BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.185 of 2016
Date of Instt. 25.04.2016
Date of Decision:17.01.2018
Sh. Swami Mahesh Puri C/o Thakur Dwara, Mohalla Mishran, VPO Alawalpur, Jalandhar Distt-144006
..........Complainant Versus
1. M/s HDFC ERGO GENERAL INSURANCE COMPANY LIMITED, 3rd Floor, Eminent Mall, Near Guru Nanak Mission Chowk, Jalandhar-144001 [through its General Manager]
2. M/s HDFC ERGO GENERAL INSURANCE COMPANY LIMITED, Stellar IT Park, Tower-I, 5th Floor, C-25, Sector-62, Noida-201301 [through its General Manager]
3. M/s HDFC ERGO GENERAL INSURANCE COMPANY LIMITED, 1st Floor, 165-166 Backbay Reclamation, H.T. Parekh Marg, Church Gate, Mumbai-400020 [through its General Manager]
..….…Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Sh. Karnail Singh (President)
Smt. Harvimal Dogra (Member)
Present: Sh. Satnam Singh, Adv Counsel for the Complainant.
Sh. RK Sharma, Adv Counsel for the OP No.1 to 3.
Order
Karnail Singh (President)
1. This complaint presented by the complainant, wherein stated that the complainant had obtained a medical insurance policy from the OPs bearing Policy No.2525200068456304 HDFC ERGO ID ERI 401725049-01E, which was valid up to 18.03.2016. At the time of issuing the said policy, the authorized agent of the OP No.1, which is local office of the OP No.2 and 3, assured the complainant that the policy is good for value and whenever the complainant will suffer from any of the disease or ailments, the OP will reimburse the amount incurred by the complainant of hospitalization and the medicines or other necessary expenditures, a copy of the insurance policy issued by the OP is enclosed herewith. The complainant, believing the assurance given by the authorized agent of the OPs, purchased the policy of OPs.
2. That unfortunately in the month of January, 2016 complainant suffered from fever pain and nausea and was diagnosed of [R] Upper Ureteric Calculus + [L] Renal Calculus, DM ailment by the doctors of Goel Kidney Care Hospital, Kapurthala Chowk, Jalandhar. The complainant remained admitted in the hospital from 03.01.2016 to 05.01.2016, where he was operated upon for the diseases, he was suffering as mentioned in prescription slips, issued by the said hospital to the complainant. The complainant paid a total amount of Rs.1,80,000/- as hospitalization charges to the Goel Kidney Care Hospital. The complainant had approached the OPs for the reimbursement of the claim, who asked the complainant to submit his claim with the OPs in a duly filled in questionnaire giving requisite information as required therein alongwith the supporting documents i.e. prescription slips and the bills paid by the complainant, which the complainant submitted accordingly. The complainant was surprised when the claim of the complainant for reimbursement of the amount under the health insurance policy referred above was repudiated vide letter dated 07.03.2016 by the OP stating the following reasons:-
“As per the documents submitted, the claim was found to be misrepresented. As per the policy terms and conditions, if any claim is in any manner dishonest or fraudulent or is 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 10.”
3. While the language used giving reasons to reject the claim of the complainant was most unwarranted, derogatory and defamatory; nothing has been stated as to what were the grounds, on which the claim was found to be misrepresented, dishonest, fraudulent etc. The action of the OPs in repudiating the health insurance claim of the complainant is illegal, unethical and contrary to the terms and conditions of the insurance policy, it is a clear malafide and dishonest act of the OPs to wriggle out of its liability by denying to give benefit accruing under the health insurance policy. That the complainant served a legal notice to the OP for reimbursement of the claim, but despite that the OP did not pay the claim, which is clear cut deficiency in service on the part of the OP and also caused harassment and mental tension to the complainant and accordingly, the instant complaint filed with the prayer that the complaint of the complainant may be accepted and OPs are directed to pay the amount of Rs.1,80,000/- incurred on the treatment of the complainant and hospitalization charges alongwith interest @ 18% per annum and further OPs be directed to pay compensation/damages for causing unnecessary harassment, mental tension and financial loss caused to the complainant, to the tune of Rs.2,00,000/- and also be directed to pay litigation expenses of Rs.35,000/-.
4. Notice of the complaint was given to the OPs, who filed a written reply, whereby contested the complaint by taking preliminary objections that the present complaint is not maintainable against the answering OPs, as such, the same is liable to be dismissed. It is 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 of repudiation dated 07.03.2015 addressed to the complainant, vide which the complainant was informed about the repudiation of the claim, specifically stating therein that as per documents submitted the claim was found to be misrepresented and as per policy terms and conditions, if any claim is in any manner dishonest or is supported by any fraudulent means or devices, whether by the insured person or anyone acting on behalf of insured person, then this policy shall be void and all benefits under it shall be forfeited. It is further averred that the repudiation is done after thorough investigation of the case and after going through the medical records and communications made through the complainant. On the basis of the investigation, it was found that the claim is not a bonafide claim, but contains misrepresentation and further submitted that there is neither any deficiency in service nor any negligence nor any unfair trade practice on the part of the answering OP No.1 to 3. Repudiating the claim which is not payable as per terms and conditions of the insurance policy does not amounts to any deficiency in service nor any negligence nor any unfair trade practice, as such, the complaint against the answering OPs No.1 to 3 is liable to be dismissed. On merits, the factum in regard to purchase of the insurance policy is admitted by the OP and further admitted that there is a liability of the Insurance Company, but subject to term and condition of the insurance policy and also admitted that the claim of the complainant received, but after due consideration the same are rejected and the other allegations as made in the complaint are categorically denied and lastly prayed that the complaint of the complainant is without merits and the same may be dismissed.
5. In order to prove the case of the complainant, the complainant Swami Mahesh Puri himself tendered into evidence his duly sworn affidavit Ex.CA alongwith some documents Ex.C-1 to Ex.C-27 and closed the evidence.
6. Similarly, the counsel for the OP No.1 to 3 tendered into evidence affidavit of Pankaj Kumar, Manager Legal Ex.OA alongwith some documents Ex.OP1/1 to Ex.OP1/9 and then closed the evidence.
7. We have heard the learned counsel for the respective parties and also gone through the case file very minutely.
8. From the scanning of the file, it has become clear that the complainant has purchased a medical insurance policy from the OPs, after paying the insurance premium and accordingly, the OP issued a cover note of the insurance policy Ex.C-1 and an insurance policy Ex.C-2, the said policy is valid up to March, 2018, but in the month of January, 2016, the complainant was admitted in the Goel Kidney Care Hospital and where he remained admitted from 03.01.2016 to 05.01.2016 and he paid hospitalization charges, to the tune of Rs.1,80,000/-, vide bill Ex.C-3 and then submitted a claim to the Insurance Company i.e. OP No.1 to 3, who repudiated the same, vide letter dated 07.03.2016 and copy of the repudiation letter is Ex.C-6, the other documents placed on the file by the complainant, are in regard to blood test, receipt of payment and other prescription given by the doctor for medicine and discharge summary.
9. The claim of the complainant has been repudiated by the OP under Section 10 of the terms and conditions, by taking a plea by the OP that as per investigation, got conducted by the OP, copy of the investigation report Ex.OP1/2 as well as from the documents i.e. Discharge Sumamry Ex.OP1/3, itself shows that the claim was submitted by the complainant, on the basis of fraudulent means or devices and as such, the claim of the complainant was found dishonest and fraudulent and misrepresented by the complainant, therefore, the same was repudiated, vide repudiation letter Ex.OP1/7 and the same repudiation letter produced on the file by the complainant Ex.C-6. The ground of the OP is that the doctor has charged an amount of Rs.10,000/- for removal of Stent and this factum is mentioned in the bill Ex.C-3, but when the matter was investigated, who found that as per doctor, no DJ Stent removed and further referred the discharge summary, issued by the Goel Kidney Care Centre Ex.OP1/3, wherein also mentioned that no DJ Stent removed, whereas by way of misrepresentation as well as by way of fraud, the amount has been charged and accordingly, the case of the complainant covered under Section 10 of the terms and conditions, which are placed on the file by the OP alongwith the insurance policy as Ex.OP1/1.
10. We have considered the rival contention of both the parties and also scanned the case file and find that the dispute in issue is only whether the DJ Stent removed or not, by the doctor, this is a main ground taken by the OPs as a misrepresentation and a fraudulent way, by adding the Stent removal charges in the bill, whereas actually no stent removal is there. For clarification the above factum, we required to go through the discharge summary, issued by the treating hospital, which is available on the file as Ex.OP1/3, on the second page of the Discharge Summary, it is categorically mentioned the procedure, followed by the doctor, wherein mentioned as under:-B/L RIRS + DJ Stenting done under S/A on 04.01.2016, this fact has been also elaborated by the Investigator in his investigation report Ex.OP1/2 that as per doctor, no DJ Stent has been removed in surgery, performed on 04.01.2016. One thing is clear from the discharge summary that on the day of operation i.e. 04.01.2016, a DJ Stent was inserted in the Urinal Pipe, if so then, the same cannot be removed on the same day i.e. the day of operation rather the removal of the said stent is mentioned by the doctor in its detailed report of dated 05.01.2016 i.e. the DJ Stent removal at one month, it is admitted fact that if due to Stone in the Kidney, any operation is conducted by the doctor and he inserted the DJ Stent in the Urinal Pipe, the same will be removed after one week or after one month as prescribed by the doctor, not on the same day of the operation date, so, from the documents, issued by the hospital, itself show that Stent is to be removed after some time, so accordingly, the doctor has charged the amount of the said removal of the stent and there is no misrepresentation or fraud on the part of the complainant or doctor because the factum in regard to conducting an operation of the complainant for removal of the Stone from Kidney is apparently established on the file from the documentary evidence. So, from over all circumstances, itself shows that the complainant is entitled for the relief claimed and claim of the complainant is wrongly and illegally repudiated by the OP through repudiation letter dated 07.03.2016 and accordingly, the same is set aside.
11. In view of the above detailed discussion, the complaint of the complainant is partly accepted and OPs are directed to pay the amount of Rs.1,80,000/- to the complainant, incurred on the treatment of the complainant and hospitalization charges alongwith interest @ 9% per annum from the date of repudiation of the claim i.e. 07.03.2016, till realization and further OPs are directed to pay compensation for mental harassment to the complainant, to the tune of Rs.20,000/- and litigation expenses of Rs.5000/-. The entire compliance be made within one month from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.
12. 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 Harvimal Dogra Karnail Singh
17.01.2018 Member President
