Chandigarh

DF-I

CC/29/2016

Sh. Ashwani Bansal - Complainant(s)

Versus

M/s HDFC Standard Life Insurance Co. Ltd. - Opp.Party(s)

Pankaj Chandgothia

11 Jul 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I, U.T. CHANDIGARH

============

Consumer Complaint  No	:	CC/29/2016
Date  of  Institution	:	12/01/2016
Date   of   Decision	:	11/07/2017

 

 

 

 

 

Ashwani Bansal C/o Messrs Kesho Ram Ramesh Chand, Anaj Mandi, Kurali, Mohali.

….Complainant

 

Vs.

 

[1]  M/s HDFC Standard Life Insurance Co. Limited, through its Branch Manager, Branch Office: 1^st and 2^nd Floor, SCO 1A – 120, Sector 43-B, Chandigarh.

 

[2]  M/s E-Meditek TPA Service Ltd., through its Medical Officer, Plot No. 577, Udyog Vihar, Phase V, Gurgaon, Haryana – 122016.

 

…… Opposite Parties 

 

 

BEFORE:   MRS.SURJEET KAUR             PRESIDING MEMBER

          SH. SURESH KUMAR SARDANA     MEMBER

 

For Complainant	:	Sh. Devinder Singh Soundh, Advocate.
For OP No.1	:	Sh. Nitin Thatai, Advocate.
For OP No.2	:	Ex-parte.

 

PER SURESH KUMAR SARDANA, MEMBER

 

 

 

          In brief, the Complainant took an HDFC Life Health Assure Plan Policy from Opposite Party No.1 on 30.09.2013 for himself and his wife amounting to cover of Rs.3,00,000/-. The policy was renewed by paying renewal premium in Sept. 2014 and Sept. 2015. Unfortunately, the wife of the Complainant namely Mrs. Neelam Bansal suffered severe vertigo and had to be admitted to Max Super Specialty Hospitality, Mohali on 1.8.2015. After treatment as an indoor patient, she was discharged on 04.09.2015. The Complainant accordingly submitted the claim form to Opposite Party No.1 on 24.08.2015 for a total claim of Rs.44,990.35P. However, the Opposite Parties wrongly repudiated the claim of the Complainant in a mechanical manner without due application of mind vide communication dated 18.12.2015. When all the frantic efforts made by the Complainant, failed to fructify, as a measure of last resort, alleging that the aforesaid acts of the Opposite Parties tantamount to deficiency in service and unfair trade practice, the Complainant has filed the instant Complaint u/s 12 of the Consumer Protection Act, 1986, seeking various reliefs. 

 

2.     Notice of the complaint was sent to the Opposite Parties, seeking their version of the case. However, nobody appeared on behalf of Opposite Party No.2 despite service, therefore, it was proceeded ex-parte.

 

3.     Opposite Party No.1 in its reply has stated that on receipt of the claim on 27.08.2015 in respect of the hospitalization of Mrs. Neelam Bansal on 01.08.2015 to 04.08.2015, the Complainant was asked by Opposite Party No.2 (TPA) to submit certain documents to enable it to process the medi-claim. However, the Complainant did not submit the same, which created serious doubts in the mind the answering Opposite Party about the claim. A reminder dated 25.9.2015 was also sent to the Complainant, but he failed to submit the desired documents, which amounted to violation of the terms of the proposal form and declarations submitted therein. Hence, the answering Opposite Party has rightly repudiated the claim of the Complainant.  Denying all other allegations, opposite party No. 1 has prayed for dismissal of the complaint.  

 

4.     Controverting the allegations contained in the written statement and reiterating the pleadings in the Complaint, the Complainant filed the rejoinder.

 

5.     Parties were permitted to place their respective evidence on record, in support of their contentions.

 

6.     We have heard the Ld. Counsel for Parties and also perused the record, with utmost care and circumspection.

 

7.     The main grievance of the Complainant is that the insurance claim of her wife has been repudiated by the Opposite Parties on the ground of pre-existing disease. It is an admitted fact that the risk commencement date is 30.09.2013 and term of the policy is for 03 years from the date of commencement. On perusal of the record placed before us, we find that the Policy was in existence during the period for which the Complainant’s wife fell ill and was admitted to the hospital. On perusal of the Discharge Summary (Annexure C-2), we find that in the column “Brief History”, it is recorded that no history of similar Complaints in the past. Further, in the Health Assure Claim Form (Annexure C-4 (Pg.35)), shows that date of injury sustained/ disease first detected is mentioned as 01.08.2015. Importantly, Dr. S.S. Bharti of Aman Nursing Home, in his certificate (Annexure C-6) has categorically mentioned 06.01.2015 as the date of first instance of the reported disease, for which the wife of the Complainant was given treatment. Since the policy was in existence w.e.f. 30.09.2013 and whereas the said disease, on the basis of which the claim was repudiated by the Opposite Parties, was detected only on 06.01.2015, hence it cannot be concluded that the Complainant was suffering from the pre-existing disease. In these set of circumstances, the rejection of the claim of the Complainant by the Opposite Parties is not tenable in the eyes of law and amounts to unfair trade practice and gross deficiency in service.  

 

8.     In the light of above observations, the present complaint of the Complainant deserves to succeed against the Opposite Parties No.1 & 2, and the same is allowed, qua them. The Opposite Parties No.1 & 2 are, jointly and severally, directed:-

 

[a]  To pay the amount of Rs.44,990.35/- to the Complainant;

 

[b]  To pay Rs.10,000/- as compensation for mental agony & harassment suffered by the complainant;

 

[c]  To pay Rs.10,000/- as costs of litigation.

 

9.     The above said order shall be complied within 30 days of its receipt by the Opposite Parties No.1 & 2; thereafter, Opposite Parties No.1 & 2 shall be liable for an interest @12% p.a. on the amounts mentioned in sub-paras [a] and [b] above from the date of institution of this complaint, till it is paid, apart from cost of litigation as in sub-para [c].  

 

10.     The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

11^th July, 2017                                    Sd/-   

 (SURJEET KAUR)

PRESIDING MEMBER

 

                                              Sd/-

(SURESH KUMAR SARDANA)

MEMBER