Chandigarh

DF-II

CC/469/2021

Avtar Singh Cheema - Complainant(s)

Versus

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

N.S Jagdeva Adv.

27 Jun 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II

U.T. CHANDIGARH

 

Consumer Complaint No.

:

469/2021

Date of Institution

:

23.07.2021

Date of Decision    

:

27.06.2023

 

                                       

                                               

Avtar Singh Cheema s/o Harbans Singh r/o H.No.348, Sector 37-A, Chandigarh.

        ...  Complainant.

Versus

1.      HDFC Ergo Health Insurance Co. Ltd., through its Managing Director, D-301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg Bhandup (West) Mumbai-400078, Maharashtra.

2.      HDFC Ergo Health Insurance Co. Ltd., through its Branch Manager, SCO No.124-125, Sector 8, Madhya Marg, Chandigarh , email id …. Opposite Parties.

BEFORE:  

SMT.SURJEET KAUR, PRESIDING MEMBER

SHRI B.M.SHARMA, MEMBER

 

Argued by:-

       

                Sh.N.S.Jagdeva, Adv. for complainant

                Sh.Nitesh Singhi, Adv. for OPs.

 

PER SURJEET KAUR, PRESIDING MEMBER

  1.         Brief facts of the case are as alleged by the complainant are that he took health insurance policy i.e. Optima Restore Floater Insurance Policy of the OPs which was valid from 05.03.2020 to 04.03.2021 by paying premium amount of Rs.21261.24P for sum assured of Rs.10.00 lacs (Annexure C-1). He had been taking the medical policies of other companies since 2014 without any break.  Due to covid-19 pandemic, he was hospitalized from 20.09.2020 to 20.10.2020 and was kept on ICU on life support system. He was discharged from the hospital on 20.10.2020 (Annexure C-2)  and incurred Rs.9,32,918/- on his treatment vide bill dated 20.10.2020 (Annexure C-4). It has been averred that the OPs have made payment of Rs.5,09,840/- and the remaining amount of Rs.4,23,078/- was paid by him.  It has been averred that the OPs have deducted the remaining amount without assigning any justified reason. He made various representations to the OPs to release the remaining amount but to no effect. Finally, he got served the legal notice dated 07.06.2021 upon the OPs but to no effect.  Alleging that the aforesaid acts of omission and commission on the part of the OPs amount to deficiency in service and unfair trade practice, the complainant has filed the instant complaint seeking directions to the OPs to refund the remaining amount along with interest, compensation for mental agony and physical harassment as well as litigation expenses.
  2.         In their written statement, the OPs while admitting the factual matrix of the case have pleaded that they have received the cashless request from the Ivy Hospital, Mohali where the complainant took the treatment under Dr.Bhavesh.  It has been pleaded that at the time of discharge final approval of Rs.5,09,840/- was given against the final bill and the remaining amount was deducted as per the State Government Notification Punjab regarding Covid treatment as reproduced in para 3 to 5 of the written statement on merits.  It has further been stated that the complainant is not entitled for any amount which is over and above the settled terms and conditions of the policy or as per the guidelines/notification of the State Government. The remaining allegations have been denied, being false. Pleading that there is no deficiency in service on their part, the OPs prayed for dismissal of the complaint.
  3.         The complainant filed replication to the written reply of the Opposite Parties controverting their stand and reiterated the contents of the complaint.
  4.         The parties led evidence by way of their affidavits and documents.
  5.         We have heard the learned counsel for the parties and gone through the record as well as written submissions.  
  6.         It is not in dispute that the complainant took treatment during the existence of the policy in question from the Ivy Hospital, Mohali for the period from 20.09.2020 to 20.10.2020 and incurred Rs.9,32,918/- on his treatment.  Concededly, the claim of the complainant was duly covered under the terms and conditions of the insurance policy and the OPs have released the claim to the tune of Rs.5,09,840/- and deducted the remaining claim under the shelter of the instructions/guidelines issued by the Punjab Govt. whereby the capping was imposed on the hospitals that they cannot charge more than the prescribed limit in the list.
  7.         Pertinently, the aforesaid instructions/guidelines issued by the Punjab Government (Ex.C-10) have come into existence on 11.01.2021 i.e. much after the hospitalization of the complainant meaning thereby the same were not in existence on the day of generating the bill and discharge of the complainant from Ivy Hospital, Mohali.  The perusal of the contents of the written statement clearly shows that the OPs have intentionally and deliberately not mentioned the date regarding the issuance of the aforesaid notification in order to deny the genuine claim of the complainant under the garb of the aforesaid instructions and to mislead this Commission.   Thus, the OPs cannot be allowed to take shelter of the aforesaid instructions, which come into existence much after the treatment of the complainant.  As such action of the OPs in not releasing the entire claim to the complainant not only amounts to deficiency in service but also unfair trade practice on their part.
  8.         In view of the above discussion, the present complaint deserves to be partly allowed and the same is accordingly allowed. The OPs are directed as under;-
  1. To refund the remaining claim of Rs.4,23,078/- to the complainant along with interest @ 9% p.a. from the date of its rejection/denial till its actual realization.
  2. To pay Rs.15,000/- to the complainant as compensation for mental agony and physical harassment suffered by them.
  3. To pay Rs.11,000/- as costs of litigation.

                This order be complied with by the OPs within 45 days from the date of receipt of its certified copy, failing which the amounts at Sr.No.(i) and (ii) shall also carry interest @12 % per annum from the date of this order till actual payment besides litigation expenses.

  1.         Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced

27/06/2023

 

 

Sd/-

(SURJEET KAUR)

PRESIDING MEMBER

 

 

 

Sd/-

 (B.M.SHARMA)

MEMBER

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