Punjab

Ludhiana

CC/21/240

Gurminder Jit Singh - Complainant(s)

Versus

HDFC Ergo Health Insurance Company limited - Opp.Party(s)

G.S.Sandhar

28 Aug 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                             Consumer Complaint No:  240 dated 30.04.2021.                                       Date of decision: 28.08.2024. 

 

Gurminderjit Singh Benipal aged about 58 yrs S/o. Manjit Singh, R/o. H. No.4728, Prem Nagar, Machhiwara Khas, Tehsil Samrala, Distt. Ludhiana. Mob. 98153-00964.

                                                                                      ..…Complainant

                                                Versus

1. HDFC ERGO Health Insurance Company Limited, branch office SCO 146, 2^nd Floor, Feroze Gandhi Market, Ludhiana-141001.
2.  
2. HDFC ERGO Health Insurance Company Limited (Formerly known as Apollo Munich Health Insurance Company Limited), 2^nd and 3^rd Floor iLABS Centre, Plot No.404-405, Udyog Vihar, Phase-III, Gurugram, 122016, Haryana.                                                                                                                                                             …..Opposite parties 

Complaint Under Section 35 of the Consumer Protection Act, 2019 for the grant of insurance claim regarding the loss caused to the complainant by suffering from accidental injuries and for compensation/costs for the deficiency in services of the respondents/opposite parties.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. G.S. Sandher, Advocate.

For OPs                         :         Sh. Alok Mohindra, Advocate.

 

 

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Shorn of unnecessary details, the facts of the case are that the complainant for himself as well as his family members purchased health insurance policy No.110600/11051/AA01081795 w.e.f. 30.04.2019 to 29.04.2020 through Mr. Rajan Gulati, an agent of the OPs. The complainant paid Rs.27,760.68 as premium to the OPs. The complainant further got renewed the policy through Mr. Rajan Gulati w.e.f. 30.03.2020 to 29.04.2021 vide policy No.110600/11051/AA01081795-01 by paying Rs.30,537.22 as premium having coverage of Rs.5,00,000/- for himself, his wife Smt. Tripat Kaur Benipal and son Jashanjot Singh Benipal. The complainant stated that in September 2020, unfortunately he suffered ankle injury when his left ankle was twisted while walking in the park due to which he underwent ligament reconstruction treatment under various doctors. He had to remained indoor patient at Fortis Hospital, Mohali for his treatment from 11.02.2021 to 13.02.2021 where surgery was conducted and Rs.2,12,141/- was charged from him. He was also under the out-patient treatment of concerned doctor of Fortis Hospital, Mohali. The complainant claimed to have spent Rs.20,000/- as other charges. The complainant further stated that as the policy was cashless and at the time of his treatment at Fortis Hospital, Mohali, he submitted cashless request with the OPs but the same was declined by the OPs due to which the complainant had to bear all the expenses from his own pocket. Even the complainant submitted alll the documents with the OPs for assessment of his claim but the OPs wrongly declined his claim on false grounds, due to which, the complainant has suffered mental pain, agony, monetary loss etc. In the end, the complainant has prayed for issuing direction to the OPs to release the claim amount and Rs.5,00,000/- as compensation along with interest etc.

2.                Upon notice,  the OPs appeared and filed written statement assailed the complaint by taking preliminary objections on the grounds of maintainability; the complaint being barred by Consumer Protection Act, 2019; lack of jurisdiction and lack of cause of action; the complainant has not approached with clean hands; concealment of material facts; the complaint being abuse of process of law etc. the OPs stated that the ailment for which the claim was raised falls under the two years waiting period exclusion in terms of the policy. Hence, no benefit is payable to the complainant within two years from the initiation of the policy for the subject claim raised by him, in terms of the policy. On reviewing his documents as well as claim, it was found that the insured was admitted for diagnosis of left ankle lateral Ligament instability with ATFL/LFL Tear + early OA left ankle and surgery of Left ankle arthroscopic debridement + lateral Ligament reconstruction left ankle done on 11.02.2021, which falls under 2 years specific waiting period as per the terms of the policy. According to the OPs, the repudiation of the cashless request is justified in consonance with Section VI A (ii) of the policy and no relief can be granted to the complainant.

                   Under the column Brief Facts of the Case, the OPs stated that the policy holder Mr. Gurminderjit Singh Benipal, submitted a Proposal Form for issuing an "Easy Health Floater Standard" to insure himself, his wife and his son, for sum assured as opted for. He had submitted the Proposal Form after going through the terms and conditions of the policy, the details of which were also explained to him by the insurance agent/sales representative. Further believing the declaration, information and details provided by the proposer including the medical history to be true, correct and complete in all respect, giving due credence to the under writing norms of the OPs, a Policy No. 110600/11051/AA01081795 was issued for sum assured opted on 01.04.2019 for period 30.03.2019 to 29.03.2020 and the Easy Health Floater Standard Policy insurance coverage which later renewed for period 30.03.2020 to 29.03.2021. The Ops further stated that all the policy documents were supplied to the complainant and he never approached the Company stating that any information given in the documents in the Policy Kit are incorrect or any term and condition therein is not understandable or acceptable to him within the free look period i.e. 15 days from the receipt of the policy document.

                   The OPs further stated that the complainant deliberately did not file the terms and conditions of the policy with ulterior motive to extract money from it. On 11.02.2021, cashless request was received by the complainant/hospital along with documents for the hospitalization for complainant at Fortis Hospital with date of admission 11.02.2021 with estimated treatment cost of Rs. 2,90,000/-. However, post reviewing the documents by the OPs, it was observed that the complainant was admitted in hospital with complaint of Pain in ankle after alleged twisting injury 8 month back and underwent LCL reconstruction and also noted that present ailment/procedure for which treatment is sought comes under two years exclusion list of policy terms & condition. i.e. Treatment of LCL TEAR is excluded from the policy if admitted in 2 Years of policy inception date and policy inception date is 30.03.2019 i.e. 23th month of inception of policy. Hence cashless request was rejected vide letter dated 12.02.2021 as per policy terms and conditions and communicated to complainant. According to the OPs, they have rightly rejected the cashless request under the policy terms and conditions, which is reproduced as under:-

“Section VI. Special terms and conditions

A. Waiting Period

ii) A waiting period of 24 months from the first policy commencement date will be applicable to the medical and surgical treatment of illness/ diagnosis or surgical procedures mentioned in the following table. However this waiting period will not be applicable where the underlying cause is cancer(s).

Sr. No.	Organ/Organ System	Illness/Diagnosis (irrespective of treatments medical or surgical)	Surgeries/procedure (irrespective of any illness/diagnosis other than cancers)
C	Orthopaedic	Non infective arthritis Gout and Rheumatism Osteoporosis Ligament, Tendon & Meniscal tear Prolapsed inter vertebral disk	Joint replacement surgeries

 

                   On merits, the OPs reiterated the crux of averments made in the preliminary objections and Brief facts of the Case. The OPs have denied that there is any deficiency of service and have also prayed for dismissal of the complaint.

3.                In evidence, the complainant tendered his affidavit as Ex. CA and reiterated the averments of the complaint. The complainant also placed on record documents i.e. Ex. C1 is the copy of policy schedule, Ex. C2 is the copy of welcome letter, Ex. C3 is the copy of certificate of Fortis Hospital, Mohali, Ex. C4 is the copy of discharge  summary dated 13.02.2021, Ex. C5, Ex. C6 is the copy of inpatient summary bill, Ex. C7 is the copy of deposit receipt of Rs.2,02,141/- dated 13.02.2021, Ex. C8 is copy of deposit receipt of Rs.10,000/- dated 11.02.2021, Ex. C9, Ex. C12 is the copy of retail invoice of Lifecraft Healthcare Pvt. Ltd., Ex. C10, Ex. C11, Ex. C13 is the copy of outpatient bill dated 25.02.2021, 08.04.2021 respectively, Ex. C14 is the copy of cashless repudiation letter, Ex. C15 is the copy of Aadhar Card of the complainant and closed the evidence.

4.                On the other hand, the counsel for the OP tendered affidavit  Ex. RA of Sh. Manoj Kumar Prajapati, Authorized Signatory of the OPs  along with documents Ex. R1 is the copy of Certificate of Incorporation pursuant to change of name, Ex. R2 is the copy of welcome letter and policy documents, Ex. R3 is the copy of cashless hospitalization request, Ex. R4 is the copy of cashless denial letter dated 12.02.2021 and closed the evidence.                 

5.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written statement along with affidavit and documents produced on record by both the parties.                 

6.                The complainant obtained a policy No.110600/11051/ AA01081795. Ex. R2 is the welcome letter, policy schedule and terms and conditions of the policy. The relevant clauses and definitions mentioned in terms and conditions of the policy are reproduced as under:-

“Section VI. Special terms and conditions

1. Waiting Period.

(ii) A waiting period of 24 months from the first policy commencement date will be applicable to the medical and surgical treatment of illness/diagnosis or surgical procedures mentioned in the following table. However this waiting period will not be applicable where the underlying cause is cancer(s).

‘Accident’ means a sudden, unforeseen and involuntary event caused by external, visible and violent means.

‘Injury’ means accidental physical bodily harm excluding illness or disease solely and directly caused by external, violent and visible and evident means, which is verified and certified by a Medical Practitioner.”

 

7.                The complainant without specifying date, time and place claimed that in the month of September 2020, he got twisted his left ankle and suffered injury while walking in the park. He remained under treatment with various doctors but he did not disclose the details of doctors nor appended respective medical records. Finally he underwent surgery during course of hospitalization from 11.02.2021 to 13.02.2021 at Fortis Hospital, Mohali. The discharge summary is Ex. C4 and according to the complainant he incurred an amount of Rs.2,12,141 as detailed in the Bill Ex. C5. Further during the course of hospitalization, cashless request with estimated treatment cost of Rs.2,90,000/- was declined on 12.02.2021 vide letter Ex. R4. The operative part of denial letter Ex. R4 is reproduced as under:-

“We have received a cashless claim request for above mentioned hospitalization. We have verified the coverage terms & conditions under the insurance pan. On primary scrutiny of the request, we are unable to extend the cashless facility due to following reasons:-

1. As per the available documents, presenting ailment/procedure for which treatment is sought comes under two year’s exclusion list of policy terms & conditions i.e. Treatment of LCL TEAR is excluded from the policy if admitted in 2 years of policy inception date.”

There is nothing on record to show that any reimbursement claim was ever lodged by the complainant after the denial of cashless claim.

9.                Now the point of determination arises whether the cashless claim of the complainant was righty rejected or not?

10.              The definition of the ‘accident’ and ‘injury’ mentioned hereinbefore when read together, postulates that the sudden and unforeseen event resulting into injury must have been caused by some external, visible and violent means which further requires verification and certification by Medical Practitioner. It is the case of the complainant that he suffered twisting of ankle while strolling in the park and apparently the twisting of ankle does not fall within the parameters of an accidental injury. Further there is no verification or certificate to this effect by a Medical Practitioner.

11.              The policy in question was incepted on 30.03.2019 and the twisting of ankle took place in September 2020 and the surgical procedure was conducted on 12.02.2021 i.e. 23^rd month from the inception of the policy. So undergoing of surgical treatment is within the waiting period of 24 months from the date of commencement of the first policy. Therefore, the OPs have rightly invoked clause VI (A) (ii) of the policy terms and conditions and have righty denied the cashless request of the complainant.

12.              As a result of above discussion, the complaint fails and the same is hereby dismissed. However, there shall be no order as to costs. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.   

13.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

 

(Monika Bhagat)                              (Sanjeev Batra)               Member                                         President  

 

Announced in Open Commission.

Dated:28.08.2024.

Gobind Ram.