Haryana

StateCommission

A/882/2015

HDFC ERGO GIC LTD. - Complainant(s)

Versus

SUNIL KUMAR - Opp.Party(s)

SANDEEP SURI

04 Aug 2016

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                 

First Appeal No  :   882 of 2015

Date of Institution:   16.10.2015

Date of Decision :    04.08.2016

 

1.     HDFC ERGO General Insurance Company Limited, 6^th Floor, Leela Business Park, Andheri Kurla Road, (Andheri East, Mumbai-400059).

2.     HDFC ERGO General Insurance Company Limited, branch office at Rohtak C/o HDFC Bank Limited, Model Town, Rohtak.

 

                                      Appellants-Opposite Parties No.1 & 2

Versus

 

1.      Sunil Kumar s/o Sh. Krishan, Resident of House No.114/14, Kirpal Nagar, Rohtak.

Respondent-Complainant

2.      HDFC Bank Limited, Model Town, Rohtak.

 

                                      Respondent-Opposite Party No.3

 

CORAM:             Hon’ble Mr. Justice Nawab Singh, President.

                             Shri B.M. Bedi, Judicial Member.

                             Shri Diwan Singh Chauhan, Member   

 

Argued by:          Shri Sandeep Suri, Advocate for appellants.

                             Shri Surinder Gaur, Advocate for respondent No.1.

Shri S.C. Thatai, Advocate proxy for Shri Sumit Narang, counsel for respondent No.2.

 

                                                   O R D E R

 

B.M. BEDI, JUDICIAL MEMBER

 

HDFC ERGO General Insurance Company Limited (for short ‘the Insurance Company’)-Opposite Parties No.1 and 2, are in appeal against the order dated January 20^th, 2015 passed by District Consumer Disputes Redressal Forum, Rohtak (for short ‘the District Forum’), whereby complaint filed by Sunil Kumar-complainant/respondent No.1, was accepted. For facilitation, the operative part of the order is reproduced as under:-

“…….it is directed that opposite party No.1 & 2 shall pay the claim amount of Rs.208000/- (Rupees two lac eight thousand only) along with interest @ 9% p.a. from the date of filing the present complaint i.e. 10.02.2011 till its realization and shall also pay a sum of Rs.2200/- (Rupees two thousand two hundred only) as litigation expenses to the complainant maximum within one month from the date of decision failing which the opposite party No.1 & 2 shall be liable to pay interest @ 12% p.a. on the awarded amount from the date of decision. Complaint is allowed accordingly.”    

2.                The complainant-respondent No.1, opened an account with HDFC Bank Limited, Rohtak (hereinafter referred to as ‘the bank”)-Opposite Party No.3. As per the scheme floated by the bank,  the complainant purchased ‘Critical Illness’ Insurance Policy (Exhibit C-8) from the appellants-opposite parties No.1 and 2. The sum insured was Rs.10.00 lacs. The policy commenced from June 29^th, 2010 to June 28^th, 2011.

3.                The complainant suffered heart problem and was admitted in Max Healthcare Super Specialty Hospital, New Delhi (for short ‘the Max Heart, Hospital’), on September 9^th, 2010 where he was operated upon on September 10^th, 2010 and was discharged on September 15^th, 2010. The complainant paid Rs.2,08,000/- vide bill Exhibit C-1, in Max Heart, Hospital.  He filed claim with the Opposite Parties-appellants but they repudiated the claim vide letter dated 6^th January, 2010 on the ground reproduced below:-

                   “Section 2: Exclusion to the Critical illness Policy

We will not make any payment for any claim in respect of the Insured Person directly or indirectly for, caused by, arising from or in any way attributable to any of the following unless expressly stated to the contrary in this policy:

(i)      A waiting period of 90 days will apply to all claims unless the Insured Person has been insured under this policy continuously and without any break in the previous policy year.”

4.                Aggrieved thereof, the complaint filed complaint under Section 12 of the Consumer Protection Act, 1986.

5.                The opposite parties contested the complaint by filing written version reiterating the fact stated in the repudiation letter and prayed for dismissal of the complaint.

6.                After evaluating the pleadings and evidence of the parties, the District Forum allowed complaint directing the appellants-opposite parties No.1 and 2, as detailed in paragraph No.1 of this order.

7.                Learned counsel for the appellants-Insurance Company has argued that there was waiting period of 90 days for reimbursement of the treatment expenses. In support, reliance has been placed upon Section 2 Exclusions (Annexure-A) of the policy, which has been mentioned in the repudiation letter, reproduced above.

8.                The contention raised by the learned counsel for the Insurance Company is tenable. The policy commenced on June 29^th, 2010 and the complainant was admitted in hospital on September 9^th, 2010, that is, within 90 days of commencement of the policy. Therefore, the complainant was not entitled for reimbursement of the treatment expenses.

9.                Hon’ble National Commission in Col. T.S. Bakshi Retd. Versus Star Health & Allied Insurance Company Limited, Revision Petition No.852 of 2013, decided on May 6^th, 2014, wherein also in a similar clause there was waiting period of 30 days, upheld the clause and justified the repudiation of claim.

10.              On the other hand, learned counsel for the respondent No.1-complainant has argued that the terms and conditions of the policy were not supplied to the complainant.

11.              The contention raised on behalf of the respondent No.1-complainant is not tenable because the complainant himself has placed on the file document Exhibit C-7, wherein it has been clearly mentioned that the terms and conditions were discussed. Besides even in the policy schedule (Exhibit C-8) giving details of the amount permissible against the treatment of a particular disease, it finds mention that “Subject otherwise to the terms, exclusions and conditions of this Policy”. 

12.              In view of the above, it is held that HDFC ERGO General Insurance Company Limited was justified while repudiating complainant’s claim and the District Forum fell in error in allowing the complaint.  Hence, the appeal is allowed, the impugned order is set aside and the complaint is dismissed.

13.              The statutory amount of Rs.25,000/- deposited at the time of filing the appeal be refunded to the appellants against proper receipt and identification in accordance with rules, after the expiry of period of appeal/revision, if any.

 

 

Announced 04.08.2016

(Diwan Singh Chauhan) Member

(B.M. Bedi) Judicial Member

(Nawab Singh) President

CL