Punjab

Faridkot

CC/17/41

HARMANDEEP SINGH - Complainant(s)

Versus

manager hdfc bank - Opp.Party(s)

Ashu Mittal

10 Aug 2017

ORDER

 

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

Complaint No. :     41

Date of Institution: 3.02.2017

Date of Decision :  10.08.2017

 

Harmandeep Singh aged 38 years, s/o Paramjit Singh, r/o # 67, Kirat Nagar, Faridkot, Tehsil and District Faridkot.

                                                                                        ...Complainant

Versus

 

1. HDFC Bank Branch Faridkot through its Manager.
2. HDFC Ergo General Insurance Company Ltd, 1^st Floor, 165-166, Backbay Reclamation, H T Parekh Marg, Churchgate, Mumbai-400020 through its M. D.

                                                                              .......Ops

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum: Sh  Ajit Aggarwal, President,

                Sh P Singla, Member.

 

Present: Sh Ashu  Mittal, Ld Counsel for complainant,

              Sh Atul Gupta, Ld Counsel for OPs.

 

ORDER

(Ajit Aggarwal, President)

                                          Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against OPs seeking directions to OPs to make payment of insurance claim worth Rs. 2,35,000/-pertaining to mediclaim insurance policy bearing no.50205037 and for further directing OPs to pay Rs 50,000/- as compensation for harassment, inconvenience, mental agony and litigation expenses.

2                                              Briefly stated, the case of the complainant is that on assurance of Ops that they would provide cashless treatment during the subsistence of policy, complainant purchased a mediclaim insurance policy bearing number 50205037and got renewed the same from time to time. It is submitted that present insurance policy is valid from 11.04.2016 to 10.04.2017 and as complainant did not make any claim earlier regarding previous policies and kept renewing the policy, therefore, OPs gave him cumulative bonus of Rs.40,000/-in addition to sum insured amount in renewed policy. Further submitted that in December, 2016 complainant felt heart pain and on advice of Dr Naveen Kumar, complainant got checked him up from Max Hospital, Bathinda, which is empanelled hospital of OPs. Doctors in Max Hospital, Bathinda, conducted some tests upon complainant and told that there is some blockage in his heart and he needs to implant stent in his heart. On recommendation of hospital authorities, complainant got ready to implant stent in his heart and then, hospital authorities intimated about this fact to OPs, who had not allowed hospital authorities to provide cashless treatment on false ground. Thereafter, operation was conducted and stent was placed in the heart of complainant. it is further submitted that before placing stent, complainant told hospital authorities that he has been suffering from Thyroid for about last ten months. After operation, hospital authorities told complainant that OPs have rejected the claim of complainant on the ground that he is suffering from Thyroid and now, complainant was to pay the bill for his operation. Complainant did not have money and thus, he took loan of Rs.2,40,000/- under Instant Jambo Loan and paid the entire bill to hospital  authorities.  After that complainant approached OPs several times and made many requests to make payment of his claim amount and tried to convince them that he is suffering from thyroid for the last ten months only and not for last ten years, but they did not pay any heed to listen to his requests and rejected the claim of complainant on this ground whereas there is no concern between Thryroid and IWMI, which amounts to deficiency in service and trade mal practice on the part of OPs and has caused harassment and mental agony to him. He has prayed for directions to Ops to pay the insurance claim and Rs.50,000/- as compensation besides cost of litigation. Hence, the present complaint.

3                                             The counsel for complainant was heard with regard to admission of the complaint and vide order dated 13.02.2017, complaint was admitted and notice was ordered to be issued to the opposite party.

4                                            On receipt of the notice, OPs filed reply taking preliminary objections that complaint is not maintainable in the present form as complainant has not come to the Forum with clean hands. Allegations levelled by complainant are false, frivolous and vexatious. Complainant wants to gain undue monitory benefits and no cause of action arises against OPs. However, it is admitted by OPs that complainant is holder of policy in question and he duly submitted the documents sought from him. It is asserted that after perusal of documents, it is observed that as per certificate issued by treating doctor of Max Hospital, complainant has been suffering from Hyperthyroidism much before the inception of policy in question and there was a history of 10 years for this disease, which complainant did not disclose the answering Ops while purchasing the policy in question and on account of non disclosure of material facts, cashless claim was denied under section 10 (r) (ii). It is further averred by OPs that denial of cashless claim to complainant does not amount to final denial of entire claim and further claim for reimbursement of claim can be lodged after the treatment. On perusal of treatment documents, if the claim is found payable, it would be reimbursed to complainant and this fact was duly intimated to complainant in cashless denial letter dated 26.12.2016 and after rejection of cashless claim, no other claim for reimbursement of expenses was ever lodged by complainant and thus, complaint filed by complainant is premature and it is liable to be dismissed. However, on merits, they have denied all the allegations of complainant being wrong and incorrect and reiterated the same pleadings as taken in preliminary objections. It is further averred that there is no deficiency in service on the part of OPs and all the other allegations levelled have been denied being wrong and incorrect and prayed that complaint deserves to be dismissed with costs.

5                                               Parties were given proper opportunities to prove their respective case. The complainant tendered in evidence his affidavit Ex.C-1 and documents Ex C-2 to C-7 and then, closed his evidence.

6                                                  In order to rebut the evidence of the complainant, the opposite party tendered in evidence, affidavit of Pankaj Kumar as Ex OP-1, documents Ex OP-2 to 4 and then closed the evidence on behalf of OPs.

7                                              We have heard the arguments addressed by all the parties and have also gone through the evidence and documents led by the parties.

8                                                Ld Counsel for complainant vehementally argued that on assurance of Ops that they would provide cashless treatment during the subsistence of policy, complainant purchased a mediclaim insurance policy bearing number 50205037and got renewed the same from time to time. It is submitted that present insurance policy is valid from 11.04.2016 to 10.04.2017 and as complainant did not make any claim earlier regarding previous policies and kept renewing the policy, therefore, OPs gave him cumulative bonus of Rs.40,000/-in addition to sum insured amount in renewed policy. Further submitted that in December, 2016 complainant felt heart pain and on advice of Dr Naveen Kumar, complainant got checked him up from Max Hospital, Bathinda, which is empanelled hospital of OPs. Doctors in Max Hospital, Bathinda, conducted some tests upon complainant and told that there is some blockage in his heart and he needs to implant stent in his heart. On recommendation of hospital authorities, complainant got ready to implant stent in his heart and then, hospital authorities intimated about this fact to OPs, who had not allowed hospital authorities to provide cashless treatment on false ground. Thereafter, operation was conducted and stent was placed in the heart of complainant. It is further submitted that before placing stent, complainant told hospital authorities that he has been suffering from Thyroid for about last ten months. After operation, hospital authorities told complainant that OPs have rejected the claim of complainant on the ground that he is suffering from Thyroid and now, complainant was to pay the bill for his operation. Complainant did not have money and thus, he took loan of Rs.2,40,000/- under Instant Jambo Loan and paid the entire bill to hospital  authorities.  After that complainant approached OPs several times and made many requests to make payment of his claim amount and tried to convince them that he is suffering from thyroid for the last ten months only and not for last ten years, but they did not pay any heed to listen to his requests and rejected the claim of complainant on this ground whereas there is no concern between Thryroid and IWMI, which amounts to deficiency in service and has caused harassment and mental agony to him. He has prayed for accepting the complaint alongwith compensation and litigation expenses.

9                                                  To controvert the allegations of complainant, ld counsel for OPs asserted that complaint is not maintainable in the present form as complainant has not come to the Forum with clean hands. Allegations levelled by complainant are false, frivolous and vexatious. Complainant wants to gain undue monitory benefits and no cause of action arises against OPs. However, it is admitted by OPs that complainant is holder of policy in question and he duly submitted the documents sought from him. It is asserted that after perusal of documents, it is observed that as per certificate issued by treating doctor of Max Hospital, complainant has been suffering from Hyperthyroidism much before the inception of policy in question and there was a history of 10 years for this disease, which complainant did not disclose the answering Ops while purchasing the policy in question and on account of non disclosure of material facts, cashless claim was denied under section 10 (r) (ii). It is further averred by OPs that denial of cashless claim to complainant does not amount to final denial of entire claim and further claim for reimbursement of claim can be lodged after the treatment. On perusal of treatment documents, if the claim is found payable, it would be reimbursed to complainant and this fact was duly intimated to complainant in cashless denial letter dated 26.12.2016 and after rejection of cashless claim, no other claim for reimbursement of expenses was ever lodged by complainant and thus, complaint filed by complainant is premature and it is liable to be dismissed. It is further averred that there is no deficiency in service on the part of OPs and all the other allegations levelled have been denied being wrong and incorrect and prayed that complaint deserves to be dismissed with costs.

10                                                 From the careful perusal of record and after going through the affidavits, evidence and pleadings of the parties, it is observed that grievance of complainant is that he was insured under the policy of Ops for cashless treatment and during the validity of insurance period, he felt heart pain and on advice of Dr Naveen Kumar, he  got checked him up from Max Hospital, Bathinda, where he  was recommended to place stent in his heart as he was having blockage in his arteries and there was a risk to his life. Hospital authorities told about this fact to OPs, who had not allowed them to provide cash less treatment to complainant. Before operation, complainant disclosed treating doctor that he is suffering from thyroid for about last ten months. Complainant underwent surgery of stent implantation at Max Hospital, Bathinda which is empanelled with OPs, but Ops did not provide cashless treatment and rejected his claim on the ground that complainant is suffering from Thyroid. Efforts made by complainant to convince OPs that he is suffering from thyroid for only last ten months and not from ten years bore no fruit and they repudiated the claim of complainant. Under compelling circumstances, complainant had to take loan for making payment of expenses occurred on his treatment. All this amounts to deficiency in service. In reply, Ops admitted that complainant was insured with OPs and had submitted the documents required by them but stressed mainly on the point that there is a concealment of fact on the part of complainant that he was also suffering from thyroid for last ten years. It is further averred that denial of cashless claim to complainant does not amount to final denial of entire claim and further claim for reimbursement of claim can be lodged after the treatment. On perusal of treatment documents, if the claim is found payable, it would be reimbursed and this fact was also intimated to complainant vide letter dated 26.12.2016, but after rejection of cashless claim, no other claim for reimbursement of expenses was ever lodged by complainant and thus, complaint filed by complainant is premature and it is liable to be dismissed. There is no deficiency in service on the part of OPs and prayed for dismissal of complaint.

11                                            We have carefully gone through the file and from careful perusal of record, we come to the conclusion that there is no dispute about the insurance claim as it is admitted fact of Ops that complainant was insured with them and complainant has also supplied them documents sought by them. In their written statement as well as before the Forum they have admitted that denial of cashless claim itself does not amount to final denial of entire claim and further claim for reimbursement can be lodged after the treatment. On perusal of treatment documents, if the claim is found payable, it would be reimbursed and this fact was also intimated to complainant vide letter dated 26.12.2016, but thereafter, complainant has not filed any claim for reimbursement and thus, complaint is premature and OPs need some time for processing the claim.

12                                              From the above discussion, pleadings and evidence produced by respective parties, this Forum is of considered opinion that present complaint is premature and therefore, complaint in hand stands dismissed being premature. Complainant is directed to lodge his claim for reimbursement of his medical expenses with OPs alongwith all documents required for settlement of his claim within 15 days from the date of receipt of copy of order and Ops are directed to process and clear the claim of complainant within 45 days of  receipt of the documents from complaiannt. Compliance of this order be made within prescribed period, failing which complainant shall be at liberty to file it afresh on the same cause of action. Copy of order be given to parties free of cost under rules. File be consigned to record room.

Announced in Open Forum

Dated : 10.08.2017                 

 

  Member                            President

                                                  (P Singla)                      (Ajit Aggarwal)