily repudiated the claim of the complainant, which amounts to deficiency in service on its part. 

        The complainant purchased HDFC ERGO Health Insurance policy on dated 29.07.2018.  the initial 30 days period was expired on 27.08.2018 i.e. 30 days of policy.  Whereas this disease (Antineutrophil Cytoplasmis Antibodies also known as ACA) was diagnosed on 04.09.2018 i.e. 38^th day of the policy.  So it is clear that Exclusion Clause provided under D2 of the policy is not applicable in the present case.  

 

11]     In view of the above discussion & findings, the present complaint deserves to be allowed and the same is accordingly partly allowed against the OP No.1 with direction to pay Rs.2,25,024/- to the complainant towards his claim of his medical expenses incurred on treatment and medicines along with interest @8% per annum from the date of filing of this complaint till the date of its actual realization.

        This order be complied with by the OP within 45 days from the date of receipt of its certified copy.

12]     The complaint qua OP No.2 stands dismissed.

13]     The pending application(s) if any, stands disposed of accordingly.

        Certified copy of this order be sent to the parties, as per rules. After compliance file be consigned to record room.

Announced

13^th July, 2023                

                                                                              Sd/-

 (AMRINDER SINGH SIDHU)

PRESIDENT

 

Sd/-

(B.M.SHARMA)

MEMBER