Uttar Pradesh

Aligarh

CC/210/2021

TANVEER ALAM - Complainant(s)

Versus

HDFC ERGO GENERAL INS CO LTD - Opp.Party(s)

31 Mar 2023

ORDER

न्यायालय जिला उपभोक्ता विवाद प्रतितोष आयोग अलीगढ

Complaint Case No. CC/210/2021 ( Date of Filing : 28 Oct 2021 )   1. TANVEER ALAM S/O SRI KHUSHID AGE 41 YEAR R/O HN 4/751 A FRIENDS COLONY THANA CIVIL LINES ALIGARH ...........Complainant(s) Versus 1. HDFC ERGO GENERAL INS CO LTD OFFICE ADDRESS 208 IIND FLOOR SEWA CORPATE SUIT MV ROAD NEAR IFFCO CHOK GURGRAM ............Opp.Party(s)

BEFORE:     HON'BLE MR. HASNAIN QURESHI PRESIDENT   HON'BLE MR. ALOK UPADHYAYA MEMBER

PRESENT:

Dated : 31 Mar 2023

Final Order / Judgement The present complaint has been filed by the complainant before this commission for  the following reliefs- The Op be directed to pay the amount of Rs.490893/ incurred in treatment in deasies. Compensation for mental and ecomics suffering at Rs. 30000/ against insured buffalo with interest 15% till the payment is made. Cost of the case 25000/  The Complainant has stated that he had purchased health insurance policy from the op wherein all his family member were included for the benefits. The policy was purchase on 12.03.2021 and it was upto the period till 10.3.2022. The policy no. 2805101013657000000. On 12.5.2021 the complainant felt trouble in breathing and also high fever. He was admitted in IT super Hospital, medical Road,Aligarh where he remained under treatment from 12.5.2021 to 24.5.2021. he incurred Rs. 70893/ in purchasing medicine and hospital charges Rs. 419887/ total Rs. 490780/. The assured sum under the insrance sum Rs.500000/. On 24.5.2021 OP allowed the claim at Rs. 374496 but on 2.9.2021 complainant was informed that the policy has been terminated on account of diabetes disease.      Op stated in WS that the claim was rejected by the op due to non-disclosure and concealment of facts. The policy was issued for the period between 11.3.2021 to 10.3.2022 complainant file a claim on 11.6.2021 for reimbursement of Rs. 419877/. The complainant was admitted on 12.5. 2021 and was discharge on 24.5.2021 from IT Super specialty Hospital. He was admitted with diagnosis of Bronchopneumonia and he was treated from the same. It was noted that insured did not submit the discharge summary which was earlier issue in which DM history was mentioned since one year and in ICP same history was noted. The complainant has the past medical history of DM since one year which was not disclosed by him at the time of taking policy hence the claim was rejected as per policy terms and conditions.  Complainant has filed his affidavit and papers in support of his pleadings. Op has also filed affidavit in support of his  pleadings. We have perused the material available on record and heard the parties counsel. The first question of consideration before us is whether the complainant committed breach of any policy condition as alleged? If so, its effects. Admittedly, the health insurance policy of the complainant was in force at the time of treatment of the complainant at IT Super Specialty Hospital where he remained under treatment from 12.5.2021 to 24.5.2021 and filed claim Rs. 419887/. Complainant stated to have incurred total amount Rs490780/. Op has repudiated the claim on account of the complainant being a case of Diabetes Mellitus (DM) since one year i.e. prior to policy inception. In this regard, the first point is that the complainant has stated in the complaint supported by affidavit that Dr. Khushid Faridi had certified while making checkup on 12.5.2021 at IT Super Specialty Hospital that the complainant had not suffering from diabetes since a year as his test report was normal. He has also filed certificate dated 22.6.2021 and 12.7.2021 issued by Dr. Khushid Faridi which are paper no. 14/9 and 14/10. Thus it is ruled out that the complainant has been suffering from diabetes prior to inception of the policy. Further, OP insurance company could have medically examined the complainant by its empaneled doctor with his pathological tests and  could have arrived at the conclusion to take decision on the matter. OP did not do so and there after OP is estopped from raising the ground of  Diabetes Milletus. Moreover, diabetes is a such type of disease which remains under control on taking medicines and cannot be treated to be a breach of conditions of policy to render the policy void on the ground of preexisting disease. The OP has wrongly repudiated the claim. Accordingly complainant is entitled for reimbursement of the ammout Rs. 490887/.  The question formulated above is decided in favour of the complainant.  Keeping in view the facts and circumstances of the case we hereby direct to Op to reimburse the sum Rs.490887/ and Rs.25000/ for harassment and Rs. 10000/ for litigation expenses.   Op shall comply with the direction within a month failing which OPs shall be prosecuted for non-compliance in accordance with section 72 of the Act for awarding punishment against him. A copy of this judgment be provided to all the parties as per rule as mandated by Consumer Protection Act, 2019. The judgment be uploaded as per rule on the website of the commission for the perusal of the parties. File be consigned to record room along with a copy of this judgment.

[HON'BLE MR. HASNAIN QURESHI] PRESIDENT     [HON'BLE MR. ALOK UPADHYAYA] MEMBER