Complaint Case No. 157/2022

Smt. Manju Mittal age about 65 years W/o Sri Ashok Kumar Mittal R/o 14-168 Candra Cinema ke samane Agra Road, Tehsil Koil Distt. Aligarh

                                                             ( Through Advocate Santosh Kumar Mathur)

V/s

1. Manager, HDFC Ergo Health Insurance Company, Indra Nagar, Lucknow         (Through Advocate Dharmendra Pandey)
2. Manager, Canara Bank Apsara Market, Railway Road, Aligarh            (Through Advocate Diwakar Agrawal)
3. Manager, Tata AIG General Insurance Company Ltd. Regd. office Baninsula Business Park, Tower-1 , 15^th  floor D. K. Marg Lower Patel Mumbai, Pin 400013 

CORAM

 Present:

1. Shri Hasnain Qureshi, President
2. Shri Alok Upadhayay, Member
3. Smt. Purnima Singh Rajpoot, Member

PRONOUNCED by Shri Hasnain Qureshi, President

JUDGMENT

1. The present complaint has been filed by the complainant before this commission for  the following reliefs-

1.       The Op be directed to pay the expenses amounting Rs.331247 incurred in treatment of the illness.
2. Compensation Rs 2000000/ for harassment be awarded.
3. Cost of the litigation be awarded.  

2. Complainant has stated that she had obtained a health plan insurance on 8.2.2019  from the Ops and paid premium Rs. 6812. The policy no. is 0239157260/ 00042960 and is valid from 8.2.2019 to 7.2.2023. on 5.2.2022 complainant had been suffered from heart ailment and she had undergone treatment at Metro Hospital and Heart Institute ,New Delhi where she incurred Rs 331247 in her treatment. Complainant claimed the amount Rs. 331247 from the op no.1 which was illegally rejected. Ops have committed deficiency in service and complainant is entitle for Rs.331247 and compensation for harassment.                 
3. Op no.1 stated in WS that the complaint was dismissed on violation of terms and condition of insurance policy. Complainant did not inform the insurance company toll free no and no document was provided about the alleged loss. It was a condition precedent to intimate within stipulated time.
4. Op no.2 stated in WS that the bank has no concern with the settlement of claim and the bank is only a facilitator and the insurance is actually issue by the insurance company.
5. Op no.3 stated in WS that the complainant had concealed the disease in obtaining the policy. The complainant had already been suffering from coronary artery disease (CAD) prior to taking the policy and thereby she had undergone percutaneous trans luminal coronary angioplasty in the year 2016 and 2018. As per condition no 7(1) of the policy related to  misrepresentation or non-disclosure of material fact, the claim is liable to be rejected.    
6. Complainant has filed his affidavit and papers in support of his pleadings. OPs have also filed their  affidavit and papers in support of his pleadings
7. We have perused the material available on record and heard the parties.
8. First question for consideration is whether the complainant is entitled for any relief?
9. Complainant has explained the statements made in written statement by the Ops in her replication supported with the affidavit it was stated that the complainant had explained every thing to the agent of insurance company whatever asked by him and she had not concealed any fact to the agent of the insurance company. Complainant has stated that the claim was wrongly repudiated presuming a case of coronary artery disease placing reliance on OPD initial assessment dated 2.5.2022 prescribed by  Metro Hospital and Heart Institute where the CAD was mentioned in the past history column based on conversation made between the patient and the doctor. Complainant has stated that it was the assessment made by the doctor that the patient had past history of CAD and it was not the accurate diagnosis of the disease based on medical and clinical tests and investigation and on the basis of alleged past history it cannot be concluded that the complainant had actually being suffering from CAD prior to the inception of the policy. Complainant has further stated that she was admitted in Metro Hospital and Heart Institute on 5.2.2022 and was discharged on 5.5.2022 and there could be an occasion past history of the complainant at the time of admission in hospital on 5.2.2022 or at the time of her discharge on 5.5.2022 and their was no occasion to record the past history of the complainant on 2.5.2022. the perception  dated 2.5.2022 containing the past history is not authentic and reliable. It is clear from the record that the complainant has asserted that the policy was obtained through the agent she had answered the queries made by the agent. Complainant has also denied from suffering any disease prior to inception of the insurance policy and the insurance company was in a position to conduct medical and clinical test to decide either to accept the proposal and issue the policy or declined to do so. Having satisfied with the reports or insurance company could have issued the policy and later on insurance company is not authorized to contend that there was preexisting disease and for that reason repudiated the claim. The insurance company has received the consideration for the policy and is under contractual obligation to reimburse the complainant. thus we are of the view that the complainant is entitled for reimbursement of amount Rs. 331247.  

10. Question is formulated in favor of complainant.     
11. We hereby direct the Op no.3 to pay the complainant  amount Rs. 331247 with pendente lite and future interest @9% per annum. Op shall also pay to the complainant Rs. 20000 as harassment and Rs.20000 litigation expenses.
12. A copy of this judgment be provided to all the parties as per rule as mandated by Consumer Protection Act, 2019. The judgment be uploaded forthwith on the website of the commission for the perusal of the parties.
13. File be consigned to record room along with a copy of this judgment.