BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 224 of 2017
Date of Institution : 7.9.2017
Date of Decision : 12.3.2018.
- Jawahar Lal son of Shri Sansar Chand
- Anju Bala wife of Shri Jawahar Lal
Both residents of House No.133/99, Water Works Road, Kalanwali, Tehsil Kalanwali, District Sirsa.
……Complainant.
Versus.
- HDFC Ergo General Insurance Company Ltd., registered & corporate office 165, 166 Blackberry, Reclamation HT Parekh Marg, Churg Gate Mumbai- 400020.
- HDFC Bank Ltd., having its Branch office at Kalanwali, District Sirsa, through its Branch Manager.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SH. R.L.AHUJA…………………………PRESIDENT
SH. MOHINDER PAUL RATHEE …… MEMBER.
Present: Sh. Manish Gupta, Advocate for the complainant.
Sh. R.K. Mehta, Advocate for opposite party no.1.
Sh. Rishi Sharma, Advocate for opposite party no.2.
ORDER
The case of the complainant in brief is that complainant purchased one health Suraksha Policy (silver plan) vide which the mediclaim to the tune of Rs.3,00,000/- was covered vide policy no.2825100061732702000 w.e.f. 23.6.2017 to 22.6.2018. The policy was firstly issued on 23.6.2015 which was continuously running. That the complainants were also issued cashless card in respect of this policy which was undertaken to be honored by recognized hospital including Max Hospital. It is further averred that in the month of March, 2017, the complainant no.1 developed a swelling over the left side of the face. However, as there was no pain or discharge etc., the complainant did not bother but since the swelling was persisting, so the complainant went to Indrani Hospital, Chandigarh for checkup, upon which on 10.7.2017 the complainant was advised ultrasound examination and the complainant was diagnosed to be having some nodes and submandibular glands with complex cystic marks relating to left parroted gland. It is further averred that doctors of Indrani Hospital immediately referred the complainant to undergo complete diagnose and referred to Max Hospital Super Specialty Hospital, Delhi. The complainant went to Max Hospoital on 14.7.2017 as per the advice of the doctors of Indrani Hospital, where he was got admitted. The complainant was subjected to thorough examinations and underwent many diagnostic test. The complainant produced his reference slip of Indrani Hospital and also produced his cashless card in the hospital and a claim was accordingly lodged with HDFC Ergo Insurance Company Ltd. through the hospital. However, the opposite party on 14.7.2017 itself repudiated the claim as told by the hospital authorities on the ground that the cashless claim is not available and the claim was repudiated on the ground that it was a pre-existing disease. The complainant was stunned to see the conduct of the op no.1 in repudiating the claim, even the complainant was never contacted before repudiating the claim and it was hurriedly repudiated. That the complainant had to take the treatment as was required and complainant was made to pay Rs.1,94,765/- and underwent surgery and was discharged on 16.7.2017 to take the further treatment. It is further averred that it was no pre-existing disease as mentioned in the repudiation letter. The op has hurriedly repudiated the claim of complainant without verifying the facts. That the problem of parotide gland has just started in the month of March, 2017 and complainant never had any problem in the past. The op no.1 has wrongly and arbitrarily repudiated the claim. Hence, this complaint for a direction to the ops to pay the claim of Rs.1,94,765/- alongwith interest at the rate of 18% per annum till realization and to pay an amount of Rs.1,00,000/- as compensation for causing mental agony and harassment and also to pay a sum of Rs.11,000/- as litigation expenses.
2. On notice, opposite party no.1 appeared and filed written statement taking certain preliminary objections regarding cause of action and that complaint of the complainant is pre-mature as the complainant after the cashless denial never approached the op for the reimbursement of his claim and that this Forum has got no territorial jurisdiction to try, entertain and adjudicate the present complaint as the policy of insurance was issued from Mumbai and the claim of complainant was processed and stands closed from Noida by HDFC Ergo General Insurance Company Ltd., where the answering op is having its office. The answering op is having no branch office at Sirsa. On merits, it is submitted that the claim of complainant was repudiated as per policy terms and condition on the ground of 48 months waiting period. The ailment for which the treatment was sought by complainant was found to be pre-existing in nature. Therefore, the claim of complainant was found not payable as per the policy terms and conditions under the purview of Section 9 A iii, which states that 48 months waiting period is required for all pre-existing disease. It is further averred that op received a pre-authorization request for cashless treatment on behalf of complainant from Max Super Specialty Hospital, Saket. The op processed the claim and documents were sought. On receipt of documents, the op duly processed the claim and on perusal of the documents, it was found that the complainant had history of Parotid swelling. In the letter issued by the hospital dated 11.7.2017, it was clearly mentioned that complainant was known case of Parotid swelling since 4-5 years. Therefore, the claim of complainant was denied by the op vide letter dated 14.11.2017 with the reasoning mentioned therein. Remaining contents of complaint are also denied.
3. Opposite party no.2 in its separate written statement also took preliminary objections regarding maintainability, locus standi, non joinder and mis joinder of necessary parties, no consumer dispute and suppression of true and material facts. On merits, it is submitted that as a matter of fact the answering op received the information that the complainants concealed the true and material facts with regard to their health while obtaining the aforesaid policy. The remaining contents of the complaint do not relate to the answering op. As per information, the op no.1 legally repudiated the claim of complainants.
4. The complainant no.1 produced his affidavit Ex.CW1/A, copy of card Ex.C1, copy of policy schedule Ex.C2, copy of repudiation letter dated 14.7.2017 Ex.C3 and copies of medical record Ex.C4 to Ex.C7. On the other hand, op no.1 produced affidavit of Sh. Pankaj Kumar, Legal Manager Ex.RW1/A, copy of repudiation letter dated 14.7.2017 Ex.R1, copy of prescription slip Ex.R2 and copy of policy Ex.R3. Op no.2 produced affidavit of Sh. Puneet Saxena, Branch Manager as Ex.RW2/A.
5. We have heard learned counsel for the parties and have perused the case file carefully.
6. During the course of arguments, learned counsel for opposite party no.1 has contended that complaint filed by complainant is a pre-mature as claim of complainant for cashless was only denied and same was not denied wholly and solely on the ground of pre-existing disease and complainant had not lodged any claim with the op no.1 after getting his treatment and discharge from the hospital nor the complainant had submitted any requisite document for settlement of the claim as a result of which the op no.1 could not decide the matter as no claim was lodged.
7. Learned counsel for op no.2 has contended that op no.2 has nothing to do with the claim of complainant. Op no.2 only paid premium amount to op no.1 on behalf of complainant.
8. On the other hand, learned counsel for complainants has contended that since the cashless facility was declined by op no.1 to the hospital of complainant no.1 on the ground of pre-existing disease, therefore, complainant no.1 was of the view that since the claim for cashless has been denied by ops then there was no need to lodge any fresh claim with the ops and to submit required documents as a result of which complainant no.1 could not lodge claim, but however, complainants are interested to lodge claim alongwith documents.
9. So, it will be in the fitness of things, if an opportunity is granted to complainants to lodge claim and submit the relevant documents and a direction is given to ops to settle and pay the claim as per terms and conditions of the policy.
10. In view of the above, we partly allow the present complaint and direct the complainants to lodge the claim alongwith the requisite documents with opposite party no.1 within a period of 30 days from today and thereafter opposite parties are directed to settle and pay the claim of the complainant no.1 as per terms and conditions of the policy further within a period of 45 days. The parties are left to bear their own costs. A copy of this order be supplied to the parties free of costs. File be consigned to the record room.
Announced in open Forum. President,
Dated:12.03.2018. Member District Consumer Disputes
Redressal Forum, Sirsa.
