Delhi

New Delhi

CC/1080/2013

Anup Singh Negi - Complainant(s)

Versus

M/s. HDFC ERGO General Insurance Ltd. - Opp.Party(s)

13 Nov 2019

ORDER

 

 

 CONSUMER DISPUTES REDRESSAL FORUM-VI

      (DISTT. NEW DELHI), ‘M’ BLOCK, 1^STFLOOR, VIKAS BHAWAN,

         I.P.ESTATE, NEW DELHI-110002.

 

Case No.CC. 1080/2013                       Dated:

           In the matter of:

Anup Singh Negi

D-1/116 B, Arawali Apartment

Sec-52, Gautam Buddha Nagar

Noida-201301, Uttar Pradesh                    

                                                                  ……..COMPLAINANT

VERSUS

           M/s HDFC ERGO General

           Insurance Co. Ltd.

          14, Kasturba Gandhi Marg,

         Janpath, Barakhamba Road,

        New Delhi-110001

       Through its Branch Manager                          ………. OPPOSITE PARTY

 

ARUN KUMAR ARYA, PRESIDENT

 

ORDER

The complainant has filed the present complaint against the OP. The gist of the complaint is that  the  complainant had applied for an overdraft facility with the HDFC Bank and accordingly the Bank agreed to grant an overdraft facility of Rs. 18,72,627/- subject to taking an exhaustive coverage policy from HDFC ERGO General Insurance Company as per their loan procedure. It is alleged that complainant was in need of money thus the complainant agreed for the same and the HDFC Bank sanctioned a Secured Dropline Overdraft vide letter dated 15/04/2011. As per the conditions for the overdraft facility the complainant took the policy named as Home Suraksha Plus from HDFC ERGO General Insurance Co. having policy no. 2918200085180700001 in the name of Anup Singh Negi  and the policy period was of 20/05/2011 to 19/05/2016 with sum insured benefits in section III, Major Medical Illness & Procedures  of Rs. 18,72,650/- and the total premium paid by the complainant was Rs. 72,588/-.

2. It is further alleged that complainant felt pain in his heart on 20/09/2013 and he was taken to Metro Hospital & Heart Institute on 20/09/2013 itself by his family members. On diagnosis it was found that the complainant was suffering from Myocardial Infraction for which he was treated from 20/09/2013 and was discharged on  23/09/2013. Complainant filed a claim with the OP under the Insurance Policy and the same was repudiated by the OP on flimsy ground, hence this complaint.

3. The OP was noticed. Reply to the complaint was filed. It is stated in the written statement that the claim of the complainant was repudiated because as per the terms and conditions of the Insurance Policy, the losses claimed under Critical illness are not covered as per the policy wordings. It is further stated that under section III of the policy, the Major Medical Illness which are covered are specifically enumerated. The treatment taken  by the complainant is no where mentioned in the list of Major Medical Illness which are covered in the policy. Hence the claim of the complainant was repudiated being not covered under the scope of the policy in question.  Accordingly, the complaint is liable to be dismissed.

4. Both the parties have filed their evidence by way of affidavit. 

 

5. We have heard argument advanced at the Bar and have perused the record.

6. It is argued on behalf of OP that as per the discharged summary the complainant was diagnose to have Coronary Artery disease with NSTEMI and were treated with PTCA.

 

7. As per section 3, major medical illness:-

The first occurrence of an acute myocardial infarction leading to the death of a portion of heart muscle as a result of inadequate blood supply to the relevant area excluding non-STEMI.

We cover surgery to correct narrowing or blockage of one or more coronary arteries with bypass graft provided it is recommended by cardiologist and supported with coronary angiographic evidence but excluding balloon angioplasty and/or any other intra-arterial procedures or laser relief.

8. Since the losses claim under the critical illness are not covered, the claim is rightly repudiated. On the other hand it is argued on behalf of complainant that alongwith the policy schedule, the OP insurance company has provided the details of the insured event along with the benefits. In section 3, major medical illness and procedure at column-c The Myocardial Infraction is duly covered, hence, the repudiation is unjustified.

 

9. We have gone through the policy schedule and the details of the insured events attached with complaint.  As para in section 3, major medical illness and procedure at column c) The Myocardial Infraction is duly covered. The OP insurance company along with its evidence by way of affidavit as attached the policy wordings, under the pretext of which the claim of the complainant was denied. We failed to understand, how these wordings are applicable in the present case when the same were never provided to the complainant, especially, when along with the policy schedule the details of the insured event coverage was given by the OP to the complainant. The repudiation of claim by the OP on the basis of policy wordings amounts to unfair trade practice because while issuing the policy the coverage was different on the other hand while dealing with the claims the fresh policy wordings were used.
10. The complainant in the present complaint has claimed a total sum insured of Rs. Rs. 18,72,650/- in the prayer clause however, he has failed to place on record the bill to the tune of Rs. 18,72,650/- hence, we are of the considered view that the complainant is not entitled for the entire sum insured as prayed. The complainant has placed on record the copy of the bill pertaining to the treatment taken for the period from 20/09/2013 to 23/09/2013 on different occasion. The sum total of the entire bill was Rs.1,40,000/- hence, in our view the complainant is entitle for this amount only.
11. In view of the above discussion, we are of the considered view that the repudiation of the claim of the complainant by OP on the ground that claim/treatment not covered under the policy wording was not justified. OP had repudiated the claim of the complainant without any basis and on wrong assumption and in an arbitrary manner which amounts to unfair trade practice as well as deficiency in service on the part of the OP.   We therefore hold, OP guilty of deficiency in services and direct it as under:

i).      Pay to the complainant a sum of Rs.1,40,000/- alongwith interest @ 9% from the date of filing of complaint i.e. 11/12/2013 till its realization.

ii)       Pay to the complainant a sum of Rs.15,000/- as compensation and Rs. 10,000/- as the cost of litigation.

 

The order shall be complied within 30 days of the receipt of the order. If the said amount is not paid by the OP within a period of one month from the date of receipt of this order, the same shall be recovered by the complainant along with simple interest at the rate of 9% per annum from the date of this order till recovery of the said amount. This final order be sent to server (www.confonet.nic.in ). A copy each of this order each be sent to both parties free of cost by post. File be consigned to Record Room.

Pronounced in open Forum on   13/11/2019.

(ARUN KUMAR ARYA)

PRESIDENT

                   (NIPUR CHANDNA)                                                    (H M VYAS)

                       MEMBER                                                                    MEMBER