BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 644 of 2019
Date of Institution : 13.11.2019.
Date of Decision : 28.11.2023.
Parhlad Singh (aged about 39 years) son of Sh. Dharam Pal, resident of Village Bakrianwali, Tehsil and District Sirsa.
……Complainant.
Versus.
1. HDFC Ergo General Insurance Company Ltd., Branch Sirsa, through its Branch Manager.
2. HDFC Ergo General Insurance Company Ltd. Registered Office: 1st Floor, HDFC House, 165/166, Backbay Reclamation, H.T. Parekh Marg, Mumbai- 400 020 through its Chief Manager/ Director/ Authorized Signatory.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act, 1986.
Before: SH. PADAM SINGH THAKUR …………PRESIDENT
MRS.SUKHDEEP KAUR………………MEMBER.
SH. OM PARKASH TUTEJA………….MEMBER
Present: Sh. Mukesh Godara, Advocate for complainant.
Opposite party no.1 already given up.
Sh. R.K. Mehta, Advocate for opposite party no.2.
ORDER
The present complaint has been filed by complainant under Section 12 of the Consumer Protection Act, 1986 (after amendment u/s 35 of the Consumer Protection Act, 2019) against the opposite parties (hereinafter referred as OPs).
2. In brief, the case of the complainant is that complainant had purchased a Health Suraksha Policy bearing No. 2952-2027-7750-7100-000 dated 09.05.2019 from ops vide which his health was insured w.e.f. 09.05.2019 to 08.05.2021 and same was purchased by him from ops through telephonic call made by representative of ops. The complainant made payment of premium of Rs.9101/- through his credit card of HDFC Bank Ltd. Sirsa and he was assured for reimbursement of medical expenses up to Rs.3,00,000/-. That on 03.07.2019 complainant suddenly fell ill and suffered from some heart problem and he was taken to Jaipur for his treatment in Eternal Hospital where he was checked up by the doctors. After diagnose, it was found that condition of complainant was very critical and on the same day i.e. 03.07.2019 he was immediately admitted in that hospital as per prescription of the doctor and was advised for operation. Then the complainant was treated by Dr. Sanjeev K. Sidana and operated by him and he remained admitted there up to 06.07.2019 and was discharged on the said date. It is further averred that after treatment immediately all the medical reports and other documents including bill etc. were submitted by complainant to the ops. The complainant is still under treatment. The complainant contacted the ops and requested to pay the claim amount of Rs.1,62,868/- incurred by him on his treatment but the ops put off the matter with one pretext or the other and finally refused the claim of complainant vide claim repudiation letter dated 21.08.2019 on the false ground that said disease was diagnosed within the period of 30 days from the policy, whereas the said disease was detected on 03.07.2019 after about two months from the date of policy. It is further averred that complainant has already approached the ops on many occasions and requested for settlement of his claim but on every occasions the ops continued putting off the matter with one pretext or the other and have caused deficiency in service and unnecessary harassment to the complainant. Hence, this complaint.
3. Notice of the complaint was issued to the ops. However, learned counsel for complainant has given up op no.1 as its branch at Sirsa was closed.
4. On notice, op no.2 appeared and filed written version submitting therein that claim of complainant was repudiated under the preview of Section 9 A (i) whereby general waiting period of 30 days is applied for all the claims, except the one which arises due to accident. The policy inception date is 09.05.2019 and the claim arose due to the hospitalization of the insured on 03.07.2019. On receipt of documents, the op duly processed the claim and on perusal of the documents, it was found that patient was admitted in hospital on 03.07.2019 and was diagnosed with Coronary Artery Disease and was managed for the same. However, during verification it was found that the insured had the symptoms of the said ailment on 03.06.2019. As general waiting period of 30 days is applied against all the claims, it was found that the present claim arose within 23rd day from the policy inception date, therefore, the claim was repudiated on the ground of general waiting period. It is further submitted that aforesaid insurance policy was issued to the complainant by answering op subject to terms and conditions of the insurance policy. In case if any liability would arise against answering op, then it would be subject to the terms and conditions of the insurance policy. The claim of complainant has rightly been repudiated vide letter dated 21.08.2019 which was duly intimated to the insured Remaining contents of complaint are also denied to be wrong and prayer for dismissal of complaint made.
5. The complainant in evidence has tendered his affidavit Ex. CW1/A and documents Ex.C2 to Ex.C32.
6. Though affidavit and documents have been placed on file by op no.2 but same have not been tendered in evidence and op no.2 did not lead any evidence despite availing several opportunities and the evidence of op no.2 was closed by order.
7. We have heard learned counsel for the parties and have gone through the case file.
8. There is no dispute of the fact that complainant had purchased health insurance policy in question from ops on 09.05.2019 for the period 09.05.2019 to 08.05.2021 by paying premium amount of Rs.9101/- on 09.05.2019 for reimbursement of medical expenses up to Rs.3,00,000/-. During the period of policy i.e. on 03.07.2019 as complainant felt some heart problem, therefore, he was taken to Jaipur for treatment in Eternal Hospital, Jaipur and after diagnose he was advised for operation. As such complainant was operated for Coronary Artery Disease in the said hospital and was discharged on 06.07.2019 and according to complainant he spent an amount of Rs.1,62,868/- on his above said treatment and surgery. The claim for reimbursement of the above said amount was also lodged with the ops but however, op no.2 vide letter dated 21.08.2019 has repudiated the claim of complainant as per exclusion clause 9 A (i) which provides General waiting period of 30 days for all claims payable under the policy except claims arising due to an accident. According to the op no.2 as the insured had symptoms of the said ailment on 03.06.2019 and as such present claim arose within 23rd day from the policy inception date, therefore, the claim was repudiated on the ground of general waiting period as per above said exclusion clause. However, we are of considered view that op no.2 has wrongly and illegally repudiated the claim of complainant on the basis of above said exclusion clause of the policy because there is nothing on file to prove the fact that insured had symptoms of the said ailment on 03.06.2019. The op no.2 has not proved on record through any cogent and convincing evidence that complainant was already under treatment prior to 03.07.2019 and was having any pre existing disease of heart whereas from the document i.e. discharge summary placed on file by op no.2 itself though not exhibited or marked, the complainant was admitted in the Etneral Hospital, Jaipur for the first time on 03.07.2019 for the treatment of his heart ailment. So, it is proved on record that op no.2 has wrongly and illegally repudiated the claim of complainant on its own assumption and presumption without any basis and as such repudiation of the claim of complainant on the basis of above said exclusion clause is arbitrary and is not acceptable in the eyes of law. The above said exclusion clause which provides general waiting period of 30 days will not be applicable in the case in hand because complainant suffered disease of heart only on 03.07.2019 i.e. after about two months after purchase of policy in question and not on 23rd day from the date of inception of policy. Therefore, the repudiation of the claim of complainant is hereby set aside. The complainant has duly proved on record through various bills/ receipts Ex.C17 to Ex.C20 and final bill Ex.C22 that he has spent an amount of Rs.1,62,868/- on his above said treatment and surgery and therefore, he is entitled to the said amount from the op no.2. Besides the claim amount of Rs.1,62,868/- the complainant is also entitled to compensation for unnecessary harassment and litigation expenses from the op no.2.
9. In view of our above discussion, we allow the present complaint and direct the opposite party no.2 to pay the claim amount of Rs.1,62,868/- alongwith interest @6% per annum from the date of filing of present complaint i.e. 13.11.2019 till actual realization within a period of 45 days from the date of receipt of copy of this order. We also direct the op no.2 to further pay a sum of Rs.10,000/- as compensation for causing unnecessary harassment to the complainant and also to pay a sum of Rs.5,000/- as litigation expenses to the complainant within above said stipulated period of 45 days. A copy of this order be supplied to the parties as per rules. File be consigned to the record room.
Announced: Member Member President,
Dated: 28.11.2023. District Consumer Disputes
Redressal Commission, Sirsa.
