District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.499/2022.
Date of Institution: 14.09.2022.
Date of Order: 14.11.2023.
Saurabh, aged about 22 years son of late Shri Sumer Singh, resident of House No. G-58, Village Sahupura, tehsil Ballabgarh, District Faridabad, Aadhar Card No. 5498 5374 9130.
…….Complainant……..
Versus
1. M/s. HDFC Ergo General Insurance Company Limited, IRDAI, rg. No. 146, Corporate office: Ist floor, HDFC House, 165/166, Backbay Reclamation, H.T. Parekh Marg, Churchgate, Mumbai – 400 020 through its Divisional Manager/Principal Officer.
2. M/s. HDFC Ergo General Insurance Company Ltd., Stellar IT Prk, Tower-1, 5th floor, C-25, Sector-62, Noida-201 301 through its Divisional Manager/Principal Officer.
…Opposite parties……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Sh. Yogesh Chaudhary, counsel for the complainant.
Sh. D.K.Gosain counsel for opposite parties Nos.1 & 2.
ORDER:
The facts in brief of the complaint are that the complainant obtained Optima Restore Folater policy bearing No. 28052042553074000000 valid form 10.8.2021 to 09.08.2022 and the insured amount was Rs.5,00,000/-. The complainant became seriously ill and he remained hospitalized at Sunshine Hospitals, Sector-64, Sahupura Road, Unchagaon, Ballabgarh, Faridabad, as he was suffering from loose stools in nature, repeated vomiting, pain in abdomen, cremping type, general weakness etc. and hence he got admitted in the above said hospital on 25.09.2021 and remained there upto 28.09.2021. The complainant informed the opposite party about his ailment immediately and requested the opposite parties to release the payment being cashless policy, but when the opposite parties did not release the payment, then the complainant again and again approached the opposite parties, then the opposite parties sent their representative namely Mr. Anuj Thakur form AAIZONE Services, who visited at the hospital on 27.09.2021 and he obtained the signature of the complainant on various documents and he submitted the same to their company. During that period the complainant spent Rs.20m802/- on account of doctors fees, room charges etc. and the complainant paid the said amount to the above said hospital. Accordingly the complainant submitted with the opposite parties his claim form for the above said amount and also completed each and every formality with the opposite parties to their entire satisfaction. Even the original bills were duly submitted by the complainant with the opposite parties at that time including on 17.12.2021. Inspite of completing each and every formality by the complainant, the opposite parties instead of releasing the payment of claimed amount, had rejected the claim of the complainant, vide their letter/ email message/intimation dated 04.01.2022, stating therein “We have received their request for reimbursement of claim for the above mentioned hospitalization. We have verified the same with respect to the coverage terms and conditions under the insurance policy plan and on primary scrutiny6 of the submitted documents we regret to inform their claim was not payable due to the following reason:-
“as per the documents submitted the claim was found to be misrepresented. As per the policy terms and conditions, if any, claim was in any manner dishonest of fraudulent, or was supported by any dishonest of fraudulent means or devices, whether by insured person or any one acting on behalf of an insured person, then this policy be forfeited. Hence this claim was being repudiated under section D-III of policy terms and conditions. Furthermore, as the policy was under process of cancellation, no further claim would be entertained.” The complainant sent legal notice dated 08.07.2022 to the opposite parties but all in vain. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) pay the amount of Rs.20,802/- alongwith interest @ 18% p.a. from the date of its due till its realization.
b) pay Rs.20,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 11,000 /-as litigation expenses.
2. Opposite parties put in appearance through counsel and filed written statement wherein Opposite parties refuted claim of the complainant and submitted that the complainant has taken the Optima Restore Family Insurance policy No. 2805204255307400 valid from the period 10.08.2021 to 09.08.2022. As alleged by the insured/complainant was admitted in Sun Shine Hospital, Faridabad form 25.09.2021 to 28.09.2021 with complaints of complainant for vomiting, loose motions and fever, since 3-4 days. Insured paid total Rs.20,802/- and thereafter a claim was lodged with the opposite parties seeking reimbursement for the expenses incurred during the hospitalization. It was submitted that the complainant had submitted the cashless claim, however, it was submitted that on investigation discrepancy was noticed and at that juncture the cashless claim was found not payable. Discrepancy were as follows:
- As per ICP patient admitted in the hospital with C/o loose stools, repeated vomiting and pain in abdomen since last 2-3 days. However, no stool test report found in ICPS.
- Insured was suffering with diarrhea but since first day he was taking lunch daily.
- Treating doctor not found during visit.
- USG was done outside but in ICPS no any radiological center visit found and vital chart found in single hand writing.
After the denial of cashless claim the complainant was advised to lodge the reimbursement claim and thereafter the complainant did lodge the reimbursement claim. However, the complainant was non-cooperative during the cashless claim, the claim was repudiated. Opposite parties denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite parties–HDFC Ergo General Insurance Company Limited with the prayer to: a) pay the amount of Rs.20,802/- alongwith interest @ 18% p.a. from the date of its due till its realization. b) pay Rs.20,000/- as compensation for causing mental agony and harassment . c) pay Rs. 11,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex. CW1/A – affidavit of Saurabh , Ex.C-1 (colly 1 & 10) – policy schedule – Optima Restore Floater, Ex.C-2 (Colly 11 & 12) – Adhaar card, Ex.C-3 (Colly) pg13 to 42) – history sheet, Ex.C-4 – Request for cashless hospitalization for health insurance policy, Ex C-5(colly 45 to 50) – claim verification form/questionnaire, Ex.C-6 (colly) pg.51 &52,, Ex.C-7 (colly) pg. 53 to 54 - letter dated 11.03.2022, Ex.C-8(colly) pg. 55 to 58 – legal notice, Ex.C-9 & C-10 - postal receipts, Ex.C-11 & 12– track consignments,
On the other hand counsel for the opposite parties strongly agitated
and opposed. As per the evidence of the opposite parties Ex.RW1/A – affidavit of Shweta Pokriyal – Sr . Manager – legal, HDFC Ergo General Insurance Co. Ltd., 5th floor, Tower-1, Stellar IT Park, C-25, Sector-62, Noida, Ex.RW1/1 – Policy Schedule – Optima Restore Individual,, Ex.RW1/2 – discharge, Ex.RW1/3 – History sheet, Ex.RW1/4 – letter dated 26.09.2021, Ex.RW1/5 – Vital Sign Chart, Ex.RW1/6 - Claim repudiation letter dated 04.01.2022, Ex.RW1/7 – Policy Schedule – Optima Restore Floater, Ex,RW1/8 – Endorsement Cum policy schedule – Optima Restore Floater,
6. As per Policy Schedule – Optima Restore Floater vide Ex.C-1 (Colly) 1 & 2, the complainant obtained Optima Restore Folater policy bearing No. 28052042553074000000 valid form 10.8.2021 to 09.08.2022 for the insured sun of Rs.5,00,000/-. The complainant was suffering from loose stools in nature, repeated vomiting, pain in abdomen, cremping type, general weakness etc. and he got admitted in Sunshine Hospitals, Sector-64, Sahupura Road, Unchagaon, Ballabgarh, Faridabad, and admitted in the said hospital on 25.9.2021 and remained there upto 28.09.2021 vide Ex.C-3 (colly) pg. 13 to 42) and the opposite parties raised a bill of Rs.20,802/-. The opposite parties repudiated the claim of the complainant on the ground of fraud vide Ex.RW1/6. On the other hand, allegation of the complainant is that the complainant has taken the claim of his wife form the same hospital. During the course of arguments, the query was made to the counsel for the opposite parties. The opposite parties has failed to establish their case. No claim was taken for his wife and the complainant has stated at Bar that he was admitted in the hospital and ultrasound was done by the doctor from outside and he has paid for Rs.80,000/ in total. In the interest of justice, the complaint is allowed with the direction to process the claim of the complainant.
7. Opposite parties Nos.1 & are directed to process the claim of the complainant within 30 days from the date of receipt of the copy of order and pay the due amount to the complainant alongwith interest @ 6% p.a. from the date of filing of complaint till its realization. Opposite parties Nos.1 & 2 are also directed to pay Rs.2200/- as compensation for causing mental agony & harassment alongwith Rs.2200/- as litigation expenses to the complainant. Compliance of this order be made within 30 days from the date of receipt of copy of this order. Copy of this order be sent to the parties concerned free of costs. File be consigned to the record room.
Announced on: 14.11.2023 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
