DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SAHIBZADA AJIT SINGH NAGAR (MOHALI)
Consumer Complaint No.459 of 2015
Date of institution: 10.09.2015 Date of decision : 28.12.2016
Rakesh Talwar son of Nand Kishore Talwar, resident of A/522, Sadar Bazar, Karnal, District Karnal, Haryana.
……..Complainant
Versus
1. HDFC Life Insurance Co. Ltd. having its registered office at Lodha Excelus, 13th Floor, Apollo Mills Compound, N.M. Joshi Marg, Mahalaxmi, Mumbai through its Managing Director.
2. HDFC Life Insurance Co. Ltd., having its local office at SCO No.149 to 151, Sector 43-B, Chandigarh through its Branch Manager.
3. e-Meditek (TPA) Services Limited, having Corporate Office at Plot No.577, Udyog Vihar, Phase-V, Gurgaon, Haryana 122016 through its Managing Director.
4. Max Super Specialty Hospital (a unit of Hometrial Estate Pvt. Ltd.), near Civil Hospital, Phase-6, SAS Nagar (Mohali) through its Managing Director.
………. Opposite Parties
Complaint under Sections 12 of
the Consumer Protection Act.
Quorum
Shri Ajit Pal Singh Rajput, President
Mrs. R.K. Aulakh, Member.
Present: Shri P.S. Bhangu, counsel for the complainant.
None for OP No.1 and 4.
Shri Nitin Thatai, counsel for OP No.2.
OP No. 3 ex-parte.
ORDER
By Ajit Pal Singh Rajput, President
Complainant Rakesh Talwar son of Nand Kishore Talwar, resident of A/522, Sadar Bazar, Karnal, Haryana has filed this complaint against the Opposite Parties (hereinafter referred to as the OPs) under Sections 12 of the Consumer Protection Act. The brief facts of the complaint are as under:
The complainant had purchased HDFC Life Health Assure Plan from OP No.1 and 2 for himself, his wife and son by paying premium of Rs.26,338/-. The risk commencement date of the policy was 25th January, 2015 and the sum insured under the policy was Rs.5,00,000/-. Before issuing the policy, OP No.1 and 2 got complete medical check up of the complainant and only after satisfying themselves issued the policy in the name of the complainant. OP No.3 is the TPA of OP No.1 and 2. On 09.04.2015 the complainant got admitted in OP No.4 as he felt some uneasiness and pain in his chest. After tests, doctors of OP No.4 recommended heart surgery of the complainant. Doctors also told the relatives of the complainant about blockage in the heart and that stents have to be planted in the heart of the complainant. Accordingly heart surgery was conducted on 09.04.2015 and 5 stents were implanted in the heart of the complainant. The total cost of surgery was around Rs.7,79,453/- and the complainant was discharged on 12.04.2015. At the time of admission of the complainant on 09.04.2015, his relatives had shown the policy document to OP No.4 for cashless treatment of the complainant under the insurance policy. The relatives of the complainant filled and submitted the form to OP No.4 for sending it to OP No.1 and 2 for disbursal of the sum assured under the policy. However, the cashless claim was rejected by OP No.3 on behalf of OP No.1 and 2 vide letter dated 10.04.2015 on the ground that the complainant has 15 years history of CAD as mentioned in the form submitted by OP No.4. However, on enquiry Dr. Sudheer Saxena of OP No.4 informed the relatives of the complainant that some error had been done by the hospital staff while entering the information in their system and the complainant does not have any history of CAD of 15 years and assured for correction in the hospital record. The doctor also given a certificate vide letter dated 10.04.2015. The relatives of the complainant submitted the claim form alongwith letter of Dr. Sudheer Saxena to OP No.1 to 3. However, these OPs did not allow the cashless facility by ignoring the letter dated 10.04.2015 given by the doctor. After discharge from OP No.4, the complainant got in touch with OP No.1 and 2 about rejection of claim but again OP No.1 to 3 rejected the claim of the complainant vide letter dated 31.07.2015. The complainant made various representations to the OP for reconsidering the claim, however, OP No.1 to 3 completely refused to accept the claim and rejected it finally vide letter dated 03.08.2015. OP No.1 and 2 have also cancelled the policy of the complainant and forfeited the amount paid by him. Hence the complainant has sought direction to the OPs to pay him Rs.5,00,000/- the annual limit under the policy alongwith interest @ 18% per annum from the first date of rejection of the claim; to pay him Rs.2,00,000/- as compensation for harassment and mental agony; to pay him Rs.50,000/- as costs of litigation and direct OP No.1 to 2 to reinstate the policy of the complainant.
2. The OP No.2 in the preliminary objections of the written statement has pleaded that before acceptance of the proposal, the contents of the proposal/application/terms and conditions of the policy and exclusions attached to the terms and conditions were read and explained to the complainant. After understanding and agreeing to the terms and conditions, the complainant applied and signed the application form with his free will and consent. The cashless treatment request was examined by OP No.2 from the comments of the doctor concerned, it was noticed that the patient was suffering from CAG (Coronary Angiography) 15 years back insignificant CAD (on medical management). History of OA Rt knee (on medicines). Hence the cashless treatment request was rightly rejected by OP No.2 vide letter dated 10.04.2015. Final claim of the complainant was rejected vide letter dated 31.07.2015 because of the fact that the complainant has given negative answers to the questions put to him in the proposal form regarding personal and family history of all lives to be insured. Thus, denying all the averments of the complaint, the OP No.2 has sought dismissal of the complaint.
3. Shri Puneet Tuli, Advocate filed power of attorney for OP No.1 on 14.12.2015 and sought time to file reply. Notice to OP No.1 was served on 13.10.2015. As per law laid down by Hon’ble Supreme Court in New India Assurance Co. Ltd. Vs. Hilli Multipurpose Cold Storage Pvt. Ltd., decided on 04.12.2015, the stipulated period of 45 days for filing reply expired on 27.11.2015. Hence, the right of OP No.1 for filing reply was struck off and the complaint against OP No.1 was proceeded vide order dated 14.12.2015.
4. Similarly Shri Vishal Gupta, Advocate filed power of attorney for OP No.4 on 14.12.2015. Notice to OP No.4 was served on 15.10.2015. As per law laid down by Hon’ble Supreme Court in New India Assurance Co. Ltd. Vs. Hilli Multipurpose Cold Storage Pvt. Ltd., (supra), the stipulated period of 45 days for filing reply expired on 29.11.2015. Hence, the right of OP No.1 for filing reply was struck off and the complaint against OP No.1 was proceeded vide order dated 14.12.2015. OP No.4 even preferred an appeal against the order dated 14.12.2015 the Hon’ble Punjab State Consumer Disputes Redressal Commission, Chandigarh. However, the appeal met the fate of dismissal vide order dated 03.05.2016.
5. Notice to OP No.3 was delivered on 24.12.2015. None having appeared for it despite repeated calling, OP No.3 was proceeded against ex-parte vide order dated 14.03.2016.
6. In order to prove the case, the complainant tendered in evidence his affidavit Ex. CW-1/1; copies of policy document Ex.C-1; treatment summary and bills Ex.C-2; rejection letter dated 10.04.2015 Ex.C-3; report of the hospital staff dated 09.04.2015 Ex.C-4; letter of the doctor dated 10.04.2015 Ex.C-5; rejection letter dated 31.07.2015 Ex.C-6; medical test of the complainant dated 06.04.2015 Ex.C-7 and rejection letter dated 03.08.2015 Ex.C-8. In rebuttal, the OP No.2 has tendered in evidence affidavit of Amit Khanna, Dy. Manager Legal Ex.OP-2/1; authority letter dated 24.09.2013 Ex.OP-2/1; proposal form dated 08.01.2015 Ex.OP-2/2 and insurance policy dated 26.01.2015 Ex.OP-2/3.
7. Learned Counsel for the complainant has submitted that the main controversy involved in the present case is that the OP No.3 repudiated the cashless claim of the complainant in an arbitrary manner. He pleaded that it is evident from the letter issued by the Head of the Department of Cardiology Ex.C-5 that complaint had not been suffering from any kind of heart related disease nor he had been under medication. Learned counsel also pleaded that the history recorded by the attending staff had wrongly been mentioned that the complainant was taking medication for the last 15 years. He stated that moreover the complaint was not in a position to give any kind of details to the attending staff as he was having a stroke. Learned counsel argued that before issuing the policy the OP No.1 and 2 got a full body medical checkup and thereafter being fully satisfied issued the said policy.
8. On the other hand, the learned counsel for the OP No.2 stated that the claim had been rightly repudiated as complainant had a pre-existing disease and this fact was concealed at the time of filling the form. He pleaded that it is established from the past history record Ex.C4 that complaint had been taking medication for heart related disease for the last 15 years and the complainant intentionally concealed this fact.
9. After hearing the learned counsel for the parties and going through the pleadings, evidence, written arguments as well as oral submissions, we find force in the contentions of the learned counsel for the complainant. It is established from the affidavit of the complainant Ex.CW-1/1 that complainant was not on medication for CAD and he was also not in a position to give any history, as when he arrived at the Hospital he was having a stroke at that time. Further it is established from the letter Ex.C-5 issued by the Head of the Department of Cardiology stating that complainant had not been suffering from any kind of CAD related disease nor he had been under medication for CAD. We are of the view that the past history recorded Ex.C-4 carries no weight, hence it cannot be considered. Moreover before issuing the policy the OP No.1 and 2 had also conducted a medical checkup and no such disease came into the notice of OP No.1 and 2 thereby being fully satisfied they issued the policy.
10. Accordingly in view of our aforesaid discussion, we find that OP No.1 to 3 have committed unfair trade practice by repudiating the claim of the complainant in an arbitrary manner. Hence we direct OP No.1 to 3 jointly and severally to pay a sum of Rs.5,00,000/- (Rs. Five Lakhs only), the sum assured under the policy. We further direct OP No.1 to 3 jointly and severally to pay a sum of Rs.50,000/- (Rs. Fifty thousand only) on account of compensation for causing unnecessary mental agony alongwith Rs. 10,000/- (Rs. Ten thousand only) for litigation costs. The present complaint is hereby allowed against OP No.1 to 3 and dismissed against OP No.4.
The OP No.1 to 3 are further directed to comply with the order of this Forum within 45 days from the date of receipt of this order.
The arguments on the complaint were heard on 22.12.2016 and the order was reserved. Now the order be communicated to the parties. Copy of the order be sent to the parties free of cost and thereafter the file be consigned to the record room.
Pronounced
Dated: 28.12.2016
(A.P.S.Rajput)
President
(Mrs. R.K. Aulakh)
Member
