District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No. 160/2021.
Date of Institution:22.03.2021.
Date of Order: 23.01.2023.
Lovely Chaudhary s/o Pawan Kumar, resident of House No. C F/7, Gali No.2, Adarsh Nagar, Ballabgarh, District Faridabad – 121004, Haryana.
…….Complainant……..
Versus
HDFC Ergo General Insurance Co. Ltd., corresponding off: Stellar IT Park, Tower-1, 5th floor, C-25, Sector-62, Noida – 201301 through its Branch/Manager/Divisional Manager/Authorized person.
…Opposite party……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Sh. Naresh Vashisth, counsel for the complainant.
Sh. D.K.Gosain, counsel for opposite party
ORDER:
The facts in brief of the complaint are that the complainant was insured by the opposite party bearing policy No. 2825100405369801 valid from 23.01.2020 to 22.01.2021 for the insured sum of Rs.5,00,000/-. The complainant namely Chaudhary was suffering from fever on & off since 4 days, pain abdomen on & off since 3 days, vomiting on & off 3 days, nausea, weakness + , bodyache. On 13.09.2020 he was rushed to Sunshine Hospital, Sector-64, Sahupura Road, Uncha Gaon, Ballabgarh, Faridabad. The complainant was admitted in the said hospital on 13.09.2020 and discharged on 18.09.2020. The complainant was diagnosed with i/v fluids, antibiotics, ppi, pain ki9llers, antipyretics, antiamoebics and other supportive treatment. The complainant informed the TPA about the treatment. The complainant had spent Rs.30298/- for this treatment as well as medicines etc. The complainant had already submitted all the original documents as required by opposite party for claiming the above said amount. On 30.10.2020 the opposite party wore a letter to the complainant that the claim was found to be misrepresented.
“As per the documents submitted, the claim was found to be misrepresented. As per the policy terms and conditions, if any claim was in any manner dishonest or fraudulent, or was supported by any dishonest or fraudulent means or devices, whether by insured person or anyone acting on behalf of an insured person, then this policy shall be void and all benefits paid under it shall be forfeited. Hence this claim is being repudiated under section 10j of policy terms and conditions. Furthermore, as the policy is under process of cancellation, no further claim will be entertained.”
The complainant had spent a sum of Rs.30298/- on his treatment, hospitalization, medicines etc. As per the terms and conditions of the insurance policy the opposite party was liable to pay all the amount of treatment of the complainant. The complainant had approached the opposite party several times but the opposite party was not paying any heed to the legitimate request of the complainant and on dated 25.2.2021 the opposite party flatly refused to accede the legitimate request of the complainant. The aforesaid act of opposite party amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite party to:
a) reconsider the claim of the complainant and pay Rs.30298/- alongwith interest @ 24% p.a.
b) reinstate the policy of the complainant.
c) pay Rs. 1,00,000/- as compensation for causing mental agony and harassment .
d) pay Rs. 25,000 /-as litigation expenses.
2. Opposite party put in appearance through counsel and filed written statement wherein Opposite party refuted claim of the complainant and submitted that the complainant had taken the Health Suraksha Policy Silver Plan Insurance Policy No. 2825 1004 0536 9801 000 valid from the period 23.01.2020 to 22.01.2021. However, it was submitted that the insurance policy was issued subject to the terms and conditions of the insurance policy. As alleged by the insured/complainant was admitted in Sun Shine Hospital, Faridabad from 13.09.2020 to 18/09/2020 with complaints of complainant from fever off and on since 3 days, weakness, nausea and bodyache. Insured paid total Rs.30298/- and thereafter a claim was lodged with the opposite party seeking reimbursement for the expenses incurred during the hospitalization. It was submitted that after receiving the claim, an independent investigator was appointed in order to verify the genuineness and veracity of the facts. During the investigation, the following observations were made:
- Investigator visited hospital many times but doctor was not found hence call was made to doctor Dr. Pushpinder who was claimed to be treating doctor. During discussion regarding treatment of said insured in sunshine hospital he was saying he was unknown to this hospital and also confirmed he was not visiting this hospital while hospital and insured was presenting all the treatment was done by Dr. Pushpinder.
- Insured was not known about final bill amount and who paid it also not know how many payment was deposited in advance.
- As per insured she was treated in a single bedded private room but hospital confirmed she was in 2 bedded semi deluxe room.
- As per insured she was treated by only Dr. Pushpinder but hospital is taking extra charges of RMO.
Further the claim was repudiated on the ground of fraud as in the previous claim filed by the complainant, he had manipulated the document sand stated that her wife had no hypertension. Section 10J of the General Conditions speaks about the “Fraud” which reads as follow:
“If any claim is any manner dishonest or fraudulent or is supported by any dishonest or fraudulent means or devices, whether by you or any insured person or anyone acting on behalf of you or an insured person, then this policy shall be void benefits paid under it shall be forfeited.”
Since there were major discrepancies/misrepresentations in the documents submitted by the complainant, the opposite party was constrained to repudiate the claim of the complainant vide the repudiation letter dated 30.10.2020. Opposite party denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite party– HDFC Ergo General Insurance Company Ltd. with the prayer to: a) reconsider the claim of the complainant and pay Rs.30298/- alongwith interest @ 24% p.a. b) reinstate the policy of the complainant. c) pay Rs. 1,00,000/- as compensation for causing mental agony and harassment . d) pay Rs. 25,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Annexure C-1 Health Suraksha Policy Silver Plan, Annexure – C2 - Claim repudiation letter, Annexure C-3 – Discharge summary.
On the other hand counsel for the opposite party strongly agitated and
opposed. As per the evidence of the opposite party Ex.RW1/A – affidavit of Vivek Yada – Senior Manager – Corporate Legal – M/s. HDFC ERGO General Insurance Company Limited, Office No. 208, 2nd floor, Sewa Corporate Park, Mehrauli – Gurgaon Rd. Gurugram, Ex.R-1 – Health Suraksha Policy Silver Plan, Ex.R-2 – Claim Repudiation Letter without prejudice,, Ex.R-3 – Investigation report (reimbursement) .
6. As per evident from HealthSuraksha Policy Silver Paln vide Annexure C-1, the complainant was insured by the opposite party bearing policy No. 2825100405369801 valid from 23.01.2020 to 22.01.2021 for the insured sum of Rs.5,00,000/-. The complainant namely Chaudhary was suffering from fever on & off since 4 days, pain abdomen on & off since 3 days, vomiting on & off 3 days, nausea, weakness + , bodyache. On 13.09.2020 he was rushed to Sunshine
Hospital, Sector-64, Sahupura Road, Uncha Gaon, Ballabgarh, Faridabad. The complainant was admitted in the said hospital on 13.09.2020 and discharged on 18.09.2020. The complainant had spent Rs.30298/- for this treatment as well as medicines etc Opposite party has repudiated the claim of the complainant vide letter dated 30.10.2020 (Ex.R-2) on the ground that “As per the documents submitted, the claim was found to be misrepresented. As per the policy terms and conditions, if any claim was in any manner dishonest or fraudulent, or was supported by any dish
onest or fraudulent means or devices, whether by insured person or anyone acting on behalf of an insured person, then this policy shall be void and all benefits paid under it shall be forfeited. Hence this claim is being repudiated under section 10j of policy terms and conditions. Furthermore, as the policy is under process of cancellation, no further claim will be entertained.”
7. During the course of arguments, counsel for the complainant has submitted the certificate of Dr. Pushpender M.B.B.S., Reg. No. DMC/R/25643, Sunshine Hospital, Sahupura Road, Ballabgarh, Faridabad vide Annx. X in which it has been mentioned that “patient Lovely Chaudhary was admitted in Sunshine Hospital for treatment of AFI i gastritis from 13.09.2020 to 18.09.2020 under my supervision.
7. After going through the evidence led by the parties, the Commission is of the opinion that the complaint is allowed. Opposite party is directed to process the claim of the complainant, subject to the verification of the certificate issued by the Dr. Pushpeder on 03.10.2022 vide Annexure X within 30 days from the date of receipt of the copy of order and pay the due amount to the complainant along with interest @ 6% p.a. from the date of filing of complaint till its realization. The opposite party is also directed to pay Rs.2200/- as compensation on account of
mental tension, agony and harassment alongwith Rs.2200/- as litigation expenses to the complainant. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 23.01.2023 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
