Punjab

Rupnagar

CC/18/70

Vir Karan - Complainant(s)

Versus

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

Sh.Satwant Singh,Adv

04 Jan 2019

ORDER

THE DISTT. CONSUMER DISPUTES REDRESSAL FORUM, ROPAR

                                  Consumer Complaint No. : 70 of 28.08.2018

                                  Date of decision           :    04.01.2019

 

Vir Karan son of Chand Singh, resident of # 1939/9, New Preet Colony, Rupnagar, Tehsil & District Rupnagar 

                                                                    ......Complainant

                                             Versus

 

1. HDFC Ergo General Insurance Company Ltd., through HDFC Bank Ltd., College Road, Rupnagar, Tehsil & District Rupnagar
2. HDFC Ergo General Insurance Company Ltd. Through its Corresponding Office: Stellar IT Park, Tower-1, 5^th Floor, C-25, Sector 62, Noida-201301
3. Ivy Hospital Super Specialty Healthcare, Sector 71, Mohali, Tehsil & District Mohali, through its Managing Director

 

   ....Opposite Parties

                                    Complaint under Section 12 of the                                               Consumer Protection Act, 1986

QUORUM

 

                         SH. KARNAIL SINGH AHHI, PRESIDENT

                         CAPT. YUVINDER SINGH MATTA, MEMBER

 

ARGUED BY

 

Sh. Satwant Singh Saini, Adv. counsel for complainant  

Sh. Ajay Kumar Talwar, Adv. counsel for OP Nos.1 & 2

          Sh. Rajbir Singh Rani, Adv. counsel for OP No.3   

 

                                             ORDER

               SH. KARNAIL SINGH AHHI, PRESIDENT

 

 

1. Complainant has filed the present complaint seeking directions to the opposite parties to release the estimated claim of Rs.1,30,000/- along with interest @ 18% per annum from the date of accident; to pay Rs.50,000/- as damages on account of physical, mental and monetary harassment; to pay Rs.10,000/- as cost of complaint; any other relief which this Hon’ble court may deems fit be granted to the complainant, in the interest of justice.  

2.     Brief facts made out from the complaint are that the employee of the O.P.No.1 approached the complainant at his house for starting of the health insurance policy with the O.Ps. No.1 & 2 and he had claimed himself agent of O.Ps. No.1 & 2 and told him about the various beneficiary plans of the health insurance policy to him and the complainant was convince to purchase the health insurance policy only with the condition to of claim with policy. The O.Ps. No.1 & 2 assured him that the said policy is the cashless policy and also assured that in future during the term of insurance policy if the complainant and his wife suffered any health problem then the O.Ps. No.1 & 2 will pay the charges of medical bills upto sum insured and the complainant and his wife need not have to pay the same as the policy is the cashless policy. The O.Ps. No.1 & 2 have assured that the complainant and his wife were at liberty to get the treatment from any recognized hospital. Thereafter swayed by the allurement given by the O.Ps. No.1 & 2 and as per the assurances given by the O.Ps. No.1 & 2, the complainant and his wife purchased the Health Suraksha Insurance Policy (Silver Plan) bearing No.2825100215680000000 from the O.Ps. No.1 & 2 and the said policy was valid from 13.07.2017 to 12.7.2018 and paid Rs.5862/- as total premium of the said policy and then O.Ps. No.1 & 2 issued the insurance policy dated 13.7.2018. Thereafter, in the midnight of 8.7.2018, the complainant suffered from Brain Hemorrhage/Blood Clot in brain and he was taken to Civil Hospital, Rupnagar, from where he was referred to Ivy Hospital, Mohali, due to his critical condition and then the complainant was admitted in the Ivy Hospital i.e. OP No.3 on 9.7.2018 where the complainant was treated and was remained under treatment from 9.7.2018 and was discharged on 13.7.2018. At the time of admission of complainant with the O.P. No.3, family members of the complainant submitted the health card as well as insurance policy issued by the O.Ps. but the official of the O.P. No.3 compelled the complainant and his family members to deposit the treatment charges and under compelling circumstances, the complainant and his family members had paid the treatment charges as well as other medical charges. The official of the OP No.3 assured the complainant that they would send the case to the Ops No.1 & 2 and after releasing the claim of the complainant they would refund the money deposited by him. On 10.07.2018, the officials of the O.Ps. No.1 & 2 again contacted the family members of the complainant and informed them that the said policy is going to expire on 12.7.2018 and also offered to renew the same, then wife of the complainant got renewed the same by paying the premium of Rs.5862/- and said policy was renewed on 10.7.2018 for one year. After repeated requests, the O.ps. No.1 & 2 did not release the claim amount as per the medical record. Hence, this complaint. 

 3.    On notice, O.Ps. No.1 &2 appeared through counsel and filed written reply taking preliminary objections; that the present complaint is false, frivolous, vague and vexatious in nature and has been made to injure the interest and reputation of the respondent as the claim of the complainant is not covered under the policy; that that the complainant has concealed and suppressed the material and relevant facts of the case; that the present complaint has been filed with malafide and dishonest intention; that the complainant has not come to this Forum with clean hands; that the complicated question of law and facts are involved in the present case which required detailed evidence i.e. examination and cross examination; that the opposite party craves the leaves of this Hon’ble Court to file the additional reply/counter if later on any new facts came into the knowledge of the O.P.; that the complaint is devoid of any material particulars and has been filed merely to harass and gain undue advantage and unjustified money from the answering O.Ps. On merits, the O.Ps. No.1 & 2 stated that as per the record of the answering O.Ps. the policy was taken by the wife of the complainant through HDFC Bank Limited. The claim amount if any is strictly payable as per terms and conditions of the policy. The complainant purchased the policy after understanding the benefits under the policy. However, the complainant did not disclosed the true and correct facts about his previous ailment. The answering O.Ps. received the preauthorization request for cashless for an amount of Rs.80,000/- for the treatment of complainant through O.P. No.3 along ICU admission record. After getting the request the answering O.Ps. required the additional informed for the cashless facility vide letter dated 9.7.2018 and the OP No.3 sent the reply disclosing the hypertension for the last four years. Thereafter, the request for cashless treatment was denied vide letter dated 11.7.2018 as per terms and conditions of the policy. Rest of the allegations made in the complaint have been denied and prayer has been made dismissal thereof. 

4.     On notice, OP NO.3 appeared through counsel and filed written reply taking preliminary objections; that the answering O.P. No.3 is the super specialty renowned hospital which is run by Ivy Health and Life Sciences Private Limited, having registered office at Sector 71, Mohali; that the contents of the complaint which were not expressly admitted in the written statement to the complaint shall be deemed denied and that the present complaint is wholly misconceived, unwarranted and not maintainable against the answering O.P in as much as there has been no negligence on the part of answering O.P.; that the present complaint is flagrant abuse of the process of law and has been filed in order to harass, malign the reputation of O.P. No.3; that the present complaint has failed to show as to how the answering O.P. has been negligent in any manner whatsoever; that the complainant has no cause of action to file the present complaint. On merits, it is stated that complainant was admitted in the hospital of answering O.P. on 9.7.2018 and was under treatment till 13.7.2018. It is denied for want of knowledge that on 10.7.2018, the official of the O.Ps. No.1 & 2 contacted the family members of the complainant and informed them about the expiry of the insurance policy and about its renewal as these contents are not related to answering O.P. and at the time of renewal of the policy the wife of the complainant informed the O.Ps. No.1 & 2 regarding the ailment of the complainant and his admission in the hospital of answering O.P. in critical condition as these facts are also not connected with the answering O.P. The complainant was discharged from the hospital on 13.7.2018. It is further stated that neither the complainant submitted all the required documents with the answering O.P. nor there was any occasion to the complainant to submit the required documents of the claim with the answering O.P as there is no privity of contract either between the O.Ps. No.1 & 2 and answering O.P. or between the complainant and answering OP regarding the insurance claim. Rest of the allegations made in the complaint have been denied and prayer has been made dismissal thereof. 

5.     On being called upon to do so, the learned counsel for the complainant has tendered duly sworn affidavit of complainant Ex.CW1/A along with documents Ex.C1 to Ex.C27 and closed the evidence. The learned counsel for the O.Ps. No.1 & 2 has tendered duly sworn affidavit of Sh. Pankaj Kumar, Authorized Signatory, HDFC Ergo Ex.OP1 along with documents Ex.OP2 to Ex.OP8 and closed the evidence. The learned counsel for the O.P. No.3 has tendered duly sworn affidavit of Sh. Sandeep Sharma, Deputy Manager (Legal) of Ivy Health and Life Sciences Pvt. Ltd. Ex.OP3/A along with documents Ex.OP31/ to Ex.OP3/3 and closed the evidence.  

6.     We have heard the learned counsel for the parties and have gone through the record of the file, carefully.

7.     Complainant’s counsel Sh. Satwant Singh Saini, argued with the allurement of O.Ps. No.1 & 2, complainant purchased of Health Suraksha Insurance Policy and the O.Ps. allured that if the complainant purchased the said Insurance Policy then the benefits of medical treatment shall extend without cash payment. Accordingly, the complainant purchased Health Surkhsha Insurance Policy for the valid period w.e.f. 13.7.2017 to 12.7.2018 by depositing premium of one year of Rs.5862/-. In the midnight of 8.7.2018, the complainant suffered brain Hemmorrhage/Blood Clot in brain and got admitted Civil Hospital, Rupnagar, from where the complainant was referred and got admitted IVY Hospital, i.e. with OP No.3 on 9.7.2018. In the said hospital, the complainant remain admitted w.e.f. 9.7.2018 to 13.7.2018 and the complainant spent about Rs.1,30,000/ for his medical treatment. As the policy was to expire on 12.7.2018, for its continuity complainant then approached the Ops No.1 & 2 for its renewal and the said O.Ps. accepted the request of renewal on 10.7.2018 for one year w.e.f. 13.7.2018 to 12.7.2019 and the premium of Rs.5862/- was received. Due to non payment by the O.Ps. No.1 & 2, the complainant had to pay Rs.1,30,000/- with the OP No.3. Now the O.P. No.3 refused to extend the benefits of the policy as well as non-payment of the medical expenses. It amounts to deficiency in service and prayed that the complaint be allowed with costs.

8.     Sh. Rajbir Singh Rai, counsel for the OP No.3 argued very briefly that so far the sale/purchase of the policy by complainant from the O.ps. No.1 & 2 that matter is not related to OP No.3. So far the admission of the complainant w.e.f. 9.7.2018 to 13.7.2018 for the treatment is admitted. Then denied qua the knowledge of renewing policy on 10.7.2018. In para No.7 of the written reply, admitted that complainant only paid Rs.83,637/- towards treatment charges which were received vide invoice dated 13.7.2018 and prayed that this complaint is without merit against the O.P. No.3.

9.     Sh. Ajay Kumar Talwar, counsel for the O.Ps. No.1 & 2 argued that as per the preliminary objections complainant got insured by concealing the true /correct health status and prayed that as per the documentary evidence/diagnosis dated 9.7.2018 proves that disease of Hypertension with gastritis, the ailment was diagnose on four years back. If any of the policy purchased and the diseased/injury/illness will not be covered until 48 months of continuous coverage have elapsed since inception of the first Health Suraksha Insurance Policy. The learned counsel then referred the citation  as well as documentary evidence then medical treatment provided by OP No.3 to the complainant and prayed that complainant concealed the illness while purchasing the policy i.e. why on the basis of true facts the claim of the complainant has rightly been rejected. The learned counsel referred the rule provided in the policy. At the same time, the complainant counsel, pleaded that no evidence qua the old diseased has come on file. Moreover, if the diseased was old then why the O.Ps. No.1 & 2 renewed the policy on 10.7.2018 w.e.f. 13.7.2018 to 12.7.2019. To check the status of the body, O.Ps. No.1 & 2 are duty bound to get the consumer medically checked up. First policy was issued after due check up and at the time of issuance of the second policy/renewed O.Ps. No.1 & 2 duly verified then issued. Lastly prayed complainant counsel that deficiency stand established, the complaint be allowed.

10.   Before coming to the conclusion, the Forum is to appreciate whether relationship of complainant as consumer with the O.Ps. exists or not. Complainant deposited the premium of Rs.5862/- with the O.Ps. No.1 & 2 who issued the Health Suraksha Insurance Policy and then renewed on 10.7.2018. Complainant fell ill on 8.7.2018 and remain admitted w.e.f. 9.7.2018 to 13.7.2018. OP No.3 admitted the deposit of Rs.83,637/-. So it is a consumer dispute, complaint is maintainable and this forum has the territorial jurisdiction.

11.   Coming to the fact whether the complainant has been able to prove deficiency on the part of O.Ps. or not. As discussed in earlier part of the order it stand established that complainant purchased Health Suraksha Insurance Policy by depositing premium of Rs.5862/- for the valid period from 13.7.2017 to 12.7.2018. It is well settled law that as and when the O.Ps. are to extend the benefits of policy then before accepting the premium the consumer/patient or applicant should be medically checked up by the Doctor. In case any of the defects comes in the body and is covered by the policy then the O.Ps. are bound to disclose the reason of denial the claim to the person (complainant). In case in hand, the commencement date of the policy 13.7.2017 and comes to an end on 12.7.2018. During the entire year complainant never approached to the O.ps. for any relief. Unfortunately, the complainant fell ill in the midnight of 8.7.2018 and got admitted in IVY Hospital i.e. OP No.3. As per complainant version, he spent Rs.1,30,000/ and the payment was made to the OP No.3. OP No.3 contested the complaint by filing reply and admitted the fact that the complainant admitted in their Hospital. OP No.3 further pleaded that complainant has only paid the medical expenses to the tune of Rs.83,637/-

12.   It is pertinent to mention that the valid policy was for the period from 13.7.2017 to 12.7.2018 and the date of admission of the complainant with OP No.3 is 9.7.2018 when the previous policy was near to mature then complainant again approached to the O.ps. No.1 & 2 and they received the premium of medical insurance for the period from 13.7.2018 to 12.7.2019 to the tune of Rs.5862/- and no medical check up. Moreso, the complainant was in hospital it means if there is any lapse qua the issuance of the policy, receipt of premium, then that goes with the O.Ps. No.1 &2.

13.   Complainant remains successful in proving the policy, deposit of premium and then the renewal of the policy for the next year. If the patient was having any of the old disease or was not legally entitled for any relief then why O.Ps. No.1 & 2 received the premium for the next year and issued the policy. It means O.ps. No.1 & 2 are only anxious to receive the premium and as and when the payment is to be made then to shirk from duty. Complainant placed on the file his affidavit, which is in accordance to the complaint. Beside this placed on file documentary evidence qua the payment of medical expenses/treatment Ex.C4 to Ex.C12. As per the documentary evidence Ex.C4 to Ex.C12 which are the receipts qua the payment of medical expenses on calculation it comes to Rs.1,02,000/- whereas the OP No.3 admitted expenses Rs.83,637/- but at the time, complainant alleged Rs.1,30,000/-. On this point, there are some authorities of Hon’ble National Commission as well as Hon’ble Supreme Court of India that as and when the patient is admitted in the Hospital and payment is made towards medical expenses/treatment of the doctor all the receipts of expenditure cannot be procured or maintained. The expenses goes much higher then the actual receipts. O.Ps in evidence has tendered an affidavit ex.OP1, which is in accordance to the reply. Beside this the OP No.2 is the general insurance policy and has relied upon Ex.OP3 and Ex.OP5. Relied upon the said documents Ex.OP1 & 2 has taken the stand that the patient was having old disease. This document is neither of the doctor prepared at the time of purchase of the policy or on the request of Ops. No.1 & 2. This document prepared on 9.7.2018 when complainant admitted in IVY Hospital because as and when the patient is admitted in the Hospital, the doctor who is supposed to treat him is to have a brief history of the patient like Age, Blood Pressure, Diabetes etc. So this document is of the same nature. Ex.OP6 is the letter issued by the O.Ps. No.1 & 2 to the O.P. No.1 and the operative part of the letter is

“As per the submitted documents, the patient was admitted on 09.07.2018 with the diagnosis of Hypertension with Gastritis and was treated for same. As the date of inspection of policy is 13.7.2018 and the ailment was diagnosed on 04 years back; the ailment is pre existing in nature. Hence this claim is being repudiated under Section 9A III of policy terms and conditions (Any preexisting disease/illness/injury will not be covered until 48 months of continous coverage have elapsed since inception of the first Healthy Suraksha Policy with us). Moreover insured had not disclosed the ailment while purchasing the policy. Hence there is non disclosure of material facts and thus this claim is being repudiated under Section 10 R III”.

14.               The complainant namely Virkaran admitted on 9.7.2018 with Diagnose of Hypertension with Gasture and was treated for the same. Finally relied upon the said denial of the claim of the complainant. Beside this OP No.3 has issued documents qua the treatment of the complainant. The Ops. No.1 & 2 has relied upon para No.8 in rule 2 in which O.ps. No.1 & 2 has taken the stand that the policy can be terminated if got issued on the ground of misrepresentation, fraud, nondisclosure of material facts etc. While declining the claim of complainant has relied upon this proof. The forum after appreciating the admitted documents between the complainant and the O.Ps. then considering the valid policy for the period from 13.7.2017 to 12.7.2018 and then its renewal dated 10.7.2018, has come to the conclusion that O.Ps. No.1 & 2 has rejected the claim of complainant regarding treatment on flimsy grounds. No solid reason has been given while denying the claim of the complainant. The complainant is having valid policy, expenses of the hospital are admitted and policy was admitted, it stands renewed. So the complainant has been able to prove deficiency on the part of O.Ps and the complainant is entitled to the claim.

15.               When it is held that the complainant is entitled to the claim then it is to be decided to what extent the complainant is entitled. In the complaint, the complainant pleaded Rs.1,30,000/- and O.P No.3  

Rs.83,637/-, whereas calculation of the Ex.C4 to Ex.C12 of Rs.1,02,000/=. So considering the totality of the document as discussed above, it is held that complainant is entitled Rs.1,00,000/- along with interest @ 7.5% per annum from the O.Ps. No.1 & 2 w.e.f. the date of discharge i.e. 13.7.2018 till its realization with cost of Rs.10,000/-.

16.               The O.Ps. No.1 & 2 are directed to comply with the said order within the period of 45 days from the date of receipt of certified copy of this order.

17.               The certified copies of this order be supplied to the parties forthwith, free of costs, as permissible under the rules and the file be indexed and consigned to Record Room.         

 

          ANNOUNCED                                                     (KARNAIL SINGH AHHI)

          Dated.04.01.2019                                PRESIDENT
              

 

 

                                                (CAPT. YUVINDER SINGH MATTA)

                                                                      MEMBER