Haryana

Yamunanagar

CC/442/2011

Tejpal S/o Jarnail Singh - Complainant(s)

Versus

M/s HDFC Yamuna nagar - Opp.Party(s)

Karnesh Verma

27 Jan 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, YAMUNA NAGAR

                                                                                          Complaint  No. 442  of 2011.

                                                                                          Date of institution: 06.05.2011.

                                                                                          Date of decision: 27.01.2017

Tejpal aged about 48 years son of Sh. Jarnail Singh R/o Village Bhagwangarh P.O. Fatehpur, District Yamuna Nagar.                                                                                                                                                                                     

                                                                                                                                          …Complainant.

                                                           Versus

1. M/s HDFC Yamuna Nagar Branch First Floor Plot No. 1/75 Opposite Meera Bazzar, Near Fountain Chowk, Yamuna Nagar.
2. M/s HDFC Fifth Floor, Eureka Towers, Mind Space Complex, Link Road, Malad, (West) Mumbai.                                                                                                                                                                                   

                                                                                                                                          …Respondents.

  

BEFORE:         SH. ASHOK KUMAR GARG, PRESIDENT,

                         SH. S.C.SHARMA, MEMBER.

 

Present: Sh. Karnesh Verma, Advocate, counsel for complainant.   

              Sh. Atul Pandey, Advocate, counsel for respondents.

 

ORDER( ASHOK KUMAR GARG PRESIDENT)

 

1.                     Complainant Tejpal has filed the present complaint under section 12 of the Consumer Protection Act, 1986.

2.                     Brief facts of the present complaint, as alleged by the complainant, are that complainant got an HDFC Unit Linked Endowment Policy bearing No. 11077877 on his life on 23.05.2007 from the respondent No.2 (hereinafter respondents will be referred as OPs) through Op No.1 and the installment of premium for the said policy was Rs. 15,000/- per annum for the term of 10 years with the sum insured of Rs. 1,50,000/-. The complainant has deposited three installments of Rs. 15,000/- each regularly without any default i.e. Rs. 45,000/- has been deposited by the complainant against the policy in question. The complainant on 06.06.2010 submitted request form for policy surrender (full withdrawal) as per provision of the policy in question. It has been further mentioned that complainant took her treatment from Escort Heart Institute and Research Centre Ltd. Okhla Road, New Delhi on which he spent more than Rs. 2,00,000/-. After the completion of his treatment, the complainant visited the office of Op No.1 and submitted personally the Photocopies of all the bills of his medical treatment for an early reimbursement of the same but the OPs gave an assurance that reimbursement was being made soon and original bills would be taken from him before making reimbursement but the reimbursement has not been made till date. A legal notice dated 26.08.2010 was also given to the OPs upon which Zonal Legal Executive of the OPs Insurance Company Chandigarh Branch submitted reply dated 30.10.2010 mentioning therein that “ we advise your client to visit any of our branch for the purpose availing benefits as per policy provision and submit proper request/application letter. Accordingly, the complainant visited the office of the OP No.1 at Yamuna Nagar and submitted the Photocopies of all medical treatment bills and other documents alongwith application/request form and requested to reimburse the amount spent on his treatment but the OpNo.2 vide letter dated 23.03.2011 informed that claim of the complainant could not be entertained for reimbursement as the death of the portion of heart muscle as a result of inadequate blood supply does not fall within the ambit of heart attack and the claim should have been lodged within a period of 26 weeks of the illness. The OPs have wrongly and illegally repudiated the claim of the complainant on the false ground. Lastly, prayed for directing the OPs to reimburse the medical bills amounting to Rs. 2,35,800/- on account of his treatment and also to pay compensation as well as litigation expenses. Hence, this complaint.

3.                     Upon notice, OPs Insurance Company appeared and filed its written statement jointly by taking some preliminary objections such as complaint is not maintainable; complainant has not presented the true facts before this Forum; complainant has entered into contract of the insurance with the OPs Insurance Company and under its benefits, the complainant was covered for only Rs. 1,50,000/- as sum insured. Apart from the above sum insured, the complainant was also covered for “critical illness” for an amount of Rs. 1,50,000/- subject to those critical illness are defined and provided in the policy documents; the present complaint is barred by limitation as the treatment undergone by the complainant is on 22.09.2008. The complainant is trying to fit his complaint within the ambit of limitation by presenting the follow up receipts but this action of the complainant is against the provision of law.  The claim submitted by the complainant does not fall under the definition of “Heart Attack” under which the complainant is claiming the benefits. Thus, no benefits is payable to the complainant and on merit it has been admitted that complainant purchased the insurance policy in question from the OPs for a sum insured of Rs. 1,50,000/- covering the risk of critical illness as defined and provided in the policy documents. However, from the contents of the complaint, it is evident that complainant has never approached the OPs for submitting the medical records. Firstly, complainant has not provided any date of visit and secondly he is saying in para No.2 of his complaint that he has given an application for surrender of his present policy. It is very strange that if he was already waiting for claim payment then why he wanted to surrender the insurance policy, because the surrender of insurance policy will cause all the benefits to end there only. Mere acceptance of claim form does not oblige the OPs to admit the claim of the complainant as the standard procedure claim is duly scrutinized before taking any decision on the same by the company. In the present matter also the claim of the complainant was scrutinized and it was found that treatment under taken by the complainant does not fall under the definition of “ Heart Attack” and likewise the claim of the complainant was rightly repudiated. The illness of the complainant was acute “Inferior Wall Myocardial Infraction” and this illness is not covered under the present insurance policy. As per terms and conditions of the insurance policy in question, the complainant was covered for “heart attack” “clause No.18 of the standard policy provision page No.11 of the policy documents” and it is defined as:

“ the death of a portion of heart muscle as a result of an inadequate blood supply as evidenced by an episode of typical chest pain, new electrocardiographic  changes and by elevation of the cardiac enzymes”

                        The 2 D Echo Doppler Report dated 23.09.2008 clearly shows that the afore mentioned conditions of the complainant is in normal range and thus he has not suffered a “heart attack”. The treatment that was taken by the complainant is “Coronary Angioplasty” for removal of blockage from valve. The terms and conditions of the policy clearly states that heart attack is death of heart muscles. The discharge summary of the Fortis Hospital dated 24.09.2008 clearly described the diagnosis as “ Acute Inferior Wall Myocardial Infraction. Hence, there was no deficiency in service or unfair trade practice for repudiating the claim of the complainant and lastly prayed for dismissal of complaint.

4.                     To prove the case, counsel for the complainant tendered into evidence affidavit of complainant as Annexure CX and documents such as Photo copy of forwarding letter for sending the policy documents dated 24.05.2007 alongwith insurance policy in question as Annexure C-1, Photo copy of reply of legal notice alongwith some documents/discharge voucher etc. as Annexure C-2, Photo copy of request letter for reimbursement of the claim amount as Annexure C-3, Photo copy of repudiation letter dated 23.03.2011 as Annexure C-4 and closed the evidence on behalf of complainant.

5.                     On the other hand, learned counsel for the OPs tendered into evidence short affidavit of DM Legal HDFC Insurance Company as Annexure RW/A and documents such as photo copy of proposal form as Annexure R-1, Photo copy of doctors hospital certificate as Annexure R-2 and R-3, Photo copy of record of Fortis Escort Hospital as Annexure R-4, Photo copy of discharge slip dated 28.09.2008 of Kapil Hospital, Yamuna Nagar as Annexure R-5, Photo copy of repudiation letter dated 23.03.2011 as Annexure R-6, Photo copy of  terms and conditions of the Insurance Policy as Annexure R-7 and closed the evidence on behalf of OPs.

6.                     We have heard the learned counsel for both the parties and have gone through the pleadings as well as documents placed on file very minutely and carefully.

7.                     After hearing both the parties, we are of the considered view that there is no deficiency in service or unfair trade practice on the part of OPs as from the perusal of the medical treatment record Annexure R-5, it is duly evident that complainant/patient underwent coronary angiography and PTCA + stent ( PRONOVA) TO LCx(m) on 22.09.2008. The procedure was uncomplicated and well tolerated. During the hospital said patient was put on some medicines. His general condition at the time of discharge was satisfactory. Meaning thereby that the illness of the complainant was “Acute Myocardial Infraction” and this illness was not covered under the present insurance policy. The treatment that was taken by the complainant is “Coronary Angioplasty” for removal of blockage from the valves of the heart and putting the stent in the valve. As per the terms and conditions of the insurance policy clause No.18(b) of the standard policy provision at page No.11 of the policy documents it has been mentioned that “balloon angioplasty, laser or any catheter based procedures are not covered” and further under the clause (C ) Heart Attack has been defined as “the death of the portion of the heart muscles as a result of an inadequate blood supply as evidenced by an episode of typical chest pain, new electrocardiographic changes and by elevation of the cardiac enzymes. After going through the above noted condition of the insurance policy, it is clearly evident that claim of the complainant does not fall under the policy in question. Learned counsel for the OPs also referred the case law titled as LIC of India Versus Shri Niwas Bansal, 2013(2) CPC Page 572 National Commission wherein it has been held “that Mediclaim Policy- Reimbursement of expenditure spent on medical treatment of angioplasty claimed by the complainant- As per terms of policy, claim could not be filed only for heart bypass surgery and angioplasty was totally excluded- Fora below committed error in granting relief to the respondent/complainant- Impugned order set aside”.   

8.                     In the circumstances noted above and going through the case law titled as LIC of India Versus Shri Niwas Bansal,(supra) we are of the considered view that the complainant failed to controvert the version of the OPs by filing any cogent evidence and he is not entitled for any relief.

9.                     Resultantly, we find no merit in the present complaint and the same is hereby dismissed with no order as to costs. Copies of this order be sent to the parties concerned free of costs as per rules. File be consigned to the record room after due compliance.

Announced in open court. 27.01.2017.

                                                                                    (ASHOK KUMAR GARG )

                                                                                    PRESIDENT,

 

                                                                                    (S.C. SHARMA )

                                                                                    MEMBER.