DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, CAMP COURT AT AMRITSAR, PUNJAB.
Complaint Case No: RBT/CC/2018/57
Date of Institution: 25.01.2018/29.11.2021
Date of Decision: 07.06.2022
- Gurinder Singh son of Sh. Major Singh Age 45 years resident of Kothi No. 24, Sehabzada Jhajjar Singh Avenue, Gali No. 2, Amritsar.
- Balwinder Kaur wife of Sh. Gurinder Singh Age 43 years resident of Kothi No. 24, Sehabzada Jhajjar Singh Avenue, Gali No. 2, Amritsar.
…Complainants
Versus
- H.D.F.C ERGO General Insurance Company Limited registered Office at 1st Floor, 165-166, Bacby Reclamation. H.T. Parekh Marg, Churchgate, Mumbai-400020 through its Officer Incharge/Manager/Authorized Officer.
- H.D.F.C ERGO General Insurance Company Limited office at 3rd Floor, Nagpal Tower-1, SCO-128, Ranjit Avenue, Amritsar, Punjab 143001, through its Officer Incharge/Manager/Authorized Officer.
…Opposite Parties
Complaint Under Section 12 & 13 of The Consumer Protection Act, 1986 (as amended upto date).
Present: Sh. B.S. Rajput Adv counsel for complainant.
Sh. R.P. Singh Adv counsel for the opposite parties.
Quorum.-
1. Sh. Ashish Kumar Grover: President
2. Sh. Navdeep Kumar Garg: Member
(ORDER BY ASHISH KUMAR GROVER, PRESIDENT):
1. The present complaint has been received by transfer from District Consumer Commission, Amritsar in compliance of the order dated 26.11.2021 of the Hon'ble State Consumer Disputes Redressal Commission, Punjab, Chandigarh. The complainants Gurinder Singh and Balwinder Kaur filed the present complaint under Section 11 and 12 of the Consumer Protection Act against HDFC ERGO General Insurance Company Limited and others (in short the opposite parties).
2. The facts leading to the present complaint as stated by the complainant are that the complainant had purchased a medical insurance policy Health Suraksha Policy Silver Plan, for himself and her wife for the year 2014-15 and renewal the policy upto the year of 2016-17 vide policy No. 2952200761371500001 and the opposite parties issued another policy to the complainant No. 2 as well as for her husband vide policy No. 2952210605311600003 valid for 10.12.2016 to 9.12.2018 for sum insured Rs. 3,00,000/- with policy premium Rs. 13,304/- and the said policy issued on 21.12.2016. It is further alleged that in the above said policy shows that no pre Existing Diseases to the complainant No. 1 & 2. It is alleged that on 4.8.2017 the complainant Gurinder Singh suffered fever, chest pain and cough for the last one month and he admitted in Randhawa Hospital 12, The Mall Amritsar and Bronchoscopy was done on 7.8.2017 shows evidence of Tuberculosis for first time. Complainant is not a chronic patient but newly diagnosed with pulmonary tuberculosis. It is alleged that at the time of admission in the hospital the complainant was fully insured as per policy period i.e. 10.12.2016 to 9.12.2018. The complainant had paid all the expenses during hospitalization for the period of 4.8.2017 to 7.8.2017 for Rs. 24,000/- and in this regard the opposite parties were informed and the original bills and other required documents for the above said period were supplied to the opposite parties for settlement of claim. The complainant number of times visited the opposite parties and requested for the settlement of claim but the opposite parties did not pay any heed. On 27.10.2017 the opposite parties issued a letter for repudiation of hospitalization claim of the complainant on the ground of that the “ailment was pre existing in nature”, as such the claim is being repudiated. The above said act of the opposite parties amounts to deficiency in service and unfair trade practice on the part of opposite parties. Hence, the present complaint is filed for seeking the following reliefs.-
1) The opposite party may be directed to pay Rs. 24,000/- on account of hospitalization of complainant.
2) To pay Rs. 1,00,000/- on account of compensation for mental agony and harassment and Rs. 10,000/- as litigation expenses.
3) Any other relief may also be granted to the complainant
3. Upon notice of this complaint, the opposite parties filed written statement taking preliminary objections interalia on the grounds of no cause of action, act and conduct of the complainant, concealment of material facts, maintainability etc. On merits, it is submitted that at the time of procuring the policy the complainant intentionally concealed the facts with regard to his pre-existing disease of breathlessness and cough for the last two years. It is further submitted that any ailment does not arise all of sudden in any manner and in the present case the complainant No. 1 not disclose about his pre-existing disease for the last two years. It is further submitted that as per the terms and conditions of the policy the claim was rightly repudiated vide letter dated 27.10.2017. All other allegations of the complainants are denied and prayed for the dismissal of complaint.
4. In order to prove the case the complainants tendered into evidence affidavit of complainant No. 1 Ex.C-1, copy of repudiation letter Ex.C-2, copy of free health check up coupon Ex.C-3, copies of policies Ex.C-4 to Ex.C-7, copy of health card Ex.C-8, copy of letter Ex.C-9, copy of bill Ex.C-10 and closed the evidence.
5. To rebut the case of complainant the opposite parties tendered into evidence affidavit of Sh. Pankaj Kumar Manager Legal Ex.O.P1.2/2, copy of claim repudiation letter dated 27.10.2017 Ex.O.P1.2/3, copy of letter dated 23.9.2017 Ex.O.P1.2/4, copy of letter dated 23.8.2017 Ex.O.P1.2/5, copy of letter dated 8.9.2017 Ex.O.P1.2/6, copy of intimation letter inadequate reply Ex.O.P1.2/7, copy of claim form Ex.O.P1.2/8, copy of policy Ex.O.P1.2/8, copy of terms and conditions Ex.O.P1.2/9 and closed the evidence.
6. We have heard the learned counsel for the parties and gone through the record on the file.
7. On the perusal of the file and evidence produced by both the parties it is established that the insurance policy was admitted by the opposite parties. In the present case the claim of the complainant was repudiated vide letter dated 27.10.2017 i.e. Ex.O.P1.2/3. The complainant has produced the treatment record and also produced the certificate issued by Randhawa Hospital in favour of HDFC ERGO General Insurance Company in which the concerned doctor certified that:-
“Sir this is for your information that patient was admitted with c/o fever, chest pain and cough from last one month. Patient was admitted in view of diagnosing the cause of fever, Bronchoscopy was done on 7.8.2017 shows evidence of Tuberculosis for first time. Patient is not a chronic patient but newly diagnosed with Pulmonary Tuberculosis. This admission was held for diagnosing and treating the patient”.
From the above said certificate it is established that the complainant has taken the treatment first time for the above said disease. The concerned doctor clearly mentioned in the said certificate that the patient is not a chronic patient but newly diagnosed with Pulmonary Tuberculosis.
8. On the other hand Ld. Counsel for opposite parties argued that the complainant is suffering from the above said treatment for the last two years and the complainant concealed the above said facts at the time of taking insurance policy. Therefore, the claim of the complainant was repudiated under the purview section 9A iii of the policy terms and conditions and the claim was rightly repudiated.
9. Dr. Mandeep Singh DM Pulmonary Medicine, Randhawa Hospital appeared into the witness box and suffered the statement that I treated the patient Gurinder Singh in Randhawa Hospital who was admitted in the hospital on 4.8.2017 and discharged on 9.8.2017. During treatment, the patient told his history of breathlessness for 2 years, cough for 2 years which has been mentioned in the progress note at point A in Ex.O.P1.2/1. It is further suffered that the patient was treated for breathlessness and cough which was prevailing for last 2 years. Therefore, it was found that patient was suffering pulmonary T.B. and after starting treatment, patient was discharged from the hospital.
10. From the perusal of the evidence produced by both the parties it is established that the complainant did not know that he was suffering from pulmonary T.B. The complainant first time knows regarding the above said disease on 7.8.2017 when Bronchoscopy was done in the hospital. Ld. Counsel for the complainant argued that the opposite parties must do the medical check-up of the complainant before issuing the policy but now after taking premium and issuing policy to the complainant, the opposite parties cannot take these types of objections. The claim of the complainant was repudiated by the insurance company on unreasonable conditions/grounds. The complainant has produced the medical bill Ex.C-10. Therefore, the present complaint is partly allowed and the opposite parties are directed to pay an amount of Rs. 24,000/- as per medical bill alongwith interest @ 7% per annum from the date of filing the present complaint. The opposite parties are also directed to pay an amount of Rs. 5,500/- on account of mental tension and harassment and Rs. 3,300/- on account of litigation expenses to the complainant. Compliance of the order be made within the period of 45 days from the date of the receipt of the copy of this order. Copy of the order will be supplied to the parties by the District Consumer Commission, Amritsar as per rules. File be sent back to the District Consumer Disputes Redressal Commission, Amritsar.
ANNOUNCED IN THE OPEN COMMISSION:
7th Day of June, 2022
(Ashish Kumar Grover)
President
(Navdeep Kumar Garg)
Member
