Chandigarh

DF-I

CC/784/2022

SANJIV ARORA - Complainant(s)

Versus

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

SHIV CHARANJIT

01 Dec 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/784/2022
Date of Institution	:	05/09/2022
Date of Decision	:	01/12/2023

 

Mr.Sanjiv Arora s/o late Sh. Mangat Rai Arora and Smt. Late Laj Wanti Arora r/o # 391, Phase-2, Mohali, 160055, Punjab.

… Complainant

V E R S U S

Dayananda Vittal Shetty, Director, HDFC ERGO General Insurance Company Ltd., SCO 124-125, Sector 8, Madhya Marg, Chandigarh 160008.

… Opposite Party

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

                                                                               

ARGUED BY	:	Sh. Shiv Charanjit, Advocate for complainant
	:	Sh. Nitesh Singhi, Advocate for OP

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Sanjiv Arora, complainant against the aforesaid opposite party (hereinafter referred to as the OP).  The brief facts of the case are as under :-

1. It transpires from the allegations as projected in the consumer complaint that the mother of the complainant namely Smt. Laj Wanti Arora had purchased a health insurance policy (Annexure 1) namely “my : health Suraksha Policy (Silver Smart) (hereinafter referred to as “subject policy”) which was valid w.e.f. 1.3.2022 to 28.2.2023, by paying premium amount of ₹40,489/- for a coverage of ₹5.00 lacs.  On 15.6.2022, mother of the complainant i.e. the insured felt unwell as a result of which she was brought to Cheema Medical Hospital (hereinafter referred to as “treating hospital”) where she was operated and stent was implanted, but, she could not recover and passed away on the same day i.e. 15.6.2022.  The treating hospital had called the OP for cashless claim, but, the same was outrightly rejected by the OP without mentioning any ground, as a result of which the complainant was compelled to pay an amount of ₹1,29,622/- to the treating hospital. Thereafter the OP sent an email dated 15.6.2022 (Annexure 2) to the complainant stating that he will be updated in 24 hours, but, on 16.6.2022 (Annexure 3), another email was received from the OP in which it was stated that the OP is unable to extend the cashless facility due the possibility of the present ailment being pre-existing. Thereafter, OP called the complainant telephonically in the last week of June 2022 asking him to provide the requisite documents i.e. Aadhar card, death certificate, death summary, medical documents, cancelled cheque etc. The OP was informed by the complainant vide email (Annexure 4) that his mother/insured had died due to heart attack and she was not having any pre-existing ailment and thereafter the complainant was informed by the OP vide email dated 22.7.2022 (Annexure 5) that the claim will be processed within 21 days.  Again the OP asked the complainant through emails (Annexure 13, 15 & 18) to provide the past record pertaining to the cataract surgery performed in the hospital, knowing fully well that the said surgery has no connection with the present ailment due to which the insured had died and finally refused to reimburse the claim to the complainant. In this manner, the aforesaid act of the OP amounts to deficiency in service and unfair trade practice on its part. OP was requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. OP resisted the consumer complaint and filed its written version, inter alia, taking preliminary objections of maintainability, cause of action, concealment of facts and also that the complainant has not approached the Commission with clean hands.  However, it is admitted that the subject policy was purchased by the mother of complainant which was valid w.e.f. 1.3.2022 to 28.2.2023. It is further alleged that the insured had concealed the factum of earlier diseases while purchasing the subject policy as the insured had not disclosed that she had past history of eye surgery (cataract) 10 days back prior to the purchasing of the subject policy and the possibility of the present ailment being pre-existing disease could not be ruled out and the claim of the complainant was rightly closed due to non-receipt of the documents from him. On merits, the facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. In rejoinder, complainant re-asserted the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.

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 mother of the complainant namely Smt. Laj Wanti Arora i.e. the insured had purchased the subject policy from the OP which was valid w.e.f. 1.3.2022 to 28.2.2023, as is also evident from Annexure 1, and she was brought to the treating hospital where she was diagnosed with ACUTE ANTERIOR WALL MI WITH RBBB CAD-DVD-PTCA(S) TO LAD (CULPRIT VESSEL) and during treatment she could not survive and ultimately died and also that the claim of the complainant was rejected by the OP on the ground of possibility of present ailment being pre-existing, the case is reduced to a narrow compass as it is to be determined if the OP is unjustified in rejecting the genuine claim of the complainant and the complainant is entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainant, or if the OP is justified in rejecting the claim of the complainant and the instant consumer complaint is liable to be dismissed, as is the defence of the OP. 
   2. In the backdrop of the foregoing admitted and disputed facts on record, one thing is clear that the entire case of the parties is revolving around the denial/rejection letter and the medical record and the same are required to be scanned carefully.
   3. Annexure 3 is the letter dated 16.6.2022 through which the OP denied/rejected the claim of the complainant and the relevant portion of the same is reproduced as under:-

“1. As per the available documents, Possibility of the present ailment being Pre-Existing (as per policy terms & conditions) could not be ruled out i.e. has possibility of being pre-existing from the inception of the policy. However, insured can file the claim for reimbursement post completion of the treatment with all medical & financial records. The admissibility of the claim would be decided post review of the documents and policy conditions.”

4. Annexure 4 is the copy of the death certificate of the treating hospital and the relevant portion of the same is reproduced as under :-

“COURSE IN HOSPITAL:-

The patient admitted with chest pain, In emergency the diagnosis of acute AWMI with RBBB made & need of urgent Angiography & angioplasty advised. The CAG was done which showed DVD & PTCA (s) to LAD done which was culprit vessles. then patient was shifted to ICU but she had ghabrahat, hypotension followed by bradycardia. Immediately Inj atropine given and Infusion norepi and inj dopamine started. The pt became unresponsive had asystole. CPR started according to ACLS protocols. Chest compression started and inj ADR given. Patient shifted to cath lab for check angio the patient could not revive CPR done for more than 30 mins, The patient could not revive, she declared dead at 4.00pm on 15/06/2022.

The family members were given the choice of post mortem but the family members refused for same. Hence the dead body handed over to family members.

CAUSE OF DEATH-

Massive Acute Anterior wall MI with RBBB.”

5. Annexure 9 is the email sent by the complainant to the OP attaching therewith the “query reply” of the treating hospital in which it was observed that the patient had not any past history of treatment/ailment. The relevant portion of the same is reproduced below for ready reference :-

“2.   No any past history of any treatment/ailment.”

6. Though the OP has come with the defence that as the complainant could not produce the documents asked by the OP qua the cataract surgery of the deceased insured 10 days prior to the purchase of the subject policy and the possibility of the present ailment being pre-existing could not be ruled out, it seems that the OP has asked the complainant for the documents which otherwise have no connection/ nexus with the disease for which the deceased/ insured had taken the treatment from the treating hospital i.e. heart treatment, as is also given in the death summary A-4 and discussed above. 
7. Not only this, even the medical officer of the treating hospital has specifically replied to the query (attached with Annexure 9) made by the OP that the patient had not any past history of any treatment/ ailment, making clear that the OP started asking the complainant to provide such documents which otherwise had no connection with the ailment for which the deceased/insured had taken the treatment from the treating hospital. Here we are strengthened by the order passed by the Hon’ble National Commission in Neelam Chopra Vs. Life Insurance Corporation of India & Ors., IV (2018) CPJ 321 (NC) and the operative part of the same reads as under :-

     12. In the present case, clearly the cause of death is cardio respiratory arrest and this disease was not existing when the proposal form was filled. Clearly, there is no suppression of material information in respect of this disease, which is the main cause of death. The other disease of LL Hansen, which was prevailing for five weeks on the date of admission on 1.8.2003 was also not existing when the proposal was filed by the DLA. The fact of DLA having been treated in the year 2002 for LL Hansen is not supported from any direct evidence though PGI Chandigarh in its certificate has mentioned that disease was treated in 2002. Moreover, this disease does not have any correlation with the cause of death in the present case. Hon’ble Supreme Court in Sulbha Prakash Motegaonkar and Ors. v. Life Insurance Corporation of India, Civil Appeal No.8245 of 2015, decided on 5.10.2015 (SC) has held the following:

        “We have heard learned Counsel for the parties.

                It is not the case of the Insurance Company that the ailment that the deceased was suffering from was a life threatening disease which could or did cause the death of the insured. In fact, the clear case is that the deceased died due to ischaemic heart disease and also because of myocardial infarction. The concealment of lumbar spondylitis with PID with sciatica persuaded the respondent not to grant the insurance claim.

                We are of the opinion that National Commission was in error in denying to the appellants the insurance claim and accepting the repudiation of the claim by the respondent. The death of the insured due to ischaemic heart disease and myocardial infarction had nothing to do with this lumbar spondylitis with PID with sciatica. In our considered opinion, since the alleged concealment was not of such a nature as would disentitle the deceased from getting his life insured, the repudiation of the claim was incorrect and not justified.”

8. In view of the foregoing discussion and the ratio of law laid down above, it is clear that the OP has not been able to connect the previous diseases/ailments with the present diseases/ailments, for which the insured had taken treatment from the treating hospital.  Hence, it is unsafe to hold that the OP was justified in repudiating the claim of the complainant and the present consumer complaint deserves to succeed. 
9. Now coming to the quantum of claim/compensation to be awarded to the complainant, since the complainant has proved the bill dated 15.6.2022 of the treating hospital (attached with Annexure 12) amounting to ₹1,29,622/-, it is safe to hold that OP is liable to pay the said amount to the complainant alongwith interest and compensation etc. for the harassment suffered by him.

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

1. to pay ₹1,29,622/- to the complainant alongwith interest @ 9% per annum from the date of denial of cashless claim i.e. 16.6.2022 onwards.
2. to pay an amount of ₹15,000/- to the complainant as compensation for mental agony and harassment;
3. to pay ₹10,000/- to the complainant as costs of litigation.

5. This order be complied with by the OP within forty five days from the date of receipt of its certified copy, failing which, the payable amounts, mentioned at Sr.No.(i) & (ii) above, shall carry 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 of accordingly.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

Announced 01/12/2023 hg		Sd/- [Pawanjit Singh] President
		Sd/- [Surjeet Kaur] Member
		Sd/- [Suresh Kumar Sardana] Member