BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 221 of 2017
Date of Institution : 1.9.2017
Date of Decision : 28.3.2018.
Rameti (aged about 55 yeares) wife of Sh. Zile Singh, resident of village Chhatriyan Wali, P.O. Baragudha, District Sirsa- 125078.
……Complainant.
Versus.
1. The Chief/ Senior Manager HDFC ERGO General Insurance Company Ltd. First Floor 165-166, Backbay Reclamation HT Parekh Marg Church Gate, Mumbai- 400020.
2. The Manager, HDFC ERGO General Insurance Company Ltd. Customer Service, 6th Floor Lila Business Park Andheri Kurla Road Andheri Mumbai- 400059.
3. Senior Manager, HDFC ERGO General Insurance Company Ltd. 5th Floor Tower-I, Steller IT Park C-25, Sector 62 Noida- 201301 UP.
4. Manager, HDFC ERGO General Insurance Company Ltd. C/o HDFC Bank, Sangwan Chowk, Sirsa.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SH. R.L.AHUJA…………………………PRESIDENT
SH. MOHINDER PAUL RATHEE …… MEMBER.
Present: Sh. Ravinder Monga, Advocate for the complainant.
Sh. R.K. Mehta, Advocate for opposite parties No.1,2 and 4.
Opposite party no.3 exparte.
ORDER
The case of the complainant in brief is that son of complainant namely Manoj Kumar was hale and hearty and on persuasion of official of op no.4, he agreed to purchase Health Surksha Policy introduced by the ops. Before entering into contract for purchasing the said policy, the ops as per their norms, guidelines, terms and conditions fulfilled all the required formalities i.e. completion of all the documents. It is further averred that as per terms of the insurance, a sum of Rs.five lacs was insured and covered qua all the ailments including sudden death. The son of complainant had paid Rs.5664/- as first installment for the above said insurance. The date for next installment was fixed 9.8.2016. So, as per the terms and conditions of the policy, Manoj Kumar was insured for one year w.e.f. 10.8.2015 to 9.8.2016 under Health Surksha Insurance Policy. The ops issued guide book duly published by HDFC ERGO General Insurance to the insured at his address. The ops obtained medical report from the paneled doctor. It is further averred that in the end of January, 2016, son of complainant suddenly surrounded with viral fever and immediately approached to nearby hospital known as Shah Satnam Ji Specialty Hospital, Sirsa in emergency. Before giving medicines by the doctor concerned, Manoj Kumar was advised to get the blood and other tests from the laboratory, so that he could be diagnosed. The blood and other tests were closely investigated by the doctors. The son of complainant complained for regular itching over his body which was not bearable. The duty doctor initially started the treatment and given the medicines. Then after few days, he was discharged by giving few medicines. Then suddenly in the month of March, 2016 Manoj Kumar became unconscious and immediately taken to Shah Satnam Ji Specialty Hospital, where he was admitted on 4.3.2016 and was discharged on 8.3.2016. During this period, the entire investigation was done and due to increasing S.Creatinine, he was diagnosed and advised for rest. That thereafter within few days, Manoj Kumar again complained for pain in abdomen and vomiting. He was admitted on 12.4.2016 and was discharged on 13.4.2016. Then in June, 2016 there was acute kidney failure of Manoj Kumar, so the concerned doctor advised for urgent dialyses and after dialyses he was discharged by the doctors. During the stay in hospital, the doctor concerned advised for USD abdomen. Dr. Dinesh Kumar M.D. Radiologist after close investigation given the impression of his report “relatively small kidney with increase renal Echogenicity likely renal tarenchymal disease 2-Moderate right pleural effusion 3-Pericardial Effusion 4- Hepaeomegaly with slide coarse echo pattern 5-Mild Splenomegaly 6-Moderate Ascites. From the observations of doctor Dinesh Kumar, it was first time diagnose regarding small kidneys with increase renal of Manoj Kumar, so he was admitted on 19.6.2016 and was discharged on 21.6.2016. That son of complainant duly informed op no.4 regarding sudden problem arose to him. The said authorized representative on behalf of ops no.1 to 3 assured that as per the terms of insurance policy the problem being faced by Manoj Kumar is fully covered, so let the treatment completed then the ops will consider the case for reimbursement of the amount. It is further averred that Manoj Kumar taken the diagnose from MAYO Health Care Super Specialty Hospital, Mohali, Gopal Hospital, Mohali, Jaipur Medical Centre, Sirsa, Fortis Hospital, Mohali for his recovery and best diagnose. But ultimately from the different treatment diagnose, it has discovered that Manoj Kumar is patient of kidney failure, so he has been advised for transplantation of the kidney. It is further averred that Manoj Kumar informed to op no.4 and inquired about the coverage of kidney disease. The op no.4 after confirmation from ops no.1 to 3 informed him that he can get the transplant from a reputed institution, the entire expenses is covered under the insurance policy known as “Health Surksha.” Upon assurances given by the op no.4 on behalf of ops no.1 to 3, the son of complainant contacted with the hospital where he was advised to fulfill all the formalities as per the Govt. policy. The father of Manoj Kumar agreed to donate his kidney, all the medical tests were done, tissues were matched, documents were prepared for clearance purpose. Manoj Kumar alongwith his father appeared before the Board. Even verification of kidney transplant case of Manoj Kumar was also done from S.P. Sirsa known as verification report. After due verification, S.P. Sirsa given report regarding genuine case vide letter reference No.3199 dated 7.4.2016. It is further averred that Manoj Kumar remained under treatment of the different doctors mentioned above. The process for transplantation of kidney was also in process, but due to ill health, Manoj Kumar suddenly died on 30.6.2017 leaving behind all the efforts being futile exercise. The family could not settle due to untimely death of Manoj Kumar who was a loving child of the family. The matter was duly reported to op no.4, who approached to the house of complainant and requested them for supplying all the medical treatment documents, medical bills, expenses etc. so that claim should be submitted and settled at the earliest. The complainant and his another son supplied all the original documents alongwith bills, treatment record of all the hospitals to op no.4 for the purpose of lodging claim before the ops. The complainant had also filled the claim form. That the complainant contacted with op no.4 for a number of occasions and inquired about the non receiving of the insured amount. The complainant waited for a long time for releasing the claim amount lodged before the ops. Though as per the rules and regulations envisaged in the Insurance Act and the policy of IRDA, no claim could retain by any insurance company after the period of two months. That the complainant personally went to the office of op no.4 and inquired about the status of her claim. The Plan was allocated to Manoj Kumar known as Silver Plan which covers all the disease including Renal Failure. The ops instead of giving positive response to the complainant postponed the matter on one or the other pretext and ultimately refused to settle the claim. That the complainant requested to op no.4 to settle the medi-claim of her son in writing. The ops did not pay any heed to the genuine request of complainant. Finally, the complainant sent a written request through registered post and courier to all the ops on 31.7.2017 and 1.8.2017 but till today the ops have failed to settle the claim or to give a reply in writing which amounts to sheer negligence, deficiency in their service. Hence, this complaint.
2. On notice, opposite parties no.1,2 and 4 appeared and filed written statement taking certain preliminary objections that complaint of complainant is liable to be dismissed on the ground of claim being pre-mature. The claim of complainant was closed by the ops on the ground of non submission of the documents by the complainant, as even after various repeated requests and reminders the complainant failed to submit the requisite documents. In absence of the requisite documents, the claim of complainant cannot be processed. It is further submitted that two reimbursement claims were filed for the period pertaining to 18.3.2016 to 19.3.2016 and 16.5.2016 to 17.5.2016. The claim was lodged by complainant on 9.2.2017 for the abovementioned hospitalization. Further, it is an admitted fact on behalf of complainant himself in the complaint that the claim was intimated to op no.4. It is pertinent to mention here that answering ops are not having any branch in Sirsa. Therefore, any kind of intimation in regard to the claim at Sirsa cannot be considered as intimation to answering op. It is further submitted that on 18.3.2016, insured was admitted into Mayo Health Care Hospital regarding to liver biopsy. He was discharged on 19.3.2016. Thereafter, the complainant lodged the claim with the answering ops and claim was registered as RR-HS16-10403117. The claim was processed and complainant was asked to submit the required document. That after scrutinizing the claim form and papers submitted by complainant, it was found that the patient was known case of End Stage Renal Disease and Hypertension as per the discharge summary. The answering ops found that the documents submitted by complainant were insufficient to settle the claim amount. Therefore, vide letter dated 11.2.2017, the answering ops requested the complainant to provide the following documents to the complainant which he has not provided at the time of lodging the claim:-
1. Duration of HTN, first consultation papers and past treatment records
2. Consultation papers against the bills submitted
3. Original cancelled cheque bearing the name of the proposer (Manoj Kumar) with his signature and IFSC Code
4. Reason for delay in intimation of the claim.
However, the complainant has failed to provide all the documents mentioned in the aforesaid letter. Therefore, again vide letter dated 13.3.2017, the answering ops requested to submit the aforesaid documents, but again the complainant failed to submit the requisite documents. That even after repeated reminder letters sent by ops to the complainant regarding the submissions of the documents but the complainant has failed to furnish required documents to the ops. Therefore, ultimately with no option left, the ops had to close the claim on the ground of non submissions of the documents vide letter dated 28.3.2017 which was duly supplied to the complainant. That again on 16.5.2016, the patient was admitted in Mayo Healthcare Hospital, Mohali, Punjab. The patient was discharged on 17.5.2016. Thereafter, the complainant lodged the claim with the ops and the claim was registered as RR-HS16-10403116. The claim was processed and complainant was asked to submit the required document. Vide letter dated 18.2.2017, the ops requested the complainant to provide documents which he has not provided at the time of lodging the claim. Thereafter, a reminder letter was issued to the complainant through vide letter dated 5.3.2017 but again the complainant failed to comply with and thus a second reminder letter was issued to the complainant vide letter dated 20.3.2017. That even after repeated reminder letters sent by ops to the complainant, the complainant has failed to furnish required documents to the ops. Therefore, ultimately a final reminder letter dated 4.4.2017 was issued to the complainant. However, again the complainant failed to furnish required documents to the ops and therefore, the ops were constrained to close the claim on the ground of non submissions of the documents vide letter dated 4.4.2017. Remaining contents of complaint are also denied.
3. Opposite party no.3 did not appear despite notice sent through registered cover and was proceeded against exparte.
4. The complainant produced her affidavit Ex.CW1/A, copy of claim form Ex.C1, copy of premium receipt Ex.C2 copy of policy schedule Ex.C3, copy of letter dated 29.7.2017 Ex.C4, postal receipt Ex.C5, courier receipts Ex.C6 to Ex.C8 and copies of treatment record Ex.C9 to Ex.C27. On the other hand, ops no.1,2 and 4 produced affidavit of Sh. Pankaj Kumar, Legal Manager Ex.RW1/A, copy of insurance policy Ex.R1, copy of claim form Ex.R2, copy of discharge summary Ex.R3, copy of reminder Ex.R4, copy of second reminder Ex.R5, copy of claim closure letter Ex.R6, copy of discharge summary Ex.R7 and copies of letters Ex.R8 to Ex.R12.
5. We have heard learned counsel for the parties and have perused the case file carefully.
6. During the course of arguments, learned counsel for complainant has contended that it is proved case of complainant that son of complainant namely Manoj Kumar had purchased Health Surksha Insurance policy from opposite parties for the period 10.8.2015 to 9.8.2016. He remained under treatment and ultimately died on 30.6.2017. The mother of insured lodged the claim but however same was repudiated arbitrarily and illegally despite submission of all the required documents.
7. On the other hand, learned counsel for ops no.1,2 and 4 has strongly contended that it is a pre-mature complaint. The claim of complainant was closed on the ground of non submission of documents by complainant despite letters dated 18.2.2017, 5.3.2017, 20.3.2017 and 4.4.2017.
8. So, it appears from the record that claim of complainant has not been repudiated so far rather same was closed due to non providing of documents by the complainant. So, it will be in the fitness of things, if the complaint is partly allowed a direction is given to the complainant to submit the documents and thereafter direction is given to the ops to consider the documents and pass an appropriate order regarding settlement of claim as per terms and conditions of the policy and in accordance with law.
9. In view of the above, we partly allow the present complaint and direct the opposite parties to issue a letter within 15 days from the date of receipt of copy of this order calling upon the complainant to submit the required documents within further period of 15 days and complainant is directed to furnish the documents within 15 days and thereafter the ops are directed to consider those documents and pass appropriate order regarding settlement of claim as per the terms and conditions of the policy and in accordance with law. The parties are left to bear their own costs. A copy of this order be supplied to the parties free of costs. File be consigned to the record room.
Announced in open Forum. President,
Dated:28.03.2018. Member District Consumer Disputes
Redressal Forum, Sirsa.
