STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA
Date of Institution: 31.01.2020
Date of final hearing: 16.08.2024
Date of pronouncement: 28.10.2024
First Appeal No.72 of 2020
IN THE MATTER OF:-
HDFC Ergo General Insurance Company Ltd., 1st Floor, 165-166, Backbay Reclamation, HT Parekh Marg, Churchgate, Mumbai, and SCO 237, 2nd Floor, Sector-12, Opp. Mini Secretariat, Karnal and 5th Floor, Tower-1, Stellear IT Park, C-25, Sector 62, Noida-201301, through Shweta Pokhriyal, Assistant Manager-Legal. Email:- ...Appellant
Versus
Seema aged about 43 years, w/o Sh. Vikram, R/o H. No.91, Ward No.2, Indri, District Karnal. …..Respondent
CORAM: Sh. Naresh Katyal, Judicial Member.
Sh. S.C. Kaushik, Member.
Argued by:- Mr. Vishal Aggarwal, counsel for the appellant.
Mr. Dinesh Maurya, counsel for respondent.
ORDER
NARESH KATYAL, JUDICIAL MEMBER:
In this appeal No.72 of 2020, order dated 18.12.2019 passed by District Consumer Disputes Redressal Forum-Karnal (In short “District Commission”) in complaint case No.298 of 2018; vide which complainant’s complaint has been allowed, has been assailed.
2. Complainant purchased ‘Health Suraksha Policy (Silver Plan)’ from OPs/appellant bearing Policy No.2825100183670800000, valid from 16.03.2017 to 15.03.2018. Sum assured was Rs.5,00,000/. As per terms and conditions of policy; all family members of complainant i.e. complainant herself, her husband-Vikram and son Akash were covered under it. On 09.02.2018; her husband suffered acute pain in stomach. She and her husband rushed at Dr. Ajay Gupta’s Sarvodaya Multispecialty Hospital, Meerut Road-Karnal, where Doctor admitted her husband and started treatment. During treatment, when condition was not under control of doctor, then on 12.02.2018 her husband was referred by doctor to superior hospital/higher centre for further treatment. She got her husband admitted at Sir Ganga Ram Hospital-New Delhi on 12.02.2018, where doctor treated him till 22.02.2018 and discharged him. During his treatment; her son submitted claim forms Part-A and Part-B, KYC Application form, Pre-Authorization Request forms before both hospital authorities, as per formats of OPs/appellant. Policy was cashless, so amounts of bills of both hospitals during indoor treatment of her husband was required to be paid by the OPs/appellant, but OPs have/had not paid said amount to hospitals. Resultantly, complainant under compelling circumstances paid entire bill amount including medicines, test, hospitalization charges etc. to both hospitals. As per plea; she had spent Rs.3,66,700/- on treatment of her husband in both hospitals. Thereafter, she lodged claim with OPs for reimbursement of paid amount and submitted required documents with OP, but OP did not pay claimed amount and lingered the matter on one or other pretext and lastly repudiated the claim vide its letter dated 27.07.2018 on ground that: “complainant has not supplied past medical history of her husband”, whereas as per plea; she (complainant) had in number of times, informed representative of OP/appellant that there is/was no previous past history of her husband regarding any disease. Other relevant treatment record has/had already been obtained by OP/appellant from concerned hospital directly, but even then; OP/appellant have/had repudiated her claim without any cogent and reliable reason. She sent legal notice to OP in this regard through his counsel but it did not yield any result. On these pleas; complaint has been filed for issuance of direction to OP/appellant to reimburse Rs.3,66,700/- in terms of insurance policy to her; to pay her Rs.50,000/- for harassment, financial loss etc.; to pay her Rs.5500/- towards litigation expenses.
3. In response, OP/insurer/appellant raised contest and pleaded in its defense that: there were two claims lodged by the insured under ‘Health Suraksha Policy’ bearing No.2825100183670800000 subject to its terms and conditions and both claims are/were separately processed. Policy was first incepted on 16.03.2017. Details of both claims are: Claim No.RR-HS17-10521922: Claim was lodged against alleged hospitalization of insured Vikram at Sarvodya Multispecialty Hospital for period from 10.02.2018 to 12.02.2018. On admission, insured was diagnosed with ‘Perforation Peritonitis’ and underwent conservative treatment for same. As per documents submitted by complainant; it was also revealed that patient was diagnosed with Perforation Peritonotis (Peptic ulcer) and was treated for it. As per Referral Slip of Sarvodaya Hospital; patient had history of NSAID (Non-Steroidal Anti Inflammatory Drugs). OP was also enlightened with the fact. From perusal of treatment note and P.A.C. form of Sarvodaya Hospital; patient had history of Alcoholic abuse. Ailment (Peptic Ulcer) as suffered by patient under hospitalization was due to use and abuse of NSAID (Non-steroidal anti inflammatory drugs), as being the main cause of Peptic Ulcer. On basis of these facts, claim of complainant was repudiated under Section 9 A.ii.a, whereby, 2 years waiting period is applicable for all ailments related to Ulcer. As per policy’s terms and conditions; illness related to Ulcer is not covered for first two years of policy. In present case, as policy inception date was 16.03.2017, and date of admission was 10.02.2018, which demonstrates that policy was in first year, thus same falls under waiting period of 2 years under Section 9(A)(ii)(a). Further, as per plea; claim was repudiated on ground of abuse of intoxicants or hallucinogenic substances, as per medical documents indicating patient’s history of NSAID (Non-steroidal anti inflammatory drugs). Claim was also repudiated under section 9 c iv of policy. With regard to Claim no.RR-HS17-10521925; it is pleaded that said claim was lodged against alleged hospitalization of insured (Vikram) at Sir Ganga Ram Hospital for period from 12.02.2018 to 22.02.2018. Insured was admitted and was diagnosed with Duodenal Perforation Peritonitis. After scrutinizing claim form and papers so submitted; OPs found that documents submitted were insufficient to settle claim amount, and thus specific query was raised against complainant so that claim may be decided on merits. Letters dated 06.04.2018, 28.05.2018, 27.06.2018 and 12.07.2018 were issued to her requesting to submit documents, but she failed to produce same till date and thus claim was closed on ground of non-submission of documents vide letter dated 12.07.2018 duly supplied to complainant. As per plea; there is no deficiency in service on part of OP. Other allegations made in complaint have been denied and prayed for dismissal of complaint has been made.
4. Parties to this lis led evidence, oral as well as documentary.
5. On analyzing the same; learned District Consumer Commission-Karnal has allowed the complaint vide order dated 18.12.2019 and directed OP/insurer to pay Rs.3,66,700/- to complainant with interest @ 9% p.a. from date of repudiation/closing of claims, till realization. Compensation of Rs.25,000/- on account of mental agony and harassment and Rs.11,000/- towards litigation expense has also been allowed to complainant.
6. Feeling aggrieved; insurer/OP has filed this appeal.
7. Learned counsel for parties has been heard at length. With their able assistance; record too has been perused.
8. Learned counsel for the appellant/insurer has urged that impugned order is erroneous on legal and factual fronts. OP/appellant has rightly invoked exclusion clause while repudiating the first claim submitted to it and rightly closed second claim for non-submission of requisite documents. It is urged that insurance contract is to be strictly construed. Claim for treatment provided to husband of complainant (for disease Perforation Peritonitis which is peptic ulcer) could not be considered under policy, for two years, from its inception and policy’s inception date is/was 16.03.2017. First claim for reimbursement of amount spent on treatment of complainant’s husband was admissible only in third policy year, if complainant had continued to enforce said policy for further period without any break. Further contention is that second claim was closed for non-submission of documents by complainant. On these submissions; learned counsel for appellant has urged that impugned order dated 18.12.2019 warrants interference by this Commission and same is liable to be set aside.
9. Per Contra, learned counsel appearing for respondent has urged that all relevant facets of the case have been appropriately analyzed and adjudicated by learned District Consumer Commission while allowing complaint through impugned order dated 18.12.2019.
10. There is no denial to the fact that appellant/insurer has issued insurance policy, which has validity from 16.03.2017 to 15.03.2018 and vide which sum assured was Rs.5.00 lacs. Also, there is no denial to the fact that all family members of complainant were covered under said policy. Admittedly, husband of complainant obtained treatment initially from Ajay Gupta’s Sarvodaya Multispecialty Hospital-Karnal and thereafter he obtained further treatment from Sir Ganga Ram Hospital-New Delhi from 09.02.2018 to 22.02.2018. Complainant allegedly had spent Rs.3,66,700/- on her husband’s treatment from both hospitals. Amount spent by complainant was within the range of sum assured under policy. Sole ground of denial of claim raised by complainant for reimbursement of expenses incurred for treatment of her husband is that: ailment suffered by her husband (Perforation Peritonitis which is peptic ulcer) for which he was diagnosed and treated had waiting period of two years as per policy enforced by complainant and as such insurer/appellant has no liability and alike is the contention on behalf of appellant/insurer that claim was rightly repudiated.
11. Once there was policy issued by appellant then denial of claim of complainant on the pretext of waiting period of two years was an inappropriate act on the part of appellant/insurer. There is no evidence much less any plea on the part of appellant/insurer that ailment of complainant was pre-existing before inception of policy which was incepted on 16.03.2017. This Commission is of view that claim of complainant has been denied by appellant/insurer on sheer technicalities, which none the less is against the spirit and flowing purpose of policy. Complainant has/had obtained the policy for consideration of payment of premium for a specific period. It would be unjustified if complainant is commanded to continue to enforce the policy for a particular time period, extending beyond the time line provided in the policy, before availing benefit under it for herself and family. It is well settled legal proposition that policy’s exclusion clauses must not refute insurance policy’s intent and purpose. Repudiation based upon exclusion clause, as it is so in present case, and which contradict the intended object of insurance contract, in firm opinion of this Commission, amounts to an unfair trade practice.
12. Regarding second claim OP/appellant has come up with a stance that said claim has been closed as “No Claim” in view of non-submission of documents by complainant. Admittedly, policy in question was cashless. There is no express denial by OP/appellant to the pleaded fact (para 7 of complaint) that complainant did inform the insurer/appellant and filled request forms pertaining to treatment of her husband at both hospitals. In any case, nothing stopped OP/appellant to collect all relevant record of treatment of husband of complainant from both hospitals, which was in fact a duty/obligation on its part in view of cashless nature of policy. Consequently, the act and conduct of OP/appellant establish clear deficiency in their service and fastening burden upon complainant to submit documents was an act which perpetuated the insurer’s own deficiency. The learned District Consumer Commission has thrashed the controversy in hand, meticulously by objectively examining all relevant facets/evidence brought on record. It has rightly been held by learned District Consumer Commission in impugned order dated 18.12.2019 that complainant is entitled to Rs.3,66,700/-. There is no fallacy, legal or factual, by learned District Consumer Commission while passing impugned order dated 18.12.2019. This order is maintained and upheld. Present appeal is hereby dismissed being devoid of merits.
13. Statutory amount of Rs.25,000/- deposited by appellant at the time of filing of this appeal be refunded to it, after due identification and verification as per rules and on expiry of period meant for further appeal /revision, if any.
14. Application(s) pending, if any stand disposed of in terms of the aforesaid judgment.
15. A copy of this judgment be provided to all the parties free of cost as mandated by the Consumer Protection Act, 1986/2019. The Judgment be uploaded forthwith on the website of the Commission for the perusal of the parties.
16. File be consigned to record room.
Date of pronouncement: 28th October, 2024.
S.C. Kaushik Naresh Katyal
Member Judicial Member
Addl. Bench Addl. Bench
