DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,

BATHINDA

C.C. No. 339 of 29-11-2017.

Decided on : 31-01-2022.

Rajinder Singh aged about 40 years son of Maghar Singh R/o H. No. 760, Street No.1 Shaheed Bhagat Singh Nagar , Abohar, Road, Sri Muktsar Sahib.

........Complainant

Versus

1. HDFC ERGO General Insurance Company Limited, HDFC House, 11^th, Floor, 165-166 Backbay Reclamation.H.T Parekh Marg, Churchgate, Mumbai-400 020, through its Director/ General Manager.

2. HDFC Bank Limited, SCO 83, 84, Phase-I, Model Town, near PUDA Office, Bathinda through its Branch Manger-151001. (Deleted vide order dated 1-12-2017)

.......Opposite parties.

Complaint under Section 12 of the Consumer Protection Act, 1986

QUORUM

Kanwar Sandeep Singh, President

Sh. Shivdev Singh, Member.

Smt. Paramjeet Kaur, Member

Present

For the complainant : Sh. Rohit Rumana, Advocate

For opposite parties : Sh. Varun Gupta, Advocate, for OP No. 1.

Opposite party No.2 deleted.

ORDER

Kanwar Sandeep Singh, President

1. The complainant Rajinder Singh (here-in-after referred to as complainant) has filed this complaint U/s 12 of Consumer Protection Act, 1986 (Now C.P. Act, 2019, here-in after referred to as 'Act') before this Forum (Now Commission) against H.D.F.C ERGO General Insurance Company Limited and others (here-in-after referred to as opposite parties).

2. Briefly stated, the case of the complainant is that he took loan from opposite party No. 2. The opposite party No.1 is Insurance Company and has tie up with opposite party No.2 and running its business from the bank of opposite party No. 2.

3. It is alleged that at the time of passing the loan to the complainant, opposite party No. 2 forced him to purchase insurance policy of opposite party No.1. One agent/employee of opposite party No.2 took the signatures of complainant on some blank printed papers of insurance and he also took blank signed cheques from complainant. The said agent/employee of the opposite party No.2 never read over and explained the terms and conditions of the insurance policy rather he suppressed the terms and conditions of the insurance policy. The opposite party No.1 issued policy bearing No. 2918 2012 6675 7400 000 named Home Suraksha Plus which provides coverage like (1) Fire & Allied Perils (2) Burglary and theft (3) Major medical Illness and procedures (4) Personal Accident (5) Loss of Job. without any terms and conditions in detailed which is mandatory as per the provisions of insurance law.

4. It is alleged that during the validation of period of the policy, the complainant suffered from cancer which is a major Medical illness. The complainant took treatment and spent about Rs, 58,270/-. He filed claim on the basis of Major medical illness for reimbursement of expenses but the opposite party No.1 repudiated the claim of complainant vide repudiation letter dated 05-02-2016 on wrong grounds, whereas there is no fault on the part of complainant and he is entitled to get medical bill reimbursement.

5. It is also alleged that complainant earlier filed a complaint before District Forum, Mukatsar and the same was withdrawn due to lack of jurisdiction.

6. On this backdrop of facts, the complainant has prayed for directions to the opposite party to pay insurance claim amounting to Rs.58,270/- along with interest @ 18% p.a. till its actual payment and Rs, 20,000/- as compensation on account of mental tension, agony, etc besides Rs, 11,000/- as litigation expenses.

7. On the statement of learned counsel for complainant, name of opposite party No. 2 was deleted from the array of the parties vide order dated 1-12-2017.

8. Upon notice the opposite party No. 1 put in appearance through counsel and contested the complaint by filing written reply. In written reply, the opposite party No. 1 submitted that the present complaint is filed without any cause of action. It is pleaded that the claim of the complainant was repudiated under the ambit of exclusion clause as mentioned under the policy terms and conditions, which states that the company is not liable to make any payment on account of 90 days exclusion clause. The clause further states that if the insured event arises within the first 90 days of commencement of policy, then company will not be liable. Therefore, in the present case, the complainant started suffering from Squamous Cell Carcinoma” on 30th, day from the commencement of the policy. Hence, the current condition was contracted within first 90 days of the policy and the same is excluded under the policy.

9. It is further pleaded that complaint pertains to insurance claim under Major Medical illness and procedures coverage provided to Mr. Rajinder Singh, who was insured under Home Suraksha Plus Policy heaving policy vide No. 2918201266757400000 for the period from15-12-2015 to 134-12-2020. The said Insurance Policy was issued to the complainant subject to the terms and conditions of the insurance policy, which was never disputed by the complainant.

10. It is pleaded that after perusal of the medical documents as submitted by the complainant, it was found that as per Histopathology Report, the insured first stated having complaints of “ Squamous Cell Carcinoma” on 15-01-2016. As the complaint started on i.e. 30^th, day from policy inception date, the opposite party repudiated the claim of the contaminant, as per the policy terms and conditions.

11. Thereafter, opposite party No. 1 took legal objections that the complaint filed by the complainant is not maintainable; that the complainant has failed to disclose any legal and valid cause of action against the opposite party; that the complainant has created a false story in his complaint to misled this Commission by false and frivolous facts and circumstances of the present case; that the complainant has no cause of action; that the complainant is estoped from filing the present complaint by his own acts, conduct, omissions and acquiescence; that the the complaint is false, frivolous and vexatious in nature; that the complainant not approached the opposite party during free look period; hat the complainant is devoid of any material particulars and has been filed merely to harass and gain undue advantage and that this Commission has no jurisdiction to entertain the present complaint.

12. On merits, the opposite party No. 1 pleaded that the complainant till the lodging of claim, not disputed that he is not aware of policy terms and conditions or he never received the same. The opposite party No. 1 admitted that the claim of the complainant was repudiated. It is pleaded that the repudiation was done after scrutiny of documents and as per policy terms and conditions. The opposite party No. 1 evaluated the claim under the policy terms and conditions and found that the claim of the complainant does not fall within the ambit of the insurance granted by the opposite party. The opposite party provided entire terms and conditions of the policy to the complainant. The complainant did not come before this Commission with clean hands and suppressed so many facts and reasons. After controverting all other averments, the opposite party No. 1 prayed for dismissal of complaint.

13. In support of his complaint, the complainant has tendered into evidence his affidavit dated 29-11-2017 (Ex.C-1), photocopy of prescription slips, bills receipts ,policy, insurance cover note and repudiation letter etc containing pages 1 to 38 ( Ex.C-2) and closed the evidence.

14. In order to rebut the evidence of complainant, the opposite party No. 1 tendered into evidence affidavit of Pankaj Kumar dated 18-07-2018 (Ex.OP1/1), photo copy of claim file and terms and conditions containing pages 1 to 41 ( ExOP-1/2) and closed evidence.

15. We have heard learned counsel for the parties and gone through the record.

16. There is no dispute between the parties that complainant is insured with opposite party No. 1 vide Home Suraksha Plus Policy bearing No. 2918201266757400000 for the period from 15-12-2015 to 14-12-2020 (Ex. OP-1/2- Page 8). The complainant suffered from Squamous Cell Carcinoma. He submitted his insurance claim under Major Medical Illness and Procedures with opposite party No. 1 for reimbursement of medical expenses incurred by him on his treatment of said disease, but opposite party No. 1 repudiated his claim vide letter dated 5-2-2016 (Ex. OP-1/2).

17. A perusal of repudiation letter reveals that opposite party No. 1 repudiated the claim of the complainant on the ground that as per case summary received, complainant started having complaint of Squamous Cell Carcinoma since 15-1-2016. The policy inception date is from 15-12-2015, hence the current condition is contracted within first 90 days of the policy and the same is excluded under the policy. The opposite party No. 1 has also referred Exclusion Clause in this regard.

18. Section 3 of policy (Ex. OP-1/2) is regarding Major Medical Illness & Procedure wherein it is mentioned that “...Insured event in relation to the insured, shall mean any illness, medical event or surgical procedure as specially defined below whose signs or symptoms first commence more than 90 days after the commencement of period of insurance and shall only include – First diagnosis of the below mentioned illness more specifically described below :

    1. Cancer.....”

    The Exclusions applicable to Section 3 also finds mentioned ;

    “The Company shall not be liable to make any payment under this policy in connection with or in respect of any insured event, as stated in this Section, occurred or suffered before the commencement of period of insurance or arising within the first 90 days of the commencement of the period of insurance.”

19. In the case in hand, the insurance policy in question was issued on 15-12-2016 as per evidence (Ex. C-2) placed on file by complainant himself, and just after 19 days of issuance of policy, sample of skin pinch Biopsy, was given by complainant, the report of which was received on 15-1-2016 which revealed “Hypertrophic Lichen planus with evolving superficial squamous cell carcinoma.”. Hence, the disease of the complainant was suffered/detected within first 90 days.

20. Therefore, as detailed above, since the complainant suffered from Squamous Cell Carcinoma within first 90 days, his claim was not covered/payable under major medical illness as per policy terms and conditions. Thus, there is no deficiency in service on the part of opposite party No. 1 in repudiating the claim of the complainant.

21. Resultantly, this complaint fails and is hereby dismissed with no order as to costs.

22. The complaint could not be decided within the statutory period due to heavy pendency of cases.

23. Copy of order be sent to the parties concerned free of cost and file be consigned to the record.

    Announced :

    31-1-2022

    (Kanwar Sandeep Singh)

    President

     

     

    (Shivdev Singh)

    Member

     

    (Paramjeet Kaur)

    Member