The Pune district consumer redressal forum has directed HDFC Ergo General Insurance to pay ₹1,96,511 with nine per cent interest for wrongly repudiating the insurance claim of the complainant. The forum held that the repudiation of the claim itself is unjust, illegal, improper, hyper-technical and against the guidelines given by the Insurance Regulatory Development Authority of India( IRDA) .
By seeing advertisements on television as well as getting information from various sources including online advertisement,the complainant identified as Priti Prashant Shinde was attracted towards the company’s health insurance policy. Priti purchased an insurance policy named, My Health Medisure Classic Insurance Policy, on March 25, 2014, from the website http:// www.policybazaar.com through internet online services. Renewal of the said policy was done on March 25, 2015, after payment of due premium for the period of March 25, 2016, to March 24, 2017. Shinde paid an amount of ₹15,024 towards the premium of the said policy and period and the company issued a premium certificate for the same.
Shinde had purchased the insurance policy for her parents (insured/insured person) named as Sandhya Vilas Bhosale (mother, age – 58 years) and Vilas Vasantrao Bhosale (father, age – 65 years) to fulfill their health related needs for the sum insured of ₹2 lakh plus bonus respectively. At the time of sale of the said plan to her, the company had assured facilities, services and benefits provided by company in their proposal form and also assured that if, during the policy period, the insured/insured person shall contact any disease or illness or suffer any injury and is required to undergo treatment by way of hospitalisation in any hospital/nursing home in India or, in any case of domiciliary hospitalisation upon the advice of a duly qualified medical practitioner, the company agrees to reimburse to the insured/insured person or, his/her nominee, expenses related to such treatment reimbursement of expenses covered under this policy subject to the limits prescribed herein, if any and not exceeding the applicable sum insured (including earned cumulative bonus, if any for all claims during such policy period. In addition, the company also offered pre-and-post hospitalisation expenses, ambulance charges, among others.
On November 3, 2016, her mother Sandhya Vilas Bhosale sustained injuries due to a fall at her house and on the same day she was admitted at MMF-Ratna Memorial Hospital with complaints of pain in the right hip joint, tenderness over right hip joint. Immediately, the complainant gave intimation about the said incident to the company for cashless facility which was assured by the company in Clause E7 of the policy clause. However, the same was rejected by the company without giving any proper reason. She was operated upon and given surgical management treatment at MMF-Ratna Memorial Hospital , in the network hospital of the insurance company. Due to rejection of claim, Shinde and her mother claimed to have suffered financial loss and the difficulties for arrangement of medical expenses and post hospitalisation expenses in the period of currency demonetisation which created lot of mental agony, physical stress, pains and suffering and hence, the complainant sought relief of ₹4 lakh.
{{/usCountry}}On November 3, 2016, her mother Sandhya Vilas Bhosale sustained injuries due to a fall at her house and on the same day she was admitted at MMF-Ratna Memorial Hospital with complaints of pain in the right hip joint, tenderness over right hip joint. Immediately, the complainant gave intimation about the said incident to the company for cashless facility which was assured by the company in Clause E7 of the policy clause. However, the same was rejected by the company without giving any proper reason. She was operated upon and given surgical management treatment at MMF-Ratna Memorial Hospital , in the network hospital of the insurance company. Due to rejection of claim, Shinde and her mother claimed to have suffered financial loss and the difficulties for arrangement of medical expenses and post hospitalisation expenses in the period of currency demonetisation which created lot of mental agony, physical stress, pains and suffering and hence, the complainant sought relief of ₹4 lakh.
{{/usCountry}}The company traversed all the adverse allegations raised against them. “It is a specific contention of the opposite party that the terms and condition of the policy were explained and known to the complainant from the beginning. The policy was issued under utmost good faith. The company denied that, the mother of the complainant, Sandhya Bhosale sustained injuries to fall in her house. It is admitted by the opposite party that the cashless facility claim of the complainant was rejected by the opposite party for the reasons in the said rejection letter. It is the contention of the opposite party that on receipt of the claim from the complainant, it had verified all the necessary documents and after going to the documents supplied by the complainant it was revealed that, “ Admittedly, the policy was issued from March 25, 2014 .However, as stated above, the patient has h/o- arthritis since four years,which is prior to policy inception and the same was not disclosed in proposal form. Hence, the claim was repudiated under the general condition F of the policy. Therefore, considering the specific exclusion clause of the policy, this opposite party vide its letter/mail dated April 22, 2017, rejected the claim of the complainant under general condition F- Duty of disclosure, of the policy terms and condition. The insured must exercise the same duty to disclose those matters to the company before the renewal,extension, variation, endorsement, or reinstatement of the contract,” the company stated.
The forum held that the complainant has duly proved that the opposite party wrongly repudiated her genuine claim without proper application of mind and thereby caused ‘deficient service’ and passed the order.