Punjab

Sangrur

CC/463/2014

Chirag Aggarwal - Complainant(s)

Versus

HDFC Ergo - Opp.Party(s)

Shri Sumir Fatta

14 May 2015

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

                                                               

 

                                                Complaint No.    463

                                                Instituted on:      12.08.2014

                                                Decided on:       14.05.2015

 

Chirag Aggarwal, Advocate son of Ashok Aggarwal, resident of Shanti Kunj, Railway RoAd, Sangrur.

                                                        ..Complainant

                                        Versus

1.             HDFC Ergo Family Health Plan Limited, Sri Nilaya CXBTR SPAZIO, Suite No.101,102,109,110, Ground Floor, Road No.2, Bajara Hills, Hyderabad, through its authorised signatory.

2.             HDFC Ergo General Insurance Company Limited, 6^th Floor, Leela Business Park, Andher-Kurla Road, Andheri (East) Mumbai through its Authorised signatory.

                                                        ..Opposite parties

 

 

For the complainant    :       Shri Sumir Fatta, Adv.

For OPs                    :       Shri G.S.Shergill, Adv.

 

 

Quorum:    Sukhpal Singh Gill, President

                Sarita Garg, Member

 

 

 

Order by : Sukhpal Singh Gill, President.

 

1.             Shri Chirag Aggarwal,  complainant (referred to as complainant in short) has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the complainant obtained the services of the OPs by getting himself insured under policies bearing number 50140656 (Health Suraksha and number 5040657 (Sarvak Suraksha Advantage) for the period from 27.3.2012 to 26.3.2012 after paying the requisite premium of Rs.4025/- and Rs.722/-, respectively through credit card of HDFC Bank Limited owned by the complainant.

 

2.             The case of the complainant is that on 29.10.2012 he was got admitted in Colombia Asia Hospital, Patiala as he was suffering from pain in abdomen and was discharged on 30.10.2012 and after that the complainant submitted medical claim with the Ops. The OPs sent a cheque for Rs.12,023/-, but the OPs did not pay the amount of Rs.1250/-.  It is further averred that on 2.12.2012, when the complainant was on his way to Kaithal, suddenly the pain started in his abdomen as such the complainant was admitted at Dev Nursing Home Kaithal and was discharged on 7.12.2012, where he spent an amount of Rs.18,800/- on his treatment.  It is further averred that complainant again fell ill on 25.12.2012 after pain in abdomen, as such he was shifted to Dayanand Medical College and Hospital, Ludhiana where he remained admitted from 25.12.2012 to 29.12.2012, where he spent an amount of Rs.43,625/-. It is further stated that thereafter the complainant lodged the claim with the Ops and submitted all the bills for reimbursement of the amount.  The OPs paid only Rs.1000/- out of the earlier claim of Rs.1250/- and issued a letter to the complainant for submission of some documents, which were duly submitted vide reply dated 1.4.2013. It is further stated that the OPs out rightly rejected both the claims of the complainant i.e. for Rs.18800/- and Rs.43,625/-, respectively.  Thus, alleging deficiency in service on the part of the OPs, the complainant has prayed that the Ops be directed to pay to the complainant the claim amounts of Rs.18,800/- and Rs.43,625/- incurred upon the treatment along with interest @ 18% per annum and further claimed compensation and litigation expenses.

 

3.             In reply filed by OPs, legal objection is taken up that the claim file of the complainant is not traceable and without claim file, it is very difficult to give proper and effective reply of the complaint.  On merits also, it is averred that the claim file of the complainant is not traceable and without the claim file proper reply cannot be filed. However, thereafter, the OPs filed amended written reply wherein in legal objections are taken up on the grounds that the complaint is false, frivolous, vague and vexatious and that the complainant is himself guilty for not supplying the requisite documents.  On merits, it is stated that the complainant did not submit all the documents to the OPs. It is further stated that from the discharge summary of the DMC Hospital it transpired that the complainant was taking ayurvedic medicines for the last 2/3 years for attention and weakness and the complainant was asked to supply the documents regarding the said medication as well as the certificate from treating doctor, but, inspite of that the complainant failed to submit the documents, as such, the claim of the complainant was repudiated vide letter dated 25.5.2013, which is said to be quite genuine and legal one.  Any deficiency in service on the part of the OPs has been denied.

 

4.             The learned counsel for the complainant has produced Ex.C-1 copy of premium receipt, Ex.C-2 and Ex.C-3 copies of policy schedule, Ex.C-4 copy of health card, Ex.C-5 and Ex.C-6 copies of payment reference, Ex.C-7 copy of letter, Ex.C-8 copy of claim, Ex.C-9 copy of claim form, Ex.C-10 prescription slip, Ex.C-11 copy of payment receipt, Ex.C-12 to Ex.C-23 copies of bills, Ex.C-24 copy of discharge summary, Ex.C-25 copy of claim form, Ex.C-26 to Ex.C-40 copies of bills, Ex.C-41 copy of discharge summary, Ex.C-42 copy of room clearance slip, Ex.C-43 copy of discharge summary, Ex.C-44 copy of test report, Ex.C-45 copy of bill, Ex.C-46 and Ex.C-47 copies of letters, Ex.C-48 copy of courier slip, Ex.C-49 and Ex.C-50 copies of letters, Ex.C-51 copy of courier slip, Ex.C-52 to Ex.C-54 copies of letters, Ex.C-55 affidavit and closed evidence. On the other hand, the learned counsel for the OPs has produced Ex.OPs/1 copy of letter, Ex.Ops/2 copy of courier receipt, Ex.OPs/3 copy of letter, Ex.OPs/4 copy of courier slip, Ex.OPs/5 copy of letter, Ex.OPs/6 copy of investigation report, Ex.OPs/7 to Ex.OPs/10 copies of questionnaire, Ex.OPs/11 copy of terms and conditions, Ex.Ops/12 affidavit and closed evidence.

 

5.             We have very carefully perused the pleadings of the parties and heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits acceptance, for these reasons.

 

6.             It is an admitted fact that the complainant purchased the policies in question from the OPs by paying the requisite premium of Rs.4025/- and Rs.722/-, respectively.  It is also an admitted fact that the complainant had submitted two claims for Rs.18,800/- for the period 2.12.2012 to 7.12.2012 as he remained admitted in Dev Nursing Home, Kaithal and for Rs.43,625/- as the complainant remained admitted in Dayanand Medical College and Hospital, Ludhiana for the period from 25.12.2012 to 29.12.2012.   

 

7.             The learned counsel for the complainant has contended vehemently that the Ops did not pay the above said claims to the tune of Rs.18,800/- and Rs.43,625/- to he complainant, despite submission of all the documents, whereas the complainant had taken the insurance policy for Rs.3,00,000/- from the OPs, which is on record as Ex.C-2.  Ex.C-10 to Ex.C-24 are the relevant documents showing that the complainant remained admitted in Dev Nursing Home, Kaithal for the period from 2.12.2012 to 7.12.2012.  Ex.C-12 is the certificate issued by Dev Nursing Home, which clearly shows that they charged Rs.13,300/- from the complainant and Ex.C-13 to Ex.C-23 are the bills and receipt for purchase of medicines.  Further Ex.C-26 to Ex.C-45 are the copies of bills/receipts of medicines showing that the complainant took treatment from Dayanand Medical College and Hospital, Ludhiana.

 

8.             On the other hand, the learned counsel for the Ops has contended vehemently that the complainant did not submit the required documents despite their best efforts, as such the claim of the complainant has rightly been rejected.  It is further contended by the learned counsel for the Ops that the complainant took ayurvedic medicines as it was revealed by the Ops from the document Ex.Ops/10 that the complainant took ayurvedic medicine for two years for weakness.  But, the Ops have not produced on record any medical record that the complainant took treatment from any of the hospital or he ever remained admitted in any of the hospital for any illness.  It is worth mentioning here that if the complainant had taken the ayurvedic medicine for weakness, then it does not at all affect the claim of the complainant, more so when the OPs have not produced any documentary evidence on record to this effect.  We have also perused the document Ex.OPs/6, which is a copy of investigation report, wherein it has been stated that ‘the hospital has provided only discharge summary, as per the discharge summary, the insured was admitted in the hospital from 25.12.2012 to 29.12.2012 for complaint of pain in abdomen since two months and diagnosed as a case of pain in abdomen. Acute lead- intoxication. History of alcoholic ¼ bottle per day since 10 years. Occasion smoker. H/O ayurvedic medication since 2-3 years for attention and weakness. During hospitalisation patient had complaint of constipation & pain in abdomen found to have anemic and colonscopy were normal in view of HTN, anemia & H/Odesi medication, possibility of lead intoxication was kept.”  In conclusion, it is further stated in the investigation report, that the claim can be repudiated as patient was diagnosed as a case of pain in abdomen-Acute lead intoxication while as per the treating doctor statement cause of present complaint in this patient is history of Ayurvedic medication for two years for weakness.”    We have very carefully perused the investigation report, but we are not unable to accept the report on the basis of which, the OPs have repudiated the rightful claim of the complainant.  It clearly reveals that the Ops have rejected the claim on the ground that the complainant was having pain in abdomen and that the complainant was consuming ayurvedic medicine for the last two years for weakness.   But, the Ops have not produced any cogent, reliable and trustworthy evidence to support such a contention.  There is nothing on record produced by the Ops that the complainant ever remained admitted in any of the hospital prior to taking of the insurance policies in question.  In the circumstances of the case, we feel that the Ops have wrongly and illegally rejected the rightful claims of the complainant.

 

9.             In view of our above discussion, we allow the complaint and direct the Ops to pay to the complainant the amounts of Rs.18,800/- and Rs.43,625/- alongwith interest @ 9% per annum from the date of filing of the present complaint i.e. 12.08.2014 till realisation.  OPs are further directed to pay to the complainant an amount of Rs.10,000/- in lieu of consolidated amount of compensation for mental tension and litigation expenses.

 

10.            This order of ours be complied with within a period of thirty days of its communication. A copy of this order be supplied to the parties free of cost. File be consigned to records.

                Pronounced.

                May 14, 2015.

                                                        (Sukhpal Singh Gill)

                                                           President

 

 

                                                          

                                                                (Sarita Garg)

                                                                   Member