District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.415/2022.
Date of Institution: 08.08.2022.
Date of Order: 14.11.2023.
Ashok Gera aged about 60 years S/o Shri Ishwar Dass Gera R/o House No. B-1349, 2nd floor, gate No.10, Greenfields Colony, Faridabad – 121010/ Aadhaar No. 6715 5940 8978, Mobile No. 9818243317.
…….Complainant……..
Versus
M/s. HDFC Ergo General Insurance Company Limited, registered & Corporate office: Ist floor, HDFC House No. 165-166, backbay Reclamation, HT Parekh Marg,, Churchgate, Mumbai – 400 020 through its Branch Manager/Principal Officer.
Having its branch/local office at:
M/s.HDFC Ergo General Insurance Company Limited, Branch office: Ist floor, Shop NO. 110 & 117, Om Shubham Tower, Neelam Chowk, NIT, Faridabad through its Branch Manager/A.R.
…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. Rajeev Kumar Nangia, counsel for the complainant.
Sh. D.K.Gosain, counsel for opposite party.
ORDER:
The facts in brief of the complaint are that the complainant and his wife Mrs. Umesh Gera were regular mediclaim policy holders of the opposite party under product name “HDFC Ergo Group Health Insurance” from 16.04.2019 and remaining continue and current policy baring certificate No. 2809 2046 0827 2500 001 valid form 16.04.2022 to 15.04.2023. On 17.05.2022, the complainant felt severe pain in his abdomen and approached Sir Ganga Ram Hospita, New Delhi on 17.5.2022 and in OPD of said hospital, the medical officer checked and seeing the condition of patient, admitted the patient/complainant and check-up/investigation was done and advise for admission for proper treatment but due to non availability of bed, referred him to Sir Ganga Ram City Hospital, Pusa Road, new Delhi (sister hospital of Sir Ganga Ram Hospital) and the complainant got admitted in said hospital vide IP No. 22/03463 on 17.05.2022 and investigation, tests were done and transferred the complainant to main hospital (Sir Ganga Ram Hospital) on 21.05.2022. Said Sir Ganga Ram City Hospital, Pusa Raod, New Delhi raised the bill bearing invoice No.22-23/1409 dated 21.05.2022 for Rs.1,15,701/- and the complainant had to pay the same (Rs.5000/- in cash on 17.5.2022 vide receipt No. 4297 and Rs.1,10,701/- through online transfer vide receipt No. 4655, the details of which were duly mentioned in final bill), because the opposite party effused to provide cashless facility vide email dated 20.05.2022. The hospital administration sent intimation to the opposite party with request for providing cashless facility but the opposite party did not provide the same vide email dated 20.05.2022. After due investigation and on receipt of billing amount, the said Sir Ganga Ram City Hospital, transferred the complainant to Sir Ganga am Hospital under in house transfer policy for further treatment. On same day at about 12-40 pm, the complainant admitted in Sir Ganga Ram Hospital, New Delhi vide episode No. IP01197582 and the medical officer done the following operations/procedures:-“23.05.2022 Right URS with Bilateral DJ Stenting Done under GA” and discharge don 24.05.2022 and issued the bill for Rs.1,15,218 same was paid by the complainant (Rs.5,000/- in cash vide receipt No. 21217 dated 21.05.2022, rs.20,000/- in cash vide receipt No. 21997 on 23.05.2022 and rs.90,218/- in cash vide receipt No.22255 dated 24.5.2022) and the complainant also spent Rs.25,684/- as day care charges. Thereafter, the complainant submitted all requisite documents with the opposite party as demanded and lodged his claim vide No. RR-HS22-12989757 and the opposite party relied vide email dated 19.06.2022 that the claim was under process and get an update 13 days. Opposite party transferred a payment of sum of Rs.12,121/- in the bank account of the complainant on dated 05.06.2022 and then the complainant approached the opposite party to know why transferred short amount instead above said claimed amount and where the complainant shocked and surprised to know that the opposite party had refunded the last year policy premium amount and cancelled the said policy and handed over a printout vide which in an illegal manner repudiated the claim and also cancelled the said policy vide email dated 20.06.2022 alleging therein that “claim was closed as policy was cancelled as preauth claim ID-RCHS2212978714 was already denied due to incorrect health declaration and hiding of the fact CAD. Hence, cannot be processed.The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) disburse the claimed amount of rs.2,71,811/- with interest @ 24% p.a. from the date of bill till actual realization.
b) restore the policy with all continuous benefits.
c) pay Rs.1,00,000/- as compensation for causing mental agony and harassment .
d) pay Rs. 31,000 /-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 HDFC Ergo Group Health Insurance firstly on 16.04.2019 and thereafter 16.04.2020 covering the period 16.04.2020 covering the period 16.04.2020 to 15.04.2021 and also obtained HDFC Ergo Group Health Insurance policy certificate No. 2809204608272500001 valid for the period 16.04.2022 to 15.04.2023 and the said policies were issued subject to the terms and conditions and exclusion clauses of the policy which were never disputed by the insured. On 18.05.2022, cashless request was received in respect of Ashok Gera from Sir Ganga Ram Hospital for acute Febrile Illness and post scrutiny of documents, it was noted that the complainant wa shaving history of CAD prior to the policy and the complainant was found to have CAD and TBD and was operated for CABG on 07.09.2014 and was following up on OPD basis for the same as per the certificate issued by Sir Ganga Ram City Hospital, New Delhi. It was submitted that the complainant while taking health insurance cover firstly on 16.4.2019 concealed the fact that he was having history of CAD prior to obtaining the policy, the opposite party cancelled the policy certificate No. 2809204608272500001 valid for the period 16.4.2022 to 15.4.2023 and transferred the amount of premium of Rs.12,121/- in bank account of the complainant. 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 Limited with the prayer to: a) disburse the claimed amount of rs.2,71,811/- with interest @ 24% p.a. from the date of bill till actual realization. b)restore the policy with all continuous benefits. c) pay Rs.1,00,000/- as compensation for causing mental agony and harassment . d) pay Rs. 31,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW1/A – affidavit of Ashok Gera, Ex.C-1 – policy, Ex.C-2 – Group Assurance Health Plan – certificate of insurance, valid form 16.4.2020 to 15.4.2021, Ex.C-3 – insurance policy valid from 16.4.2022 to 15.4.2023,, Ex.C-4 – insurance policy valid from 16.4.2021 to 15.4.2022, Ex.C-5 - bill dated 17.05.2022, Ex.C-6 – summary bill, E.C-7 – receipt, Ex.C-8 – not readable, Ex.C-9 – Transfer summary,, Ex.C-10 – discharge summary,, Ex.C-11 to 13– Advance receipts,, Ex.C-14 to 16- bills, Ex.C-17 & 18 – receipts,, Ex.C-19 – Claim form – Part A, Ex.C-20 - email dated 19 June 2022, Ex. C-21 payment successful Ex.C-22 –Tax invoice, Ex.C-23 – Receipt, Ex.C-24 – OPD Bill cum receipt,
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 Shweta Pokhriyal, Senior Manager – Legal claims, HDFC Ergo General Insurance co. Ltd., 5th floor, Tower-1, Stellar IT park, C-25, Sector-62, Noida,, Ex.R-1 –Enrolment form,Ex.R-2 – insurance policy valid from 16.4.2019 to 15.4.2020,, Ex.R-3 – casualty card, Ex.R-4 – discharge summary, Ex.R-5 – certificate, Ex.R-6 – Denial of a cashless claim facility,, Ex.R-7 – discharge summary,
6. In this complaint, the claim of the complainant was repudiated on the ground of non disclosure of previous disease in the year 2014 . Heart surgery was done by the complainant in the year 2014 and mediclaim insurance policy was issued in the year 2018. Since the complainant has got the mediclaim policy and opposite party has repudiated the claim of the complainant on the ground of non disclosure.
On the other hand, counsel for the opposite party argued at length and state at Bar that the cashless denial letter was issued on 20.05.2022 vide Ex.R6. As per discharge summary vide Ex.R4 the patient was admitted on 21.05.2022. It means that the opposite party have informed that the opposite party is denying the claim of the complainant on non disclosure. Opposite party cancelled the policy certificate No. 2809204608273200001 valid for the period 16.04.2022 to 15.04.2023 and transferred the amount of Rs.12,121/- in bank account of the complainant which is not rebutted by the complainant.
The counsel for the complainant has argued at length and also stated that the treatment was taken for heart surgery in the year 2014. Moreover, when the insured is above 61 years then the Insurance Company was at liberty to get the complainant medically examined prior to issuance of the policy in question. Insurance Company cannot take advantage of its act of omission and commission as it is under obligation to ensure before issuing the policy in question whether a person is fit to be insured or not. It was the duty of the opposite party to get the complainant immediately examined before issuing the policy as per IRDA guidelines. Now the patient has taken the treatment of prostrate gland. It is totally different from previous ailment from the heart surgery and also given the two citizens:
i) Sulbha Prakash Motegaonkar Vs. Life Insurance Corporation in Civil Appeal No. 8245 of 2015 (Arising out of S.L.P © No. 13589 of 2015) which was decided on 5th October 2015 passed by the Hon’ble Supreme Court of India.
ii) Birla Sun Life Insurance Co. Ltd. & Ors. Vs. Ettedi Gangamma in Revision petition No. 3363 of 2017 passed by the Hon’ble National Consumer Disputes Redressal Commission, New Delhi which was decided on 26th September 2023 in which it has been stated that “6…….The death of the insured due to ischemic heart with disease and myocardial infarction had nothing to do with his lumbar spondylitis with PID with sciatica. In our considered opinion, since the alleged concealment was not of such a nature as would disentitle the deceased from getting his life insured, the repudiation of the claim was incorrect and not justified”.
7. After going through the evidence led by both the both the parties as well as the arguments , the Commission is of the opinion that the complaint is disposed off with the direction to opposite party to allow the complainant on non standard basis after deduction of 35% of the total bill and restore the policy. Opposite party is directed to process the claim of the complainant within 30 days from the date of receipt of the copy of order. 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. Compliance of this order be made within 30 days from the date of receipt of copy of this order. Copy of this order be sent to the parties concerned free of costs. File be consigned to the record room.
Announced on: 14.11.2023 (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.
