BEFORE THE DISTRICT CONSUMER DISPTUES REDRESSAL FORUM, KAITHAL.
Complaint no.63/15.
Date of instt.: 08.04.2015.
Date of Decision:01.08 .2016.
Spinder Singh son of Sh. Gurnam Singh, r/o H.No.3, VPO Badsikri Kalan, Block No.458, Tehsil & Distt. Kaithal.
……….Complainant.
Versus
- HDFC ERGO General Insurance Company Ltd., HDFC Bank, Ambala Road, Kaithal, Distt. Kaithal through its Sales Executive Sh. Nakul Singh.
- HDFC ERGO General Insurance Company Ltd., 6th floor, Leela Business Park, Andheri-Kurla Road, Andheri (E), Mumbai-400059 through its Manager.
.……..Opposite Parties.
COMPLAINT UNDER SEC. 12 OF CONSUMER PROTECTION ACT, 1986.
Before: Sh. Jagmal Singh, President.
Sh. Rajbir Singh, Member.
Smt. Harisha Mehta, Member.
Present : Sh. Satish Sharma, Advocate for complainant.
Sh. Sudeep Malik, Advocate for the opposite parties.
ORDER
(JAGMAL SINGH, PRESIDENT).
The complainant has filed the present complaint under Section 12 of Consumer Protection Act, 1986, with the averments that he approached the Op No.1 for taking a car loan in the year 2012 and Op No.1 sanctioned the said car loan. It is alleged that on the advice of Op No.1, the complainant purchased two health insurance policies No.2950200394391100000 dt. 21.12.2012 and 2950200687627400000 dt. 21.02.2014 respectively and he paid the premium of Rs.6438/- each. It is further alleged that the complainant faced the heart attack on 31.05.2014 and got admitted in Bansal Hospital, Kaithal on the same day and he was referred to P.G.I. Chandigarh. It is further alleged that that the complainant was got admitted in P.G.I. Chandigarh on 31.05.2014 and got treatment for two days in emergency and discharged on 01.06.2014. It is further alleged that he was again admitted in PGI Chandigarh on 05.06.2014 to 06.06.2014. It is further alleged that the complainant lodged the claim of both the policies with the Ops and submitted all the required documents but the Ops repudiated the claim of complainant vide letter dt. 30.06.2014. The said repudiation of claim is wrong and illegal. This way, the Ops are deficient in service. Hence, this complaint is filed.
2. Upon notice, the opposite parties appeared before this forum and filed written statement raising preliminary objections with regard to maintainability; cause of action; locus-standi; the answering Ops have already repudiated the claim under intimation to the complainant vide registered letter dt. 30.06.2014. The claim under the policies were repudiated for two reasons: (i) ailment suffered within the period of ninety days from inception of policy and hence, it falls under ninety days exclusion clause of the policy (ii) ailment does not fall under the category of critical illness as described under the policy. The first ground of repudiation is applicable to claim No.C295014001038 because as per OPD ticket dt. 05.06.2014, the complaint of chest pain and coronary artery diseases was diagnosed one month back and thus exclusion (i) to Section-I of policy condition gets attracted and the ailment falls within ninety days exclusion clause since policy inception date is 21.02.2014 and ninety days expired on 21.05.2014. However, ailment was diagnosed around 05.05.2014 as per OPD ticket. However, the second ground of repudiation is applicable of both the claims as the ailment does not fall under the category of critical illness. The list of nine critical illness are mentioned under Section 1 of the policy and the insured ailment does not fall under any of the category. The ailment as appeared from the treatment documents states about Angine which does not quality to be a Myocardial Infarction, as described under the policy. Hence, the claim is not payable under both the policies, hence, the claim under the policies were rightly repudiated vide letter dt. 30.06.2014. There is no deficiency in service on the part of answering Ops. On merits, the contents of complaint are denied and so, prayed for dismissal of complaint.
3. In support of his case, the complainant tendered in evidence affidavit Ex.CW1/A and documents Ex.C1 to Ex.C11 and Mark CA to Mark-CQ and closed evidence on 25.02.2016. On the other hand, the Ops tendered in evidence affidavit Ex.RW1/A and documents Annexure R1 to Annexure R5 and closed evidence on 21.04.2016.
4. We have heard ld. counsel for both the parties and perused the case file carefully and minutely and have also gone through the evidence led by the parties.
5. Learned counsel for the complainant argued that the complainant has purchased a health insurance policy bearing No. policies No.2950200394391100000 dated 21.12.2012 after depositing the premium of Rs.6438/- in the office of OP No.1. He further argued that the complainant purchased another health insurance policy bearing No.2950200687627400000 dated 21.02.2014 on depositing the premium of Rs.6438/-. Both the policies were Sarv Surksha Policy and are for a period of five years. He further argued that on 31.5.2014 the complainant faced the heart attack and was admitted in Bansal Hospital, Kaithal, who referred the complainant to PGI, Chandigarh. The complainant was admitted in PGI on 31.5.2014 in the evening and was discharge from there on 1.6.2014 after advising the conducting of angiography. He further argued that the complainant again admitted in PGI, Chandigarh for two days i.e. 5.6.2014 & 6.6.2014 and got conducted the required test and diagnosis. He further argued that on 7.6.2014 the complainant inform the Ops about his critical illness of heart attack. He further argued that the critical illness mentioned in the terms and conditions of the policy is covered the illness of heart attack. According to both policies, the complainant was entitled for Rs.1,00,000/- for each policy under the head critical illness. He further argued that the Ops sought some documents vide letter dated 9.6.2014 and the complainant sent the same to the Ops on 26.6.2014 through courier. He further argued that inspite of completion of entire formalities by the complainant, the Ops have not made the payment of any claim of the complainant. On the other hand learned counsel for the Ops argued that the claim under both the policy of the complainant have been repudiated vide letter annexure R-1 dated 30.6.2014 for two reasons; i) ailment suffered within a period of ninety days from inception of policy and hence it falls under ninety days exclusion clause of the policy. ii) Ailment does not fall under the category of critical illness as described under the policy. He further argued that besides the above clause of critical illness, the case of the complainant regarding second policy falls under 90 days exclusive clause. He further argued that the claim of the complainant has been rightly repudiated.
6. From the pleadings and evidence of the parties, it is clear that there is no dispute that the complainant had purchased two Sarv Surksha Policies vide policy bearing No.2950200394391100000 valid from 21.12.2012 to 20.12.2017 and policy bearing No. 2950200687627400000 valid from 21.2.2014 to 20.2.2014. It is clear from the policies that the insurance amount in the critical illness is Rs.1,00,000/- in each policy. From the terms and conditions of the policies, Ex.C-6, it is clear that illness of heart attack is covered under the critical illness. The complainant has specifically mentioned in his complaint that he was admitted in PGI, Chandigarh on 31.5.2014 in the evening and was discharge on 1.6.2014 with the advice of conducting the angiography. It is further mentioned in the complaint that the complainant was again admitted in PGI, Chandigarh for two days i.e. 5.6.2014 and 6.6.2014 and got conducted the required test. As already stated above, the doctor of PGI has advised the complainant for angiography, the complainant has not placed any test report of angiography on the file. The complainant has not placed any other test report which shows that he had suffered from heart attack. Even the complainant has failed to place the report of angiography on the file inspite of asking of this Forum. Without a report of angiography, it can not be said that whether the complainant had suffered any heart attack or not. So, complainant has failed to prove that the disease from which he had suffered was a heart attack. Hence, the disease of the complainant has not covered under the head of critical illness of policy. In these circumstances, we find no deficiency on the part of Ops.
7. Thus, as a sequel of above discussion, we find no merit in the complaint and same is hereby dismissed. No order as to costs. A copy of this order be sent to both the parties free of costs. File be consigned to the record room after due compliance.
Announced.
Dt.01.08.2016.
(Jagmal Singh),
President.
(Harisha Mehta), (Rajbir Singh),
Member. Member.
Spinder versus HDFC etc.
Present : Sh. Satish Sharma, Advocate for complainant.
Sh. Sudeep Malik, Advocate for the opposite parties.
Arguments heard. Order announced. Vide our separate detailed order, the complaint is hereby dismissed. File be consigned to record room after due compliance.
Dated:01.08.2016 President
Member Member
