Delhi

North East

RBT/CC/183/2022

SANDEEP KUMAR - Complainant(s)

Versus

THE HDFC ERGO GENERAL INSURANCE - Opp.Party(s)

27 Feb 2024

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

RBT/Complaint Case No. 183/22

 

 

		Sh. Sandeep Kumar, S/o Sh. Suresh Chand, R/o F-115, Rajiv Nagar, New Delhi 110086		Complainant
		Versus
	1.         2.	The HDFC ERGO General Insurance, (Formerly Known as Apollo Munich) 5th Floor Tower 1, Steller IT Park, C-25, Sector 62, Noida 201301   Saroj Super Speciality Hospital, MadhubanChowk, Rohini, Delhi		Opposite Parties
			DATE OF INSTITUTION:      JUDGMENT RESERVED ON:                        DATE OF ORDER:		31.10.2018 21.12.2023 27.02.2024

 

CORAM:

Surinder Kumar Sharma, President

Anil Kumar Bamba, Member

Adarsh Nain, Member

 

ORDER

Ms. Adarsh Nain, Member

The Complainant filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against Opposite Party No.1 i.e. HDFC Ergo Health Insurance Ltd. (formerly known as Apollo Munich Health Insurance Ltd.and Opposite Party No.2 i.e. Saroj Super Speciality Hospital.

 

Case of the Complainant

1. The case of the Complainant as revealed from the record is that the Complainant had taken an Optima Restore Floater Policy bearing no. 110101/11121/AA00566990-01 for himself and his family members from the Opposite Party No. 1. The period of the said policy was from 04.03.2017 to 03.03.2018 and the insured amount was Rs. 3,00,000/-. Complainant stated to have renewed the same on 07.03.2018 after paying a total premium amount of Rs. 14,329 and the policy was effective till 04.03.2019. Complainant stated that his wife who is insured in the said policy got admitted in the Opposite Party No. 2 hospital on 20.08.2018 with a problem of vomiting and headache and was discharged on 22.08.2018. Complainant stated that he lodged his claim with the Opposite Party No. 1 for an amount of Rs. 27,131/-. Vide email dated 04.09.2018, Opposite Party No. 1 acknowledged the claim of the Complainant and informed that his claim is under process andon 06.09.2018, Complainant received an email from the Opposite Party No. 1 mentioning that the claim of the Complainant was not payable on the ground that the submitted claim is for the illness which has a specific 2 year (s) of waiting period as per the policy and the policy start date is 04.03.2017. Hence, the claim of the Complainant was repudiated under section V A ii of the policy. Complainant stated that on 04.09.2018 Opposite Party No.1 had shown the diagnosis vomiting and headache however in the e-mail dated 06.09.2018 it had alleged in the diagnosis as Cholelithiasis. Complainant stated that Opposite Party No.1 without any justification had repudiated the claim of the Complainant which is totally against the law. Complainant stated that he several timesrequestedthe Opposite Party No. 1 to reimburse the claim but they did not pay any heed. Hence, this shows the deficiency of service on the part of Opposite Party No.1. Complainant has prayed for Rs. 27,131/- i.e. spent on medical expenses along withinterest @ 18 % p.a. from the date of hospitalization bill till its realization. Complainant also prayed for Rs. 50,000/- on account of mental harassment and also prayed for litigation cost.
2. During the pendency of present complaint, Opposite Party No.1 company merged with The HDFC ERGO General Insurance and memo of parties were amended accordingly and it was substituted in place of Apollo Munich Health Insurance Ltd. as Opposite Party no.1

Case of the Opposite Party No. 1

The Opposite Party No.1 contested the case and filed its written statement. While admitting the policy, Opposite Party No.1 objected to the complaint that no cause of action has arisen in favour of Complainant as the claim falls under special terms and conditions of the policy. It has been contended that it was found that the insured (wife of the Complainant) was diagnosed and treated for Cholelithiasis with BPPV and the said condition had a specific waiting period of 24 months from policy commencement date. It is submitted that repudiation of the said claim by answering Opposite Party being in consonance with section V(A)(ii) of the policy, is totally justified. Hence, Opposite Party No.1 prays for the dismissal of the complaint.

Case of the Opposite Party No.2

3. The Opposite Party No. 2 contested the case and filed its written statement. It is stated that the complaint is bad for misjoinder of parties as there are no allegations/averments made against them in entire complaint, hence no case of action. It is further submitted that neither there was any deficiency of services on their part nor did they indulge into any sort of unfair trade practices. 

Rejoinder to the written statement of Opposite Party No.1.

4. The Complainant filed rejoinder to the written statement of Opposite Party No.1 wherein the Complainant has denied the pleas raised by the Opposite Party No.1 and has reiterated the assertions made in the complaint.

Evidence of the Complainant

5. The Complainant in support of his complaint filed his evidence by way of affidavit, wherein he has supported the averments made in the complaint.

 

 

Evidence of the Opposite Party No. 1

6. In order to prove its case, Opposite Party No.1 has filed affidavit of Shri. Aviraaj Singh, Assistant Manager-Legal, wherein the averments made in the written statement of Opposite Party No. 1 have been supported.

Evidence of the Opposite Party No. 2

7. In order to prove its case, Opposite Party No.2 has filed affidavit of Shri Anil Sharma, AR for the Opposite Party No.2, wherein the averments made in the written statement of Opposite Party No.1 have been supported.

Arguments & Conclusion

8. We have heard the Ld. Counsel for the Complainant and Ld. Counsel for the Opposite Parties. We have also perused the file and written arguments filed by the Complainant and Opposite Party No. 1.
9. The case of the Complainant is that he and his family were insured under subject policy for an insured amount of Rs. 3,00,000/-. The Complainant’s wife got admitted in Opposite Party No.2 hospital with complaints of vomiting and headache and received treatment there. The Complainant lodged a claim with the Opposite Party No. 1 for an amount of Rs. 27,131/- on account of medical expenses. Allegedly, Opposite Party No.1 wrongly repudiated the Complainant’s claim on the ground that the submitted claim was for the illness which has a specific 2 year (s) of waiting period as per the subject policy and the policy start date is 04.03.2017.
10.  On the other hand, contention of the Opposite Party No.1 is that since the claim falls under special terms and conditions of the subject policy, the claim was rightly repudiated. It has been contended that it was found that the insured (wife of the Complainant) was diagnosed and treated for Cholelithiasis with BPPV and the said condition had a specific waiting period of 24 months from policy commencement date. It is submitted that repudiation of the said claim by answering Opposite Party being in consonance with section V(A)(ii) of the policy, is totally justified.
11. On perusal of the record including the pleadings of the parties, it is revealed that it is not in dispute that the Complainant had taken the subject insurance policy for himself and his family and the claim in question arose during subsistence of the valid policy. The contention of Opposite Party No.1 is that it was found that the insured (wife of the Complainant) was diagnosed and treated for Cholelithiasis with BPPV and the said condition had a specific waiting period of 24 months from policy commencement date. As the claim falls under special terms and conditions of the subject policy, repudiation of the said claim by answering Opposite Party being in consonance with section V(A)(ii) of the policy, is totally justified.
12. It is worth to note that the Complainant has taken the stand in his rejoinder to the reply of Opposite Party No.1 that he was not provided with the terms and conditions of the policy. The Complainant strongly submits that at the time of taking Insurance Policy, the Complainant was never apprised about such terms and conditions. The Complainant has vehemently denied that policy kit containing all relevant documents was duly sent to the Complainant.
13. The genesis of the dispute lies in whether the Special Conditions of the policy which was issued by Opposite Party No.1 to the insured Complainant were drawn to the notice of the Insured or not. The Complainant has denied that categorically shifting the onus to Opposite Party No.1 to prove otherwise. The perusal of material on record shows that Opposite Party No.1 has merely made the averment that special terms and conditions were supplied but has not supported their averment by any evidence showing that same was sent and received by the Complainant. Since the Opposite Party No.1 has failed to produce any cogent evidence proving the terms and conditions of the policy were supplied to the Complainant at the time of issuing the subject policy, the burden of proof was not discharged.
14. In this context, we are guided by M/s Texco Marketing Pvt. Ltd. v TATA AIG General Insurance Company Ltd. & Other, 2022 SCC Online SC 1546, where the Hon’ble Supreme Court of India highlighted the duty of insurance companies to disclose all material terms of the policy to the insured, in accordance with the Insurance Regulatory and Development Authority (Protection of Policyholders’ Interests) Regulations, 2002 (Regulations) and the doctrine of ‘uberrimae fidei’ or utmost good faith and issued a ‘word of caution’ to all the insurance companies to comply with the IRDA Regulations which mandate fair and open disclosure of all material terms of the policy, non-compliance of the which will leave the insurer remediless when denying and/or rejecting a claim. 
15. In view of above, the Opposite Party No.1 cannot be held justified in rejecting the claim for breach of certain condition of the policy which was not brought to the knowledge of the insured Complainant.
16. In view of above case law and discussion held, we are of the considered view that Opposite Party No.1 i.e. HDFC Ergo Health Insurance Ltd. (formerly known as Apollo Munich Health Insurance Ltd.) has been deficient in services by wrongly repudiating Complainant’s valid claim under the effective Policy in force at the time of incident.
17. Thus, the present complaint is allowed and Opposite Party No.1 i.e. HDFC Ergo Health Insurance Ltd. is directed to pay to the Complainant Rs. 27,131/-, the claim amount along with 9% interest from the date of filing the complaint till its recovery.The Opposite Party No.1 is further directed to pay Rs. 25,000/- towards compensation and litigation cost along with 9 % interest from the date of this order till its recovery.

 

18. Order announced on 27.02.2024.

 

Copy of this order be given to the parties free of cost.

 

File be consigned to Record Room.

 

(Anil Kumar Bamba)          Member

(Adarsh Nain) Member

(Surinder Kumar Sharma) President