District Consumer Disputes Redressal Commission, Hooghly
PETITIONER
VS.
OPPOSITE PARTY
Complaint Case No.CC/10/2022
(Date of Filing:-28.01.2022)
- Sri Sujoy Sadhu
Tolafatak (Near Sujata Sweets),
P.O. & P.S. Chinsurah
Dist. Hooghly, Pin:- 712101.…..complainant
- The Branch Manager, Howrah Branch
HDFC ERGOGeneral Insurance Company Ltd.
At Parmar House, 3rd Floor, P/4, Dobson Lane
P.O. Dobson, P.S. Golabari, District:-Howrah, Pin:- 711101.
- HDFC ERGO General Insurance Company Ltd.
22, Camac Street, P.O. & P.S. Park Street
- Mr, Pimmoy Paul, AAM-Agency
HDFC ERGO General Insurance Company Ltd.
At Parmar House, 3rd Floor, P/4 Dobson Lane,
P.O. Dobson Lane, P.S. Golabari, District:- Howrah-711101
- The Chairman, HDFC ERGO General Insurance Company Ltd.
HDFC House, 165/166, Backbay Raclamation, H.T. Parekh Marg
Churchgate, P.O. Churchgate, P.S. Marine Drive, Mumbai-400020
Before:-
Mr. Debasish Bandyopadhyay, President
Mrs. Babita Choudhury, Member
Mr. Debasis Bhattacharya, Member
-
Final Order/Judgment
Debasis Bhattacharya:- PRESIDING MEMBER
Being aggrieved by and dissatisfied with the repudiation of a claim by the OP Insurance Company, for reimbursement of medical expenses incurred by the Complainant in a listed hospital, the instant case has been filed by the complainant, u/s 35 of the Consumer Protection Act 2019.
The fact of the case in a nutshell is as follows.
The complainant, being a holder of the Health Insurance Policy bearing No. 2805203541013901000 of the OP Insurance Company, having been treated in a listed hospital since 18.05.2021 for several ailments viz. Covid-19, Pneumonia, Diabetes Mellitus, Ketosis, Hypertension, Hyperkalemia, acute kidney injury and dyslipidemia was finally discharged on 25.05.2021. Consequent upon that, the corresponding claim for reimbursement of medical expenses of Rs.2,50,404/- was lodged with the OP Insurance Company’s branch office at Howrah vide claim ID No. RR-HS21-12494964 dtd.22.06.2021.
However, from the poorly constructed complaint petition it can somehow be managed to make out that in spite of repeated persuasions the claim was finally repudiated by the OP Insurance Company and the Complainant was compelled to send legal notices to the OP Insurance Company twice the first one on 21.09.2021 and the other one on 09.11.2021 which proved to be futile exercises.
Allegedly, OP 1,2 and 3 sent some hooligans to the Complainant’s place on 07.01.2021 introducing themselves as representatives of OP Insurance Company and in presence of the people belonging to the Complainant’s family and neighbours threatened the Complainant and his family members and advised them to forget the claim.
All these reportedly were causes for the Complainant’s worries and anxieties.
Considering the treatment extended by the OP Insurance Company as deficiency of service and unfair trade practice the Complainant approaches to this Commission with a prayer to impose direction upon the opposite parties, particularly OP 1& 2 to reimburse the medical expenses, compensation of Rs.2,50,000/-, cost of the case which is not specified and any other relief which the Complainant is entitled to get according to law.
The Complainant along with his petition has annexed certain related documents viz. copies of legal notices, corresponding postal track reports, discharge summary, exhaustive bills and receipt vouchers of the concerned medical institution, medical test reports, claim form, certain reminders of the OP Insurance Company and claim closure letter.
Evidence on affidavit and brief notes of argument filed by the Complainant are almost replicas of the Complaint petition.
Apparently in the instant case the OP Insurance Company was a service provider.
Thus, in view of the above discussion and on examination of available records it transpires that the complainant is a consumer as far as the provisions laid down under Section 2(7)(ii)of the Consumer Protection Act 2019 are concerned.
The complainant is a resident within the district of Hooghly.
The claim preferred by the complainant does not exceed the limit of Rs.50,00,000/-.Thus, this Commission has territorial as well as pecuniary jurisdiction to proceed in the instant case.
The issues related to the questions whether there was any deficiency of service and whether the complainant is entitled to get any relief, being mutually inter-related, will be taken together for convenient disposal.
Defence case
OPs belonging to the same organization have contested the case by filing written version, evidence on affidavit and brief notes of argument. However on prayer the written version filed by the OPs has been treated as evidence on affidavit.
However simultaneously the OPs have claimed that this Commission is not the proper forum to seek relief and this Commission has no jurisdiction to entertain the present complaint as there is no deficiency of service and serious disputes both on facts and question of law have been involved in the present matter. Thus the present matter cannot be decided under summary proceedings and can be decided in civil court. In this reference the OP side has referred to certain judicial pronouncements.
Now the Commission finds the propositions placed by the OPs to be absurd and a blatant attempt to disregard the existing provisions of the Consumer Protection Act. The Judicial pronouncements mentioned in this connection are not applicable in this case.
Firstly it is the Commission who is supposed to decide whether there was any deficiency of service. On the contrary in the instant case the OPs themselves are under the preconceived notion that there was no deficiency of service.
Secondly in the instant case there are no such serious disputes both on facts and question of law for which the case has to be dragged to civil court. Scores of identical cases have already been decided in several district Commissions and State Commissions.
Hence the OPs’ claim that this Commission has no jurisdiction to try this case deserves to be brushed aside.
However, the OP side points out that the claim of the Complainant was rejected due to non-compliance of the query raised by the OPs for submission of the investigation reports (Pathological/Radiological), supporting diagnosis, treating doctor’s certificate for exact duration of diabetes, hypertension, acute kidney injury along with past consultation papers and treatment records. Besides the Complainant was also asked to submit KYC details and one passport size coloured photograph signed across by the proposer.
The OP side further clarifies that the said documents were required for scrutiny of the claim.
The claim was closed by the answering opposite parties as the said documents were not submitted despite several reminders.
Materials on records are perused.
Now the OPs in their representations i.e. in the written version turned evidence on affidavit and brief notes of argument have denied the allegations leveled against them in totality.
The OP Insurance Company points out that on 01.07.2021 they received a reimbursement request from the Complainant who got admitted in a medical institution on 18.05.2021 with complaints of fever, cough, shortness of breath. Copies of the claim form and discharge summary have been annexed.
However on scrutiny of the documents submitted by the Complainant it was noted that the patient had history of diabetes and hypertension. Resultantly queries were raised for additional documents and several reminders were sent to the Complainant on different dates. Copies of all those reminders, the policy schedule, the renewed policy schedule and customer information sheet have been annexed by the opposite parties along with their representation.
Decision with reason
Materials on records are perused. The discharge summary reflects that the final diagnosis of the Complainant was Covid-19, Pneumonia, Diabetes Mellitus, Ketosis, Hypertension, Hyperkalemia, Acute Kidney Injury and Dyslipidaemia.
History of past illness as noted in the discharge summary was Diabetes Mellitus and Hypertension.
On receipt of the claim the OP Insurance Company by first letter dtd.13.07.2021, and by several subsequent reminders asked for certain documents viz. investigation reports (Pathological/Radiological), treating doctor’s certificate for exact duration of the diabetes Mellitus and Hypertension and acute kidney injury in DD/MM/YY format, past consultation papers and treatment records and duly filled KYC form with one signed across passport size coloured photograph of the proposer.
However the claim was closed for non-submission of the said documents.
Now so far as the complaint petition, evidence on affidavit and brief notes of argument of the Complainant are concerned the Complainant has neither mentioned a single word about the requisition letter and reminders sent by the OP Insurance Company nor has assigned any reason for non-submission of the same.
It is to be appreciated that for scrutiny and to determine the extent to which the claim was admissible the Complainant was required to submit the documents as requisitioned by the OP Insurance Company.
As regards the issue involving threatening by some hooligans sent by the OP Insurance Company on 07.01.2021, the Complainant does not appear to have filed a GD/FIR with the concerned police station. Thus the allegation cannot be substantiated.
In view of the above the Commission is of the opinion that any sort of deficiency of service or unfair trade practice on the part of the OP Insurance Company in the instant case cannot be established in unequivocal terms.
Hence it is
ORDERED
that the complainant case no.10/2022 be and the same is dismissed on contest.
However there is no order as to costs.
Let a plain copy of this order be supplied free of cost to the parties/their Ld. Advocates/Agents on record by hand under proper acknowledgement/sent by ordinary post for information and necessary action.
The final order will be available in the website www.confonet.nic.in
