State Consumer Disputes Redressal Commission
Krishan Bir vs Hdfc Standard Lic Ltd. on 9 February, 2018
2nd Additional Bench
STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
PUNJAB, CHANDIGARH
Consumer Complaint No. 210 of 2017
Date of Institution : 07.04.2017
Date of Decision : 09.02.2018
Krishan Bir son of Dharampal, resident of Vill. Alamgir, Kala
Sanghian, Lapurthala, District Kapurthala.
....Complainant
Versus
1. HDFC Standard Life Insurance Company Limited, Mall Road
Branch, 2nd Floor Aventura Mall, Plot No.35B/36/13, The Mall
Road, above KFC & Yes Bank, Amritsar through Authorized
Signatory/ Branch Manager.
2. HDFC Standard Life Insurance Company Limited, having
registered office at 12th & 13th Floor, Lodha Excelus, Apollo
Mill Compound, N.M. Joshi Marg, Mahalaxmi, Mumbai-
400011.
....Opposite parties
Consumer Complaint under Section 17
of the Consumer Protection Act, 1986.
Quorum:-
Mr. Gurcharan Singh Saran, Presiding Judicial Member
Mr. Rajinder Kumar Goyal, Member
Present:-
For the complainant : Sh.Vaibhav Narang, Advocate
For the opposite parties : Sh.Bhupinder Singh, Advocate
GURCHARAN SINGH SARAN, PRESIDING JUDICIAL MEMBER
ORDER
Complainant has filed this complaint against the opposite party under Section 17 of the Consumer Protection Act, 1986 (for short the Act), on the averments that complainant had taken one policy from the opposite parties bearing No.90139353 affective from 04.08.2015 for a period of 10 years with annual premium of Rs.29,661/-. As per the policy, if the diagnose is made at early Consumer Complaint No. 210 of 2017 2 stage cancer then opposite parties will give benefit of 25% of applicable some assured and in a major cancer 100% would be released. The complainant has already paid two instalments of the premium. In the month of February, 2016, complainant felt some uneasiness in his neck. He approached Sharda Hospital, Jalandhar, where certain tests were conducted. As per histopathology it was diagnosed that there are certain suspicion cells and it was advised for Excision Biopsy. Thereafter, biopsy was conducted and found in the test report dated 19.03.2016 that the complainant had cancer in the neck. The complainant then started treatment with Mohandai Oswal Hospital, a specialized hospital for cancer treatment. Few tests were conducted initially. There also complainant was diagnosed as a case of unknown Primary with neck metastatic and thereafter Histopathology test was conducted. It was reported that the complainant is suffering from cancer and thereafter treatment of cancer was started. Treatment of Radiotherapy was given to the complainant from 14.07.2016 to 07.09.2016 but there is no much improvement. The complainant alongwith his wife started follow up with the opposite parties for disbursement of claim. The opposite parties demanded certain documents from the complainant, which were duly provided to the opposite parties number of times. Opposite parties vide their letter dated 23.12.2016 confirmed that all the documents have been successfully received by them and no other document is pending. The complainant again received a letter dated 26.12.2016 from the opposite parties. In response to reply to the said letter Consumer Complaint No. 210 of 2017 3 again certain documents were demanded by the opposite parties just to delay and harass the complainant, especially when their letter dated 23.12.2016 confirmed that no document is pending. On 01.03.2016, the complainant had written to the opposite parties that the documents have been supplied but no reply has been received from the opposite parties. Another letter dated 21.03.2016 was written by the complainant but no response. The complainant is taking the treatment of cancer. Clinical reports showing that the cancer is major and 70% is infected. However, the opposite parties have not responded to the claim of the complainant. Alleging deficiency in service on the part of the opposite parties, this complaint has been filed by the complainant seeking directions against the opposite parties; to pay a sum of Rs.40,00,000/- alongwith interest at the rate of 9% p.a.; pay Rs.50,000/- as litigation expense and Rs.4,00,000/- as compensation for mental agony and harassment.
2. Upon notice, opposite parties appeared and filed their written reply taking preliminary objections that the complaint is not maintainable in the present form and that no cause of action has accrued in favour of the complainant to file this complaint. The complaint is based on misleading and false averments; the relevant treatment record has not been produced by the complainant pertaining to the treatment taken on 19.03.2016 till 17.05.2016. On merits, the issuance of a policy is a matter of record. However, it was further stated that vide letter dated 06.02.2017, the complainant was requested to supply complete set of documents. Consumer Complaint No. 210 of 2017 4 The perusal of the record dated 27.02.2016, 29.02.2016 and 19.03.2016 would show that during the said period cancer was suggestive and on 19.03.2016, the complainant was diagnosed of cancer and thereafter the report dated 19.05.2016 was submitted and it was mentioned that fourth chemotherapy was carried out on 30.04.2016, whereas the complainant submitted the treatment record of 18.07.2016. Therefore, it is necessary to go through the treatment taken during the period from 19.03.2016 to 18.07.2016 in order to process the claim. The claim of the complainant is pending till the treatment record is supplied to it to assess the claim of the complainant. Therefore, the complaint is without merit, it be dismissed.
3. In support of their contentions, complainant tendered into evidence the affidavits as Ex.C-A, copy of policy as Ex.C-1, receipt dated 07.08.2015 as Ex.C-2, receipt dated 12.07.2016 as Ex.C-3, treatment slip dated 27.02.2016 as Ex.C-4, histopathology report dated 29.02.2016 as Ex.C-5, report dated 19.03.2016 as Ex.C-6, test reports dated 19.05.2016 as Ex.C-7 to Ex.C-9, test report dated 08.07.2016 as Ex.C-10, Radio Diagnosis report dated 17.05.2016 as Ex.C-11, test report dated 30.09.2016 as Ex.C-12, histopathology report dated 13.06.2016 as Ex.C-13, treatment report dated 28.06.2010 as Ex.C-14, letter dated 23.12.2016 as Ex.C-15, letter dated 06.02.2017 as Ex.C-16, letter dated 21.03.2016 as Ex.C-17, clinical details as Ex.C-18, whereas opposite parties filed the affidavit of Sh.Amit Khanna, Authorized Signatory as Ex.OP-A. Consumer Complaint No. 210 of 2017 5
4. We have heard the counsel for the complainants and have carefully gone through the averments as alleged in the complaint, evidence, written reply and documents filed by the parties.
5. It is a matter of record that the complainant has taken the insurance policy from the opposite parties for a term of 10 years and date of risk commencement is 04.08.2015 and sum insured is Rs.40,00,000/-. The complainant has already paid two premiums and after that he was detected the case of cancer and as per the policy, coverage is as under:-
Diagnosis of % of Applicable sum Insured
Early Stage cancer or 25%
Carcinoma-in-situ (CIS)
Major Cancer 100 less Early Stage Cancer
or CIS claims, if any.
6. Policy document is Ex.C-1, Premium receipt is Ex.C-2, Ex.C-3 is payment of cheque of Rs.34,110/- dated 12.07.2016 for the second year. Ex.C-4 is treatment slip issued by Sharda E.N.T. Hospital dated 27.02.2016. Ex.C-5 is histopathology report dated 29.02.2016 and acknowledged in the diagnosis "Appearance Suggestive of Suspicious Cells seen" and Biopsy was recommended and in the Biopsy dated 19.03.2016 it was pointed out "Metastatic Carcinomatous Deposits Possibly of Squamous Cell Type". Then there is a report of PET-CT issued by Mohandai Oswal Hospital dated 19.05.2016, wherein under the head of Head & Neck, it has been suggested as under:-
Consumer Complaint No. 210 of 2017 6
"Study reveals intensly FDG avid (SUV max 15.35) large lymph nodal mass measuring 40 x 26 mm seen in neck on right side at level II.
Normal physiological FDG distribution is noted in brain parenchyma. No definite abnormal FDG activity in the brain parenchyma.
(Note : All brain metastases may not be apparent on a PET-CT scan and an MRI may be performed where clinically indicated).
Physiologic FDG activity in oropharynx & vocal cords. No abnormal FDG activity."
7. There is another report of PET-CT dated 19.05.2016, wherein impression has been referred as under:
"PET-CT findings suggestive of FDG avid hypermetabolic large lymph nodal mass on Rt side of neck as described. ADV: Biopsy & IHC.
Further no definite PET evidence of hypermetabolism elsewhere.
Please correlate clinically & with previous relevant investigations."
8. Then there is a certificate dated 08.07.2016 issued by Mohandai Oswal Hospital that complainant has been diagnosed as under :
"Mr.Krishan vir, C.R. No.577879, is diagnosed case of unknown primary with neck metastasis, IHC, suggestive of metastatic Squamous Cell Carcinoma. Patient is receiving treatment at Oswal Hospital."
9. Then there is a Radiodiagnosis Report dated 17.05.2016 in which the Impressions has been taken as under:- Consumer Complaint No. 210 of 2017 7
"Impression : Lymphnodal Mass RT Side Neck and B/L Level II Lymphnodes Advised : FNAC"
10. Ex.C-12 is the Case Summary dated 30.09.2016 with regard to Chemotherapy. Ex.C-13 is the Histopathology Report dated 13.06.2016, in which the opinion has been given as under:-
"Consistent with metastatic squamous cell carcinoma, cervical tissue biopsy."
11. There is a letter dated 23.12.2016 (Ex.C-15), in which there is a detail of documents received and in column of pending documents it has been shown as NIL but subsequently in another letter dated 06.02.2017 the pending documents has been shown as under:
"Documents pending
1) Complete Chronology with Signs and Symptoms of the said ailment from dated 19 march 2016 to 17 May 2016 with respective documents For the same.
2) Please submit All Chemotherapy treatment papers for the said ailment Till date.
3) Please submit the Referral note for Dr. Harish Nanda, Kataria Hospital (Who referred the patient to Dr.Harish Nanda).
4) Please submit the first consultation paper of Dr.Surinder Sharda."
12. Vide letter dated Ex.C-17 dated 21.03.2016, he again submitted the final diagnosis report. The final diagnosis report dated 07.07.2016 is as under:-.
IHC Markers : Result
CK Positive strongly in majority of
tumor cells
CK5/6 Positive strongly in majority of
Consumer Complaint No. 210 of 2017 8
tumor cells
p63 Positive strongly in majority of
tumor cells
P53 Positive strongly in majority of
tumor cells
CK7 Negative
TTF-1 Negative
Synaptophysin Negative
EMA Positive in many tumor cells
KI-67 70%
13. Whereas, apart from the affidavit of authorized signatory, no document has been placed on record, therefore, once the sufficient documents have already been submitted by the complainant to the opposite parties, opposite parties kept on sitting on the claim and did not pass any order. Even during the pendency of the complaint, no application was filed by the opposite parties for production of any other specific document. The opposite parties are now in the knowledge that as per the report dated 07.07.2016 (Ex.C-18) KI-67 is 70%. They could easily process the claim of the complainant but no steps were taken by the opposite parties to settle the claim of the complainant despite having on record the sufficient documents for decision of the claim. Therefore, we are of the opinion that there is deficiency in service on the part of the opposite parties.
14. In view of the above, the complaint filed by the complainant is accepted with the following directions:
(i) opposite parties are directed to process the claim of the complainant within a period of one month from the date of passing of the order by this Commission on the basis of documents already submitted and the documents placed on the record with this complaint;Consumer Complaint No. 210 of 2017 9
(ii) In case the order passed by the opposite parties is not upto the satisfaction of the complainant, the complainant will reserve his right to file a fresh complaint;
(iii) The opposite parties is directed to pay Rs.25,000/- as compensation for mental agony and harassment for not deciding the claim within the required time despite having the sufficient documents; and
(iv) to pay Rs.21,000/- as litigation expenses.
15. The complaint could not be decided within the statutory period due to heavy pendency of court cases.
16. Since there is shortage of postal stamps in this Commission, therefore, the parties themselves or through their counsel are directed to receive free certified copies of the order by hand and it is the responsibility of the learned counsel for the parties to inform them accordingly.
(GURCHARAN SINGH SARAN) PRESIDING JUDICIAL MEMBER (RAJINDER KUMAR GOYAL) MEMBER February 09, 2018 parmod