Delhi

New Delhi

CC/314/2016

Subhash Chandra Sharma - Complainant(s)

Versus

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

16 Mar 2022

ORDER

 

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION­­­-VI,

DISTT.NEW DELHI, M-BLOCK, VIKAS BHAWAN, NEW DELHI-110002.

 

CC No.314/2016

IN THE MATTER OF:

 

SUBASH CHANDRA SHARMA

S/O SH. JAGANNATH

R/O L-48, SECOND FLOOR,

SRINIWASPURI, NEW DELHI-110065                        … COMPLAINANT

VERSUS

1.THE GENERAL MANAGER,

HDFC ERGO GENERAL INSURANCE CO.LTD.

FIRST FLOOR, 165-166,

BACKBAY RECLAMATION, HT PAREKH MARG,

CHURCH GATE, MUMBAI-400020

 

2.MANAGER/SETLER I.T. PARK,

TOWER-I, 5^TH FLOOR, C-25,

SECTOR-62, NOIDA, U.P.-201301

 

3. MANGAER

HDFC ERGO GENERAL INSURANCE CO.LTD.

GROUND FLOOR, AMBADEEP BUILDING-14,

KASTURBA GANDHI MARG,

NEW DELHI-110001                                                  … OPPOSITE PARTY(IES)

 

CORAM : SH. POONAM CHAUDHRY, PRESIDENT

                SH. BARIQ AHMAD, MEMBER

      MS. ADARSH NAIN, MEMBER   

                                                                                                                                Date of Institution: 17.05.2016

                                                                                                                                  Date of Order     : 16.03.2022

BARIQ AHMAD, MEMBER 

ORDER

Hearing Through Video Conferencing.

1. The complainant has filed the present complaint against the OPs under the Consumer Protection Act, 1986.The facts as alleged in the complaint are that  during the continuance of the policy for the year 19.03.2014 to 18.03.2015, the wife of the complainant fell ill and was admitted at Max Hospital, Saket on 26.10.2014 and was discharged on 23.12.2014, the wife of complainant again admitted in the Hospital where she was treated and was again admitted on 26.05.2015 at around 06:00 am and sadly expired on 26.05.2015. It is further alleged that on 08.07.2015 the complainant had filed a claim for re-imbursement of medical expenses incurred which was duly received by the OP vide No.RR-HS 15-10300244 for the amount covering Rs.5,00,000/- as the wife of complainant had incurred medical expenses about Rs.25,00,000/-. 

2. It is further stated that during these period Smt. Suraksha Rani was also having another Mediclaim Policy for Rs.5,00,000/- from West-East Assists, the complainant had applied to get claim for the same period for Rs.5 Lac  on the basis of medical documents, bills of the hospital. The complainant had already received mediclaim of Rs.5 Lac from West-East Assists but the OP had not p-aid claim of Rs.5 Lac to the complainant, thereafter, issued a legal notice dated 16.11.2015 to the OP through speed post but till date neither the payment of mediclaim policy has been made nor any reply of the legal notice. It is further stated that deceased was having two policies from two companies each of Rs.5 Lac of an additional coverage, each insurer will contribute an amount equivalent to the ratio of the sum insured. Alleging deficiency in service, and unfair trade practices, the complainant filed this complaint against the OP praying for payment of claim of Rs.5,00,000/- with compensation of Rs.1,00,000/- and cost of the  litigation of Rs.22,000/-.

3. Notice of the complaint was sent to the OP. OP has been contesting the case and have filed written statement. In the reply, OP submitted that the complaint is not maintainable, as there is no deficiency in service on their part, there is no cause of action has arisen in favor of the complainant. OP further submitted that the complainant does not fall within the definition of the term consumer as defined under section 2(1)(d) of the CP Act,1986 as the complainant is not consumer. It is also stated that the on the requests made by the complainant OP had issued the insurance policy namely “Health Sureksha Policy- Silver Plan” for the period 19.03.2014 to 18.03.2015 and then subsequently renewed the policy for the period of 19.03.2015 to 18.03.2016 on a premium of Rs.24,537/- to the  sum insured @ Rs.5,00,000/-, issued a policy Schedule No.2952 2010 2807 4400 000/ 50168049. It is further stated that the complainant approached the OP on 08.07.2015, filed a claim for reimbursement of medical expenses incurred which was duly received vide claim No.RR-HS 15-10300244 for the amount covering of Rs.1002626/- but only  filed hospital bill of Rs.14,147/-, requisite documents were sought from the complainant against the claim amount, issued many letter & reminders to the complainant in order to make the claim, but the complainant not provided the requisite documents, the claim was closed vide letter dated 23/12/2015. The complainant is simply trying to avoid his liability to submit requisite documents by filling this false and frivolous complaint, it is prayed that complaint be dismissed.

4. The complainant did not file rejoinder.

5. In order to prove his case the complainant filed his affidavit in evidence. The complainant also placed on record, copy of election card of complainant Ex.CW1/B, Copy of Aadhar Card of complainant Ex.CW1/C, copy of death summary Ex.CW1/D, copy of death certificate Ex.CW1/E, copy of death report  Ex.CW1/F, copy of death certificate issued by Delhi Govt. Ex.CW1/G, copy of legal notice  Ex.CW1/H, copy of speed post receipt Ex.CW1/I, copy of health card Ex.CW1/J, and  copy of health card for the period from 19.03.2014 to 18.03.2015 Ex.CW1/K.

6. On the other hand, Sh. Neeraj Kumar working as Manager (Legal) with OP at its branch/registered office at 5^th Floor, Tower-1, Stellar IT Park, C-25, Sector-62, Noida, UP-201301, authorised representative of OP by virtue of authority dated 23.07.2012, copy of authority as Ex.OP-1, filed his affidavit in evidence. The complainant also placed on record, copy of insurance policy Ex.OP-2, Copy of claim receipt Ex.OP-3, copy of letter dated 25.07.2015, 09.08.2015, 25.08.2015, 07.09.2015, final reminder dated 08.12.2015  and copy of claim closure letter dated 23.12.2015 Ex.OP-4 collectively, with copy of the terms & conditions of the insurance policy, Copy of emergency bill (details) dated 26.05.2015 of Rs.14,147.29 alongwith settlement receipt of Max Hospital Ex.OP-6.

7. Learned Counsel for the parties have filed Written Arguments wherein they have reiterated the allegations made in complaint.
8. This Commission has considered the case of the complainant in the light of evidence of both the parties and documents placed on record by the complainant and OP. Perusal of record shows that the OP has not denied the policy, lodging the medical reimbursement claim of Rs.14,147/- vide claim No.RR-HS 15-10300244,  pertains to Max Hospital, Saket. However,  the Opposite Party vide letter dated 23.12.2015 closed the claim of the complainant on the ground that `Insufficient query reply, as the documents required were not supplied by complainant, despite  many letters and reminders sent by OP to the complainant.
   9.  

Section 5 (I). “in case of multiple policies taken by an insured person during a period from one or more insurers to indemnify treatment costs, the insured person shall have the right to require a settlement of his/her claim in terms of any of his/her policies. In all such cases the insurer chosen by the insured person shall be obliged to settle the claim as long as the claim is within the limits of and according to the terms of the chosen policy.

(ii). Insured person having multiple policies shall also have the right to prefer claims under this policy for the amounts disallowed under any other policy/policies even if the sum insured is not exhausted. Then the insurer shall independently settle the claim subject to the terms and conditions of the policy.

(iii). If the amount to be claimed exceeds the sum insured under a single policy, the insured person shall have the right to chose insurer from whom he/she wants to claim the balance amount.”

10. We are of the considered view that the OP is liable to settle or reject claim, as the case may be, within 30 days from the date of receipt of last necessary document, i.e. all emergency bill (Details) after discharge on 23.12.2014,  for treatment period from 26.10.2014 to 23.12.2014 and bill no.DTIC83579 dated 26.05.2015 of Rs.14147.29 of the deceased/insured of Max Hospital Saket, Delhi, as per Guidelines issued under the Provisions of Section 34(1) of the Insurance Act,1938 read with Regulation 20 and Schedule III of IRDAI (Health Insurance) Regulations, 2016 vide Circular No.IRDAI/HLT/REG/CIR/152/06/2020 dated 11.06.2020. However, where the circumstance of a claim warrant an investigation in the opinion of the OP Company, it shall initiate and complete such investigation at the earliest, in any case not later than 30 days from the date of receipt of last necessary document. In such cases, the OP Company shall settle or reject the claim within 45 days from the date of receipt of last necessary document.

Accordingly, The complainant is directed to submit all the emergency bill (Details)/necessary document to OP Company, within 30 days of receipt of this order and the order shall be complied by OP company as as per above directions. The complainant may approach this Forum/Commission as per the Consumer Protection Act, if claim rejected by OP Company, as per law. The Complaint  stand dismissed ,  with no costs.

11. A copy of this order be provided to all the parties free of cost as mandated by the Consumer Protection Act, 2019. The order be uploaded forthwith on the website of the commission for the perusal of the parties.
12. File be consigned to record room along with a copy of this judgment.

Announced on this 16^th day  of March, 2022.

 

 

MS.POONAM CHAUDHRY

(PRESIDENT)

BARIQ AHMAD                                                                                                                         MS. ADARSH NAIN          

    (MEMBER)                                                                                                                                        (MEMBER)