Haryana

Karnal

CC/448/2020

Hardeep Singh - Complainant(s)

Versus

HDFC ERGO Health Insurance Limited - Opp.Party(s)

Arun Sharma

12 Dec 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No.448 of 2020

                                                        Date of instt 22.10.2020

                                                        Date of Decision: 12.12.2024

 

Hardeep Singh since deceased through his legal heirs. a) Kesar Devi mother, b) Manisha wife, c) Sahil son, d) Saneha daughter of Hardeep Singh son of Shri Rajbir Singh, resident of village Jaisingpura, tehsil Assandh, District Karnal.

 

                                                                        …….Complainants.

                                              Versus

 

HDFC ERGO Health Insurance Ltd. (formerly known as Apollo Munich Health Insurance Company Limited) Central Processing Centre, 2^nd and 3^rd floor ILABS Centre Plot no.404-405, Udyog Vihar, Phase-III Gurugram 122016, Haryana through hits Divisional Manager, opposite mini Secretariat SCO no.237, 2^nd floor Sector-12, Urban Estate Karnal.

 

                                                                   …..Opposite Party.

 

Complaint under Section 35 of Consumer Protection Act, 2019.

 

Before   Shri Jaswant Singh……President.     

              Ms. Neeru Agarwal…….Member

      Ms. Sarvjeet Kaur…..Member

 

Argued by:  Shri Arun Sharma, counsel for the complainants.

                    Shri Sanjeev Vohra, counsel for the OP.

                   

                     (Jaswant Singh, President)

ORDER:   

                

                The complainant Hardeep Singh (since deceased) has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite party (hereinafter referred to as ‘OP’) on the averments that complainant purchased  Health insurance policy named as Easy Health Floater Standard from the OP, bearing policy no.110103/11051/AA01355019, valid from 06.03.2020 to 05.03.2021. In the said policy complainant (self), his wife Smt. Manisha, Sahil(son) and Sneha (daughter) are covered. The sum insured under the policy is Rs.3,00,000/- and complainant make the payment of premium of Rs.11,239.50/- to the OP. The complainant was suffering from fever etc. and he remained admitted in Amrithdhara My Hospital, Karnal from 14.06.2020 to 19.06.2020 and thereafter he remained outdoor patient. Complainant spent an amount of Rs.4,00,000/- on his treatment including tests, doctor fee, attendant fee etc.  While complainant was admitted in the said hospital and during treatment intimation was sent to the OP for providing cashless treatment facility but cashless treatment denied by the OP. Then complainant lodged the claim alongwith required documents with the OP for reimbursement of the abovesaid amount. But OP did not pay the claim amount and repudiated the claim of complainant, vide letter dated 04.08.2020 on the ground that the claim is for acute febrile illness and gastrointestinal bleeding with jaundice but patient is having history of chronic intake of alcohol alongwith chronic liver disease with jaundice and the treatment related to alcohol comes under standard exclusion and any treatment related to alcohol is not payable. The said repudiation letter is totally wrong and claim of complainant denied by the OP on the false and frivolous ground. Due to this act and conduct of OP, complainant has suffered mental pain, agony and harassment as well as financial loss. In this way there is deficiency in service and unfair trade practice on the part of the OP. Hence complainant filed the present complaint seeking direction to the OP to pay Rs.4,00,000/- i.e. amount spent by the complainant on his treatment alongwith 18% interest from its accrual till its realization, to pay Rs.50,000/- as compensation for mental pain, agony and harassment and Rs.11000/- as litigation expenses.

2.             On notice, OP appeared and filed its written version raising preliminary objections with regard to maintainability; jurisdiction; cause of action; locus standi and concealment of true and material facts. On merits, it is pleaded that complainant purchased Easy Health Floater Standard Policy from the OP w.e.f. 06.03.2020 to 05.03.2021 under policy no.110103/11051/AA01355019. The claim of the complainant was duly processed in due course on being presented and the entire documents as provided by complainant in favour of his claim were scrutinized and during processing, it was observed and established by the doctor notes dated 14.06.2020 and 15.06.2020 that patient is chronic Alcoholic. Further, from the doctor’s notes dated 16.06.2020, it came into the knowledge of the OP that patient in case of CLD. As per the policy terms and condition, any treatment related to alcohol comes under standard exclusion and any treatment related to alcohol is not payable. Therefore, the claim of the complainant was repudiated as per the terms and conditions of the insurance policy and its exclusion clause by the competent authority legally after application of mind. The complainant was informed about the fate of her claim, but complainant in order to put undue pressure filed this false complaint. There is no deficiency in service and unfair trade practice on the part of the OP. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Parties then led their respective evidence.

4.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of insurance policy Ex.C1, copy of discharge summary Ex.C2, copy of medical bill Ex.C3, copy of claim repudiation letter dated 04.08.2020 Ex.C4, Certificate of Dr. Amit Sharma regarding complainant illness and treatment Ex.C5, medical bill Ex.C6, copy of blood unit bill Ex.C7 to Ex.C13 and closed the evidence on 30.09.2022 by suffering separate statement.

5.             On the other hand, learned counsel for the OP has tendered into evidence affidavit of Manoj Kumar Prajapati, Manager Ex.RW1/A, copy of treatment record Ex.R1, copy of claim repudiation letter dated 04.08.2020 Ex.R2, summary of Alcohol and Gastrointestinal Bleeding Ex.R3, copy of terms and conditions of the policy Ex.R4 and closed the evidence on 17.04.2023 by suffering separate statement.

6.             We have heard the learned counsel for the parties and perused the case file carefully and have also gone through the evidence led by the parties.

7.             Learned counsel for complainants, while reiterating the contents of the complaint, has vehemently argued that complainant (since deceased) purchased a Health Insurance Policy from the OP. The sum insured under the policy is Rs.3,00,000/-. During the subsistence of the insurance policy, the insured Hardeep Singh had taken the treatment from Amrithdhara My Hospital, Karnal and spent Rs.4,00,000/- on his treatment. Insured Hardeep Singh lodged a claim with the OP and submitted all the required documents and requested for reimbursement of said amount, but OP did not pay the claim amount and repudiated the claim of the insured Hardeep Singh on the false and frivolous ground. He further argued that during the pendency of the complaint, complainant has expired on 31.01.2023. Hence his legal heirs (present LRs) are entitled for claim amount and lastly prayed for allowing the complaint.

8.             Per contra, learned counsel for the OP, while reiterating the contents of written version, has vehemently argued that OP issued a health insurance policy named as ‘Easy Health Floater ‘Standard for the sum insured of Rs.3,00,000/- for covering complainant (self) and his spouse Manisha, Sahil and Sneha dependent children. Complainant lodged the claim for reimbursement. On scrutiny of the documents, OP observed that claim is for acute febrile illness and gastrointestinal bleeding with jaundice and the treatment related to alcohol comes under standard exclusion and any treatment related to alcohol is not payable. Thus, the claim of the complainant (since deceased) has rightly been repudiated, vide letter dated 04.08.2020 and lastly prayed for dismissal of the complaint.

9.             We have duly considered the rival contentions of the parties.

10.           Admittedly, complainant Hardeep Singh (since deceased) purchased Health Insurance Policy from the OP. It is also admitted that during the subsistence of insurance policy, insured has taken treatment from Amritdhara My Hospital, Karnal.

11.           The claim of the complainant (since deceased) has been repudiated by the OP, vide letter Ex.C4/Ex.R2 dated 04.08.2020 on the ground, which are reproduced as under:-

“We have received your request for reimbursement of claim for the above mentioned hospitalization. We have verified the same with respect to the coverage terms and conditions under the insurance policy plan. And on primary scrutiny of the submitted documents, we regret to inform that your claim is not payable due to following reason:

The claim is for acute febrile illness and gastrointestinal bleeding with jaundice but patient is having history of chronic intake of alcohol alongwith chronic liver disease with jaundice and the treatment related to alcohol comes under standard exclusion and any treatment related to alcohol is not payable. Hence we regret to inform you that your claim is repudiated.”

12.           The claim of the complainant has been repudiated by the OP on the abovesaid ground. The OP has alleged that patient is having history of chronic intake of alcohol alongwith chronic liver disease with jaundice and the treatment related to alcohol comes under standard exclusion and any treatment related to alcohol is not payable. The onus to prove its version was relied upon the OP but OP has miserably failed to prove the same by leading any cogent and convincing evidence. In the certificate of doctor, it is nowhere mentioned that patient was history of chronic intake of alcohol.  Patient further relied upon discharge summary Ex.C2 in the said discharge summary, it is also nowhere mentioned that complainant has history of chronic intake of alcohol alongwith chronic liver disease with jaundice. Hence, the repudiation of the claim of complainant is only on the basis of presumption and assumption, which is not admissible in the eyes of law.

13.           Further, for the sake of arguments, if it be presumed that insured patient is chronic alcoholic and violated the terms and conditions of the insurance policy, in that eventuality, the claim of the complainant cannot be repudiated in toto.  In this regard, we are relying upon the authority cited in Revision Petition no.1870 of 2015(NC) decided on 14.08.2018 titled as New India Assurance Co. Ltd. Versus Thirath Singh Brar,  and authority of our own Hon’ble State Commission in First Appeal no.717 of 2016 decided on 6.4.2017 titled as United India Insurance Company Limited and others Versus Anshul Bansal.  In both judgments it was held that in case of any breach of warranty/condition of the policy the insurer is liable to pay 75% of admissible claim on non-standard basis.  Moreover, it has become the routine practice of the insurance companies to reject the genuine claim on minor technicality.

14.           Furthermore, nowadays it has become a trend of insurance companies, they issue the policies by giving false assurances and when insured amount is claimed, they make such type of excuses. Thus, the denial of the claim of complainant is arbitrary and unjustified. In this regard, we place reliance on the judgment of Hon’ble Punjab and Haryana High Court titled as New India Assurance Company Ltd. Versus Smt. Usha Yadav & others 2008 (3) RCR (Civil) 111, wherein the Hon’ble Punjab and Haryana High Court has held as under:-

“It seems that the Insurance Companies are only interested in earning the premiums which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance companies make the effected people to fight for getting their genuine claims. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy”.

15.           Keeping in view that the ratio of the law laid down in aforesaid judgment, facts and circumstances of the present complaint, the act of the OP while repudiating the claim of complainant in toto amounts to deficiency in services and unfair trade practice, which is otherwise proved genuine one.

16.           The insured Hardeep Singh had spent an amount of Rs.4,00,000/- on his treatment and in this regard he had submitted the medical bills Ex.C6 and Ex.C7 to Ex.C13, cash receipt dated 20.06.2020, the said amount neither denied nor rebutted by the OP. But as per insurance policy, the sum insured is Rs.3,00,000/-. Hence, the complainant is entitled for Rs.2,25,000/- i.e. 75% of the insured amount of Rs.3,00,000/- alongwith interest, compensation for mental pain, agony harassment and litigation expenses etc.

17.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OP to pay Rs.2,25,000/- (Rs. two lakhs twenty five thousand only) alongwith interest @ 9% per annum from the date of filing the complaint i.e.22.10.2020 till its realization to the complainants i.e. LRs of deceased Hardeep Singh. We further direct the OP to pay Rs.20,000/- to the complainants on account of mental agony and harassment and Rs.11,000/- towards the litigation expenses. This order shall be complied within 45 days from the date of receipt of copy of the order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Dated: 12.12.2024    

                                                       

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

 

(Neeru Agarwal)         (Sarvjeet Kaur)

                   Member                          Member