Tamil Nadu

South Chennai

CC/54/2014

M.Alima - Complainant(s)

Versus

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

M/s.Mohamed Fayaz Ali

26 Aug 2022

ORDER

Date of Complaint Filed : 17.01.2014

Date of Reservation      : 29.07.2022

Date of Order               : 26.08.2022

 

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,

CHENNAI (SOUTH), CHENNAI-3.

 

PRESENT:    TMT. B. JIJAA, M.L.,                                           : PRESIDENT

                       THIRU. T.R. SIVAKUMHAR, B.A., B.L.,           :  MEMBER  I 

                       THIRU. S. NANDAGOPALAN., B.Sc., MBA.,    : MEMBER II

 

CONSUMER COMPLAINT No.54 /2014

FRIDAY, THE 26^th DAY OF AUGUST 2022

Mrs. M. Alima,

W/o T.K. Mohammed Ali

Residing at:

No.22/3B, Thiru Nagar,

II nd  Street,

Chennai - 60 026.                                                           ... Complainant                         

 

..Vs..

                                          

HDFC ERGO, General Insurance Company Limited.,

Rep. by Authorised signatory,

6th Floor, Leela Business Park,

Andheri East, Andheri Kurla Road,

Mumbai - 400 059.                                                      …Opposite Party

******

Counsel for the Complainant         : M/s. Mohammed Fayaz Ali

Counsel for the Opposite Party       : M/s. Michael Marie Antony

 

        On perusal of records and after having heard the oral arguments of the Counsel for the Complainant and the Counsel for the Opposite Party, we delivered the following:

ORDER

Pronounced by Member – I, Thiru. T.R. Sivakumhar, B.A., B.L.,

1.      The Complainant has filed this complaint as against the Opposite Party under section 12 of the Consumer Protection Act, 1986 and prays to pay compensation of a sum of Rs.32,117/- towards policy claim and to pay a sum of Rs.15,000/- for the mental agony caused to the Complainant and to pay Rs.15,000/- towards deficiency in service along with cost of Rs.5000/-.

2.     The averments of Complaint in brief are as follows:-

The Complainant had obtained a Health Insurance Policy bearing Policy No.51352038 from Opposite Party for the period 29.10.2012 to 28.10.2014 which was proposed by her son. The Health Insurance obtained from Opposite Party provides cover for medical expenses incurred due to hospitalization involving more the 24 hours. The plan also covers pre and post hospitalization expenses, day care procedures, domiciliary treatment etc.  The Complainant suffered loose stools along with abdominal pain and she was admitted in the Billroth Hospital on 31.01.2013. The Complainant was diagnosed with mild erosive gastritis and was treated with oral medication and was discharged on 04.02.2013 and that she had incurred expenses of Rs.32,117 towards pre, post and inpatient Hospitalization expenses. She had applied for cashless facility, however the same was rejected by Opposite Party stating that she had a pre-existing disease. Since the cashless facility was rejected, she was constrained to pay the hospital charges from out of their own pocket. Thereafter her son wrote a letter to the Opposite Party on 19.02.2013 requesting to disburse the amount spent towards hospitalization. In reply to the above said letter, the Opposite Party on 06.03.2013 requested the entire original bill which was duly surrendered to Opposite Party by the 2^nd Complainant under letter dated 14.03.2013. Since there was no reply from Opposite Party, the Complainant wrote a letter to the Secretary, Office of the Insurances Ombudsman on 26.03.2013 together with the entire medical case history and bill details. Once again on 23.04.2013 upon Opposite Party's request all original documents of entire case papers and Treating Doctor Certificate were sent to Opposite Party for processing the payment. Despite having received the entire Document pertaining to the case and the medical bills in original, once again on 01.05.2013 the Opposite Party has stated that they have not received the Treating Doctor Certificate which is completely erroneous. Despite having submitted all the documents required, Opposite Party is demanding the same documents over and over again only with an intention to deceive and deprive her from rightful claim. The ailment for which she was treated is not pre-existing falling under the exclusion clause. The ailment for which she was treated was a mild erosive gastritis which cannot be considered as a pre-existing disease on any stretch of imagination. The Opposite Party's undue delay in processing the claim amounts to serious deficiency in service. Though she had a varied choice of choosing an insurance policy from various insurance companies, she chose HDFG ERGO General Insurance Company Limited as she believed that she would be offered good customer service, however she has now met with a rude shock. To her rude shock and surprise the insurance claim was repudiated by the Opposite Party on 17.06.2013 stating that the claim is excluded under the exclusion clause as a pre-existing disease. The claim by the Opposite Party is completely erroneous as gastritis, loose stools and abdominal pain cannot be considered as a pre-existing disease and the discharge summary of the hospital and the treating doctor certificate does not state that the treatment underwent by her was for a pre-existing disease. She is a "consumer" as envisaged under the Act. The Opposite Party is due and liable to pay a sum of Rs. 32,117/- towards claim. The Opposite Party is also liable to compensate the Claimant for deficiency in service for wrongful repudiation of the claim and for delay in compensating and also towards mental agony suffered at the hands of the Opposite Party despite having been sufficiently insured. Hence the complaint.

3. Written Version filed by the Opposite Party in brief is as follows:-

It is admitted that the Complainant had obtained a Health Suraksha' Policy with them for an Insured Sum of Rs.2,00,000/- vide Policy No. 51352037 for the period from 29.10.2012 to 28.10.2014. The health insurance cover has been granted subject to terms and conditions as stipulated the Policy. The reasons attributed by the Complainant regarding the admission at Billroth Hospital, diagnosis made, treatment given and the expenses alleged to be incurred are well within the knowledge of the Complainant and as such put to strict proof of the same. Complainant's son after admitting the Complainant at Billroth Hospital on 31.01.2013, made a request for cashless facility vide CCn No. RC-HS12-10032269. In the cashless request form, ailment was mentioned as AGE/?IBS/DM ie. Acute Gastroenteritis/ Irritable Bowel Syndrome/ Diabetes Mellitus and the consultation papers of Billroth Hospital dated 30.01.2013 mentioned IBD (Irritable Bowel Disease) with loose tools.On receipt of the claim form with preliminary documents, the Opposite Party herein perused the same and sent a letter dated 01.02.2013 to the Hospital requesting additional information namely 1. Exact duration of irritable bowel syndrome (IBS) and underlying etiology for the same 2. First consultation papers and investigation reports pertaining to IBS and 3. Clarification for difference in date of birth in order to process the claim. This Opposite Party humbly submits that in response to the query, the Hospital authorities sent a reply stating that 1. Duration of present illness as few days 2. IBS was suspected because patient had history of loose stools on and off since 4 months and history of previous admission for AGE. It further mentioned the final diagnosis as AGE/?IBS/?diabetic gastroperesis. Along with the reply, first consultation papers, medical records and previous discharge summaries were submitted by the complainant. On perusal of the aforesaid medical records, it was seen that the Complainant herein had been admitted as in-patient at Clinic Nallam, Pondicherry as early as 05.01.2012 for a day with complaints of loose stool, vomiting and abdomen pain diagnosed as Acute Gastero Enteritis (AGE) with dehydration. Further, the consultation papers dated 30.04.2012 and 30.05.2012 from Clinic Nallam, Pondicherry reveals that the complainant. had gone to the clinic with complaints of loose stools, restlessness, gastric, anxiety disorder and IBS. She was again admitted as in-patient at Clinic Nallam, Pondicherry on 17.09.2012 till 20.09.2012 for 4 days with complaints of loose stools and lower abdominal pain since 7 days that was provisionally diagnosed as Gastritis and Acute Gastero Enteritis (AGE) and the final diagnosis read as Anxiety neurosis with systemic hypertension with chronic vertigo cervical radiculopathy. She had repeated history of loose stools and was on treatment for IBS since 05.01.2012, whereas the date of commencement of policy is 29.10.2012. Therefore, it is evident from the medical documents submitted by the Complainant for cashless facility that the present ailment was a pre-existing disease before the inception of the policy. In this connection, this Opposite Party forwarded a letter dated 02.02.2013 to Billroth Hospital rejecting the cashless facility as the current ailment/symptom was found to be pre-existing. Since the denial of cashless facility does not deny claiming for treatment, the complaint's son sought this Opposite Party for the settlement of the claim. In this connection, this Opposite Party had requested for further medical records, bills, etc. taken at Billroth Hospital. However, even before processing the claim, the Complainant herein had approached the Ombudsman by his complaint dated 26.03.2013, A detailed self contained note was duly submitted to the Ombudsman by this Opposite Party. A personal hearing was fixed on 17.09.2013, Nevertheless, the Complainant did not turn up and informed the forum while contacted that he has filed the above consumer complaint. After carefully perusing the documents submitted by the Complainant with reference to the claim, it was evident that the insured has been treated for Gastritis/Irritable Bowel Syndrome. It is also apparent to note that the Complainant had a known case history of Gastritis, Chronic loose stools/IBS/DM/HTN/Hypothyroidista with history of hospitalizations for related treatment since 05.01.2012 prior to the inception of the policy. As per the policy terms and conditions, the said ailment falls under pre existing disease exclusion of the policy. Hence, this Opposite Party repudiated the claim and forwarded a claim repudiation letter dated 17.06.2013 to the complainant. Hence the complaint is to be dismissed.

4.      The Complainant submitted his Proof Affidavit and Written Arguments. On the side of the Complainant, documents Ex.A-1 to Ex.A-18  were marked.   The Opposite Party submitted his Proof Affidavit and Written Arguments. On the side of the Complainant, documents Ex.B-1 to Ex.B-11  were marked.  

Point for consideration:-

1. Whether the Opposite Party had committed Deficiency in service?

2.Whether the Complainant is entitled for reliefs claimed in the complaint and for any other relief/s?

 

Point No1:

        It is an undisputed fact that the Complainant had availed Health Insurance policy bearing No.51352038 from the Opposite Party valid from 29.10.2012 to 28.10.2014.

It is also not in dispute that the Complainant was admitted in Billroth Hospital, for loose stools along with abdominal pain on 31.01.2013 and had requested for cashless claim to the Opposite Party.

The dispute arose when the Opposite Party rejected the cashless claim of the Complainant on the ground of waiting period of 48 months for pre existing disease and had also repudiated the claim of the Complainant on the same ground.

The contention of the Complainant is that inspite of receipt of entire medical records from the hospital, the rejection of claim made is erroneous and further the ailment for which she was treated does not include in pre existing disease mentioned in the exclusion clause in the terms and condition of the policy, as she was treated for mild erosive gastritis, and the rejection made is a clear deficiency of service on the part of the Opposite Party and she is entitled for the medical expenses of Rs.32,117/- paid to the hospital.

The contention of the Opposite Party is that the Complainant had submitted her entire medical records including the previous records of treatment undergone.  As per the records submitted by the Complainant was clear that she had undergone treatment for Acute gastro enteritis with dehydration on 05.01.2012 itself as found in Ex.B-6  the discharge summary of Nallam Clinic, Puducherry, which is even before availing the subject policy. Further contended that the Complainant was well aware of the pre-existing disease would not be covered until 48 months of continuous coverage have lapsed, which is evidenced from Ex-B1 in page No.5 being transcript of telephonic conversation. Hence as per condition No.6-D of the policy the claim of the Complainant was rejected. 

On Perusal of the exhibits marked on both sides, the illness suffered by the Complainant is pre-existing in nature as she had undergone treatment i.e., Acute Gastro enteritis with dehydration with the complaints of loose stools, vomiting, pain Abdomen, as early on 05.01.2012 as evident from Ex. B-6, which is even before availing the subject policy on 29.01.2012, and the present treatment undergone by the Complainant as found in reply given by Billroth Hospital to the Opposite Party which was marked as Ex.B5, it is found that the complaints of loose stools and she was diagnosed as “AGE”-Acute Gastero Entritis. From Ex-B-1 in page no.15, under Exclusions in condition No.6(d) clearly refers to waiting period for pre-existing disease as “ Pre-existing conditions will not be covered until 48 months of continuous coverage have elapsed, since inception of first health Suraksha policy with us”. Further from Ex.B-1 in page No.5 of transcript the Complainant had aware of the said condition, as the Complainant had also filed the terms and condition of the policy as Ex.A-2 , but the reliance made by the Complainant on  Ex-A-10 being the treating Doctor’s certificate to show the treatment undergone is not for the pre-existing disease is not at all sustainable, as the same is contra to Ex-B5, being the reply given by the Billroth Hospital to the Opposite Party.  Hence, we hold that the repudiation of claim made by the Opposite Party is legally Sustainable.  Therefore, we are of the considered view that the Opposite Party has not committed any deficiency of service. Accordingly point No.1 is answered.

Point No 2:-

      As discussed and decided Point No1 in favour of the Opposite Party, the Complainant is not entitled for any relief claimed in the complaint and also not entitled for any other relief/s. Accordingly point no.2 is answered.

In the result the complaint is dismissed. No Costs.

Dictated to Steno-Typist, transcribed and typed by her, corrected and pronounced by us in the Open Commission, on 26^th of August 2022.  

 

 

S. NANDAGOPALAN               T.R. SIVAKUMHAR                 B.JIJAA

         MEMBER II                       MEMBER I                        PRESIDENT

 

List of documents filed on the side of the Complainant:-

 

Ex.A1	29.10.2012	Copy of Certificate of Insurance Policy
Ex.A2	-	Copy of Terms and Conditions of the Policy
Ex.A3	29.10.2012	Copy of Health Card issued by the O.P.
Ex.A4	31.01.2013	Copy of Discharge Summary
Ex.A5	31.01.2013	Copy of Bio Chemistry Lab Results
Ex.A6	01.02.2013	Copy of Colonoscopy Report
Ex.A7	01.02.2013	Copy of Oesophago-Gastro Duodenoscopy –Report
Ex.A8	-	Copy of Bills issued by the Billroth Hospital
Ex.A9		Copy of Medical Prescriptions given by the Billroth Hospital
Ex.A10	22.04.2013	Copy of Treating Doctor's Certificate
Ex.A11	19.02.2013	Copy of Letter from the Complainants to the Opposite Party
Ex.A12	06.03.2013	Copy of letter from the  Opposite Party to the Complainant
Ex.A13	14.03.2013	Copy of Letter from the Complainants to the Opposite Party
Ex.A14	26.03.2013	Copy of Letter from the Complainant to the Secretary Office of the Insurance Ombudman
Ex.A15	23.04.2013	Copy of Letter from the Complainant to the Opposite Party
Ex.A16	01.05.2013	Copy of Letter from the Opposite Party to the Complainant
Ex.A17	18.05.2013	Copy of Legal Notice issued by the Complainant to the Opposite Party
Ex.A18	17.06.2013	Copy of Letter of Repudiation of claim by the Opposite Party. to the Complainant

 

List of documents filed on the side of the Opposite Party:-

 

 

Ex.B1	-	Copy of Insurance policy with terms and conditions
Ex.B2	-	Copy of Pre-authorization request form
Ex.B3	-	Copy of Billroth hospital prescription dated 30.01.2013
Ex.B4	-	Copy of Additional information request form
Ex.B5	-	Copy of Billroth hospital reply
Ex.B6	-	Copy of Discharge summary Nallam clinic
Ex.B7	-	Copy of Nallam clinic-prescription dated 30.04.2012
Ex.B8	-	Copy of Nallam clinic-prescription dated 30.05.2012
Ex.B9	-	Copy of Discharge summary –Nallam clinic
Ex.B10	-	Copy of Cashless facility rejection letter
Ex.B11	-	Copy of Ombudsman award copy

 

 

 

S. NANDAGOPALAN               T.R. SIVAKUMHAR                    B.JIJAA

         MEMBER II                       MEMBER I                         PRESIDENT