BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.421 of 2016
Date of Inst. 26.09.2016
Date of Decision: 25.11.2019
Rakesh Kumar S/o Mathura Parshad, 113, Tobri Mohalla, Satya Narayan Mandir, Jalandhar, Punjab, 144001.
..........Complainant
Versus
1. M/s HDFC ERGO General Insurance Company Limited, Stellar IT Park, Tower-1, 5th Floor, C-25, Sector-26, NOIDA-201301. Through its Managing Director.
2. M/s HDFC ERGO General Insurance Company Limited, Eminates Mall, Near Guru Nanak Mission Chowk, Third Floor, Jalandhar City. Through its Area/Branch Manager.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Sh. Karnail Singh (President)
Smt. Jyotsna (Member)
Present: Sh. S. K. Chopra, Adv. Counsel for the Complainant.
Sh. R. K. Sharma, Adv Counsel for the OPs.
Order
Karnail Singh (President)
1. The instant complaint has been filed by the complainant, wherein alleged that he purchased health insurance policy No.2822201310350900 from respondent’s company at Jalandhar Office, the said policy is valid upto 28.01.2017. In the said insurance policy critical illness of the complainant is covered as insured for Rs.10,00,000/-. In this regard the complainant paid requisite premium to respondent’s company, which was duly received by respondent and issued the said policy.
2. That during the subsistence of above said health insurance policy, complainant suffered heart problem on 21.01.2016 and was treated at Shri Ram Cardiac Centre, Joshi Hospital, Kapurthala Chowk, Jalandhar. The complainant was diagnosed for Coronary Artery Disease (CAD), Acute Anterior Wall MI, Angina. As per medical terms, the said disease leads to Heart Attack and the treatment for heart attack was given. As per terms and conditions of the policy, in case of acute illness the complainant is entitled to lump-sum amount of Rs.10,00,000/- from OPs as health and insurance. The illness of the complainant for Heart Attack is fully covered under the definition of critical illness as defined under the Health Insurance Policies, therefore, the complainant is entitled to recover an amount of Rs.10,00,000/- from OPs. As per terms and conditions of the above said policy, the complainant lodged his health insurance claim with respondent’s company. But surprisingly OPs have repudiated the insurance claim of the complainant on flimsy grounds, vide letter dated 16.08.2016. The decision of the OPs to repudiate the health insurance claim of the complainant is illegal, wrong and against the public policy on the following grounds:-
i. That the main objection of the respondent to repudiate the claim of the complainant is that angina and CAD (Coronary Artery Disease) does not come under the definition of critical illness of Heart Attack, the inference drawn by respondent’s company is completely based upon conjectures and surmises. It transpires that OPs are seeking false and frivolous pretext to refrain from giving true claims to deserving people. The complainant got treatment of CAD (Coronary Artery Disease) also. The said disease leads to only Heart Attack, therefore, the decision of OPs to repudiate the claim of the complainant is vague, indefinite and without any basis.
ii. That OPs had received the money from complainant and issued health insurance policy and during the subsistence of the said policy the complainant suffered critical illness, therefore, OPs are bound to pay lump-sum insurance claim to the complainant on account of critical illness.
3. The OP has adopted unfair trade practice and is proved to be deficient in providing services to the complainant and thus, the complainant served a legal notice dated 22.08.2016 upon the respondents, but all in vain and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to make a payment of Rs.10,00,000/- being the health insurance claim along with Rs.50,000/- as mental agony due to their illegal acts and the respondents may also be directed to make the payment of Rs.11,000/- as litigation expenses.
4. Notice of the complaint was given to the OPs and accordingly, both the OPs appeared through its counsel and filed joint written reply, whereby contested the complaint by taking preliminary objections that the complaint is not maintainable against the answering OPs, as such, the same is liable to be dismissed and further averred that the claim of the complainant stands repudiated after due application of mind as per terms and conditions of the insurance policy, vide letter dated 16.08.2016 and the copy of the same sent to the complainant, wherein specifically stating that as per the submitted documents, insured was admitted on 21.06.2016 with the diagnosis of Anterior Wall Myocardial Infarction-Coronary Artery Disease, wherein the first inception of the policy is 29.01.2016. As per definition 7 (iii) of “First Heart Attack” as one of the Critical Illness defined under Section 5 of the policy terms and conditions and as such, the claim of the complainant has been rightly repudiated after due application of mind. It is further averred that the insurance contract is governed by its terms and conditions and coverage are the sine qua non for deciding liability under the insurance policy. Thus, in the present case, the complainant’s case does not fall within the four corners of the condition relating to Myocardial Infarction (Heart Attack) as defined under the policy. The discharge summary clearly mentions about the investigations done as per which CAG was done which revealed non-significant coronary artery disease and is advised for medical management. The investigation does not state about any factors, which are required under the policy condition No.7 (iii) to be qualified for coverage under the policy and further averred that there is no deficiency in service nor any negligence nor any unfair trade practice on the part of the answering OPs. On merits, the purchase of the insurance policy by the complainant is not denied and even it is also admitted that the complainant filed health insurance claim, but the same was repudiated and the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
5. Replication not filed.
6. In order to prove the case of the complainant, the complainant himself tendered into evidence his own affidavit Ex.CA alongwith some documents Ex.C-1 to Ex.C-16 and then closed the evidence.
7. Similarly, counsel for the OPs tendered into evidence affidavit of Sh. Pankaj Kumar, Manager as Ex.OA and affidavit of Nilutpal Bora as Ex.OB alongwith some documents Ex.O-1 to Ex.O-6 and closed the evidence.
8. We bestowed our thoughtful consideration to the submissions made by learned counsel for the respective parties and also gone through the written arguments submitted by both the counsel for the parties as well as case file very minutely.
9. Without any hesitation, we can say that the purchase of the policy by the complainant from OP valid upto 28.01.2017, is admitted fact and further, the complainant remained under treatment at Shri Ram Cardiac Centre, Joshi Hospital, Kapurthala Chowk, Jalandhar from 21.06.2016 to 22.06.2016 and thereafter, the complainant submitted health insurance claim, but the same was repudiated by the OP, vide letter dated 16.08.2016, are admitted facts.
10. Now, through this complaint, the complainant has challenged the said repudiation of the insurance claim, by way of filing the instant complaint, wherein alleged that the claim of the complainant has been wrongly and illegally repudiated by alleging that the claim of the complainant does not cover under the definition of critical illness of heart attack. Virtually, the inference drawn by respondent’s company is completely based upon conjectures and surmises and further alleged that the OPs are seeking false and frivolous pretext to debar the complainant from taking the benefit of health insurance claim. In fact, the complainant got treatment of CAD (Coronary Artery Disease) also. The said disease leads to only Heart Attack, therefore, the decision of the OPs to repudiate the claim of the complainant is totally vague and without any basis and in support of this version, the complainant brought on the file his own affidavit as well as produced on the file Discharge Summary Ex.C-4 and Certificate issued by the Hospital Ex.C-5 and Investigation conducted by the aforesaid hospital is Ex.C-6 and receipt of payment Ex.C-3 and further, placed on the file copy of the extract of the terms and conditions i.e. Ex.C-16 and as per this extract, Critical Illness covered Heart Attack (Myocardial Infarction) and further, submitted that the complainant virtually suffered the problem of Myocardial Infarction, which is a heart attack, but the OP has illegally rejected that the same does not cover under the definition Heart Attack.
11. We have gone through the repudiation letter Ex.C-2 dated 16.08.2016 and virtually in the said letter, the OP has observed that the problem suffered by the complainant does not cover under the terms and conditions of the policy and it is not a heart attack, but if we go through the Discharge Summary Ex.C-4, wherein ‘History of Present Illness’ has been explained as under:-
“Patient Mr. Rakesh Kumar, 41 years old male was admitted in this hospital with chief complaints of chest pain radiating to right arm, head heaviness and sweating for last 2 days.”
No doubt, the angiography report Ex.C-8 states that “Non-significant Coronary Artery Disease”. The OP took this line of the Summary of Angiography Report and declined the claim of the complainant, which is absolutely wrong because the angiography report is to be taken into consideration along with the other medical documents and if we see the Discharge Summary Report Ex.C-4, wherein the doctor categorically mentioned that there is a chief complaint of chest pain radiating of right arm, head heaviness and sweating these are the initial and basic features of heart attack. The treating doctor nowhere stated that the complainant had not suffered first heart attack and moreover, if the OP found that there was no heart attack, then they can get analyze the medical document of the complainant from any expert doctor and then placed on the file the second opinion of the doctor, but the OP for the best known reason did not to do so by knowing that the facts explained by the complainant are true one and just to decline the claim of the complainant, took a vague and flimsy plea that there was no first heart attack. So, with these observations, we are of the opinion that the claim of the complainant has been wrongly and illegally repudiated by the OPs.
12. Now, we have to consider the quantum of medical insurance claim required to be awarded to the complainant, no doubt, the complainant has claimed Rs.10,00,000/- as a health insurance claim, no doubt, the complainant got insurance policy for insured amount of the Rs.10,00,000/-, but in this complaint, the complainant can claim only the expenditure incurred for getting a treatment of the said hospital, for that purpose, the complainant has brought on the file document Ex.C-9, whereby, if we calculate, the total amount paid by the complainant is not more than Rs.1,00,000/-. However, we have not exactly calculated, but it is rough calculation i.e. not more than Rs.1,00,000/-, so, accordingly, we find that the complainant is entitled for the health insurance claim of Rs.1,00,000/- and further, we find that the complainant is entitled for the relief as claimed.
13. In the light of above detailed discussion, the complaint of the complainant is partly accepted and OPs are directed to pay Rs.1,00,000/- being the health insurance claim to the complainant alongwith compensation for causing mental tension and harassment to the complainant, to the tune of Rs.25,000/- and litigation expenses of Rs.7000/- and further, OPs are directed to make the entire above said amount to the complainant i.e. Rs.1,32,000/- within one month from the date of receipt of the copy of order, failing which the complainant will entitle to get interest on the whole above said amount @ 12% per annum from the date of filing complaint i.e. 26.09.2016, till realization. This complaint could not be decided within stipulated time frame due to rush of work.
14. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jyotsna Karnail Singh
25.11.2019 Member President
