Chandigarh

DF-II

CC/519/2020

Aman Singh Brar - Complainant(s)

Versus

HDFC ERGO Health Insurance Ltd. (Formally Known as Apollo Munich Health Insurance Co. Ltd.) - Opp.Party(s)

Rahul Rampal

04 Oct 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II

U.T. CHANDIGARH

 

Consumer Complaint No.	:	CC/519/2020
Date of Institution	:	06/10/2020
Date of Decision	:	04/10/2024

       

                                       

              

 

         

Aman Singh Brar, age 28 years, son of Har Roop Inder Singh, resident of House No.2266-A, Sector 47-C, Chandigarh.

                                ...  Complainant

Versus

1.HDFC ERGO Health Insurance Limited, (Formally known as Apollo Munich Health Insurance Company Ltd.) through its General Manager, registered office at 101, 1^st Floor, Inizio Cardinal Gracious Road, Chakala Opposite PNG Plaza, Andheri East, Mumbai, Maharashtra.

2.HDFC ERGO Health Insurance Limited, (Formally known as Apollo Munich Health Insurance Company Ltd.) through its Manager, Office at SCO No.124-125, Sector 8, Madhya Marg, Chandigarh.

…. Opposite Parties

 

BEFORE:
	SHRI AMRINDER SINGH SIDHU	PRESIDENT
	SHRI B.M.SHARMA	MEMBER

 

 

ARGUED BY:
	Sh. Ankush Rampal, Adv. Proxy for Sh. Rahul Rampal, Counsel for complainant. Sh. Sachin Gupta, Adv. Proxy for Sh. Sachin Ohri, Counsel for OPs

 

ORDER BY AMRINDER SINGH SIDHU, M.A.(Eng.),LLM,PRESIDENT

1.        The complainant has filed the present consumer complaint alleging that he purchased a health insurance policy namely “Optima Restore Individual Insurance Policy” from Apollo Munich Health Insurance, now known as HDFC Ergo Health Insurance Limited i.e. the OPs.  The said policy (Annexure C-2) was valid w.e.f. 8.10.2019 to 7.10.2020.  Unluckily on 23.9.2020, the complainant with his family had gone to Siswan Jungle Hotel at Mullanpur, New Chandigarh and suffered a fall due to which he suffered a fracture neck of femur left and wound over scalp and was admitted in the Fortis Hospital, Mohali.  The complainant underwent surgery and he remained hospitalized at the said hospital from 23.9.2020 to 25.9.2020.  After treatment the said hospital raised total bill of ₹2,34,023/- but the OPs rejected the claim of the complainant vide letter dated 24.9.2020 (Annexure C-5) on the ground that treatment related to alcohol and related complications is not covered as per policy terms. Alleging that the aforesaid act amounts to deficiency in service and unfair trade practice on the part of OPs, complainant has filed the instant consumer complaint seeking claim amount alongwith interest, compensation and litigation expenses.
2.        In their written version OPs admitted that the complainant was duly insured under the policy in question and the same was valid at the relevant time.  However, it is averred that the liability of the OPs was strictly as per terms and conditions of the policy.  It is not disputed that on 23.9.2020 complainant suffered a fracture due to fall and he remained admitted at the Fortis Hospital from 23.9.2020 to 25.9.2020.  However, it is averred that as per the Medico Legal Certificate (MLC), complainant was badly under the influence of alcohol, therefore, the cashless request of the complainant was rightly repudiated on account of breach of terms & conditions of the policy. The remaining allegations have been denied, being false. Pleading that there is no deficiency in service or unfair trade practice on their part, OPs prayed for dismissal of the consumer complaint.
3.        The parties filed their respective affidavits and documents in support of their case.
4.        Complainant chose not to file replication.
5.        We have heard the learned Counsel for the parties and gone through the documents on record, including written arguments.
6.        The main question involved in the present consumer complaint is, whether there is any deficiency on the part of OPs in rendering service to the complainant or not?

              In order to find out answer to the above mentioned question, it is necessary to discuss the following facts and circumstances.

7.        OPs have rejected the claim of the insured/ complainant vide letter dated 24.9.2020 on the basis of the terms and conditions of the policy (Annexure R-1) i.e. clause (v) under the head Medical Exclusions as per which OPs were not supposed to pay any claim which is caused by, arising from or in any way attributed to treatment of illness or injury as a consequence of the use of alcohol, tobacco, narcotic or psychotropic substance and also on the basis of Medico Legal Case Intimation Form (Annexure R-2) wherein it has been mentioned that the patient (complainant) sustained injuries at 2:00 a.m. on 23.9.2020 as he was in inebriated state with foul smell of alcohol in breath.
8.        However, there is nothing on record that the terms and conditions of the policy were ever signed and agreed upon by the complainant, especially containing the exclusion clause. In M/s Modern Insulators Ltd. v. Oriental Insurance Co. Ltd., (2000) 2 SCC 734, it was held as under:-

        “(8) It is the fundamental principle of insurance law that utmost good faith must be observed by the contracting parties and good faith forbids either party from non-disclosure of the facts which the parties know. The insured has a duty to disclose and similarly it is the duty of the insurance company and its agents to disclose all material facts in their knowledge since the obligation of good faith applies to both equally.

9. …….. As the above terms and conditions of the standard policy wherein the exclusion clause was included, were neither a part of the contract of insurance nor disclosed to the appellant, respondent cannot claim the benefit of the said exclusion clause…….”

As such, in the absence of signature of the insured/ complainant on the terms & conditions of the policy containing the exclusion clause, it cannot be said that the same were ever disclosed/informed to him and thus are of no help to the OPs.

9.        Not only this, it is usual with the insurance companies to show all types of green pastures to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sorts of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation.  This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible.  It is generally seen that the insurance companies are only interested in earning premiums and find ways and means to decline claims.
10.        In similar set of facts the Hon’ble Punjab & Haryana High Court, Chandigarh in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others, 2008(3) RCR (Civil) Page 111 went on to hold as under:-

       “It seems that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy.  The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.

 

11.        As far as the plea of the OPs regarding consumption of alcohol by the complainant/insured is concerned, OPs have placed on record the photocopy of Medico Legal Case Intimation Form (Annexure R-2).  Though the OP has mentioned in its written version that it is a medical certificate yet it is found that the same is not a medical certificate, but, only a photocopy of Medico Legal Case Intimation Form.  Photocopy of Medico Legal Case Intimation Form is not per se admissible until and unless it is verified and certified by the concerned doctor or any competent person to that effect. Mere mentioning on the Medico Legal Case Intimation Form that there is foul smell of alcohol does not itself conclude that the insured/ complainant was drunk and in inebriated state unless any medical report, issued by the competent doctor, is placed on record.  In the absence of above said proof, it cannot be held that the insured/complainant was under the influence of alcohol when the accident took place.  Hence, we are of the opinion that the OPs should not have repudiated the claim of the complainant in toto and should have settled the same on non-standard basis and the said act certainly amounts to deficiency in service on their part.
12.        In view of the above discussion, the present consumer complaint deserves to be allowed and the same is accordingly partly allowed and OPs are directed to pay 80% of the claim amount of ₹2,34,023/- to the complainant alongwith interest @ 6% per annum from the date of repudiation till the date of its actual realization. 
13.        This order be complied with by the OPs within 60 days from the date of receipt of its certified copy.
14.        The pending application(s) if any, stands disposed of accordingly.
15.        Certified copy of this order be sent to the parties, as per rules. After compliance file be consigned to record room.

ANNOUNCED 04/10/2024 hg	(AMRINDER SINGH SIDHU) PRESIDENT
	(B.M.SHARMA) MEMBER