Haryana

Ambala

CC/153/2021

Jaideep Singh - Complainant(s)

Versus

M/s HDFC ERGO Gen Inss Co Ltd - Opp.Party(s)

Bharat Bhushan

18 Apr 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

 

Complaint case no.	:	153 of 2021
Date of Institution	:	07.04.2021
Date of decision	:	18.04.2023.

 Jaideep Singh, aged about 44 Yrs s/o Late Sh.Sardar Rachpal Singh, R/o H.No.9431/6, Kalal Majri, Distt. Ambala.

          ……. Complainant.

                                                Versus

 

1. M/s HDFC ERGO General Assurance Company Ltd. registered and Corporate Office Ist Floor, 165-166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai-4000001
2. M/s HDFC ERGO General Assurance Company Ltd. through its Branch Office, Policy issuing office, Near Geeta Gopal Chowk, HDFC Bank, Ambala Cantt.

 

                                                                                   ….…. Opposite Parties.

Before:       Smt. Neena Sandhu, President.

                             Smt. Ruby Sharma, Member,

          Shri Vinod Kumar Sharma, Member.           

 

Present:      Shri Bharat Bhushan Chawla, Advocate, counsel for the complainant.

                   Shri Mohinder Bindal, Advocate, counsel for the OPs.

 

Order:        Smt. Neena Sandhu, President.

 

1.                Complainant has filed this complaint under Section 35 of the Consumer Protection Act, 2019 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘OPs’) praying for issuance of following directions to them:-

1. To pay the insured amount of Rs.5 lacs alongwith interest till realization.
2. To pay compensation to the tune of Rs.1,50,000/- for harassment, mental pain, agony and financial loss due to the deficiency in service.
3. To pay litigation expenses to the tune of Rs.25,000/- to the complainant.

 

2.             Brief facts of the case are that the complainant purchased a Cashless Health Jin Policy, bearing no.AAO1437777 from the OPs on making payment of one time premium to the tune of Rs.19,085.32/-, which was valid for the period from 29.06.2020 to 28.06.2021. The OPs had assured the complainant, at the time of issuing the policy, that if he suffers accidental death or permanent total disability or accidental hospitalization or critical illness or any other disease which is curable in nature, the OPs will be equally liable to pay compensation in that regard. On 03.10.2020 the complainant immediately rushed to the doctor. After examination, the doctor advised the complainant to admit in the hospital and  as such on 04.10.2020 he was admitted in Healing Touch Super Specialty Hospital, situated at Ambala Chandigarh Highway. The complainant immediately contacted O.P.No.2 and narrated the whole story, regarding his illness. O.P.No.2 after verifying the disease of the complainant agreed to pay the claim and released part amount of Rs.50,000/- in his favour. The complainant was operated in hospital and remained admitted from 04.10.2020 to 14.10.2020. However, he was shocked on receipt of message from the OPs that his claim has been rejected without any cause or reason. The complainant immediately contacted the O.P.No.2 and asked him regarding rejection of the claim, whereupon it was told that the disease of tumor for which he took treatment was not covered under the policy. The complainant requested the OPs and showed the report dated 19.10.2020 in which it was clearly mentioned that the complainant did not suffer from any tumor, but the OPs refused to pay the claim to the complainant. The complainant served a legal notice dated 16.01.2021 upon the OPs in the matter, but to no avail.   Hence, the present complaint.
3.           Upon notice, OPs appeared and filed written version wherein they raised preliminary objections to the effect that the present complaint is an abuse of process of law; the complaint is not maintainable etc. On merits  it has been stated that the complainant / Patient was admitted in the hospital for treatment of the Intussusception with Right Hydronephrosis with Septicemia of which underline cause as given by the Treating Doctor is a Tumor in his Left Descending Colon which fell in the waiting list for initial 2 years of issuance of the policy in question. In view of the above waiting period cashless claim of the complainant was rejected and accordingly the same was informed to him. It is not the case of the complainant that the questions were not asked or filled by the Policyholder. The proposal form was read and understood by the Policyholder, which is the basis of the contract of insurance. The policy wordings clearly speaks about the waiting period of 24 Months with respect to the Tumor related illness, whereas complainant was admitted in the Hospital on 04/10/2020 and this period came in the 1st Year of the Policy itself and would have been covered only in the 3rd Policy year. The OPs received a Cashless request from the complainant for treatment taken in Healing Touch Super Specialty Hospital, Ambala. A query was sent to the Hospital for providing the Treating doctor's certificate mentioning underline cause/ etiology of presenting ailment. Reply was received from the Hospital and the Treating Doctor confirmed that underline cause of the illness of the complainant is a Tumor in his Left Descending Colon. It is further mentioned by the Treating Doctor that the Tumor may be benign or malignant and its HPE Report is awaited. Upon receipt of the confirmation with regard to the underline cause of the medical condition of the complainant another query was sent to the Hospital for providing the HPE report along with Copies of ICP (Indoor Case Papers) including the Initial assessment sheet, Doctor's notes, nursing notes, daily Vital/ TPR chart duly certified by hospital authority. Documents except HPE report were received and taking a customer centric approach that Hospital would share the HPE report, an initial approval of Rs.50000/- was given with a condition for providing exact nature of Tumor along with HPE Report. However, HPE report was not sent and Discharge Summary along with final bill were sent for giving the final approval. Upon receipt of the Discharge Summary, a query letter was sent to the Hospital for providing HPE Report as well as exact nature of the tumor present in Left Descending Colon. Reply was received that the HPE Report is still awaited and will be sent later. After reviewing the Discharge Summary and the cause given by the Treating Doctor, cashless claim was denied as any illness, of which the cause is Tumor, would come under the waiting period of 2 Years (24 months) as per the policy terms and conditions.  Rest of the averments of the complainant were denied by the OPs and prayed for dismissal of the present complaint with costs.
4.           Complainant tendered his affidavit as Annexure C-A alongwith documents as Annexure C-1 to C-13 and closed the evidence of the complainant. On the other hand, learned counsel for the OPs tendered affidavit of Manoj Kumar Prajapati, Manager-Corporate Legal of the OPs-company HDFC Ergo General Insurance Co. Ltd. as Annexure OP-A, alongwith documents as Annexure OP-1 to OP-7 and closed evidence on behalf of the OPs
5.           We have heard the learned counsel for the parties and have also carefully gone through the case file.
6.           Learned counsel for the complainant submitted that since the complainant has taken medical cover under the policy in question therefore he was entitled to get the claim amount reimbursed, which was spent by him on his treatment during existence of the policy in question, yet, his genuine claim has not been considered by the OPs, which act amounts to deficiency in providing service, negligence and adoption of unfair trade practice on their part. 
7.           On the contrary, learned counsel for the OPs submitted that in the Biopsy report Annexure C-1, it is clearly mentioned that there is no evidence of Malingnancy, therefore, as per the terms and conditions of the policy, he is not entitled to get any claim and the OPs have rightly repudiated the claim of the complainant. 
8.           Admittedly, the policy in question was purchased by the complainant from the OPs, on making payment of premium of Rs.19085.32 ps. which was valid for the period from 29.06.2020 to 28.06.2021. It is also not in dispute that the complainant was hospitalized and took treatment in the Healing Touch Super Specialty Hospital, Ambala on 04.10.2020, for which in the first instance, an amount of Rs.50,000/- stood released by the OPs as part payment and thereafter rest of the amount incurred by the complainant on his treatment was not paid.   In the claim details Annexure C-10 in column “Claim Status” ‘Rejected’ has been found mentioned and the column “rejected reason”, it has been mentioned that 1.1. As per the available documents, presenting ailment/procedure for comes under two year’s exclusion list of policy terms & condition i.e. Treatment of tumor (diagnosis/ailment/procedure) is excluded from the policy if admitted in 2 years of policy date”.  As per Section V.A (Special Terms and Conditions of the policy) there was a waiting period for illnesses and treatments in case of claims to be lodged with the OPs. In one of the main conditions i.e. in Section V (A) (ii) h of the said policy, it was clearly mentioned that there is a waiting period of 24 months for the illness-Benign tumors of non-infectious etiologye eg. Cysts, nodules, polyps, lump, growth etc. At the same time, it is also mentioned under the said section that this waiting period will not be applicable where underlying cause is cancer(s). It is significant to mention here that the conjoint reading of the said section clearly goes to show that the claim of the insured is payable only if it is proved that the insured suffered from cancer/malignant tumor. However, in the Biopsy report dated 19/20.10.2020, Annexure C-1, it has been clearly mentioned by the medical specialist that “ There is no evidence of malignancy” meaning thereby that the disease/illness for which the complainant took treatment on 04.10.2020 fell under the waiting period of 24 months from the date of issuance of the policy in question i.e. from 29.06.2020 and as such, the OPs cannot be compelled to make payment, incurred by the complainant on his treatment in the hospital referred to above. It is significant to mention here that the insurance policy between the insurer and the insured represents a contract and the insured cannot claim anything more than what is covered by the insurance policy. Our this view is supported by the ratio of law laid down by the Hon’ble Supreme Court of India in Oriental Insurance Co. Ltd Vs Sony Cherian (II 1999 CPJ 13 SC) wherein it was held that- ―’The insurance policy between the insurer and the insured represents a contract between the parties. Since the insurer undertakes to compensate the loss suffered by the insured on account of risks covered by the insurance policy, the terms of the agreement have to be strictly construed to determine the extent of liability of the insurer. The insured cannot claim anything more than what is covered by the insurance policy. That being so, the insured has also to act strictly in accordance with the statutory limitations or terms of the policy expressly set out therein”.
9.           In view of peculiar facts and circumstances of this case, it is held that because the complainant has failed to prove his case, therefore, no relief can be given to him. Resultantly, this complaint stands dismissed with no order as to cost. Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.

Announced:- 18.04.2023.

 

(Vinod Kumar Sharma)	(Ruby Sharma)	(Neena Sandhu)
Member	Member	President