HDFC ERGO Responded on 17 Jan 2023

I’ve converted the hard copy text with Optical Character Recognition.

BEFORE THE DISPUTE CONSUMER DISPUTES REDRESSAL COMMISSION, NORTH 24 PGNS, AT BARASAT

CC/353/2022 edaakhil A22090004397

RATUL AICH — Complainant
Vs
HDFC ERGO HEALTH INSURANCE COMPANY LTD.& ORS. — Opponent

WRITTEN VERSION ON BEHALF OF THE OPPONENTS

Most Respectfully Sheweth:

PRELIMINARY OBJECTION

1. That the alleged complaint is barred by the principles of estoppels waiver, acquiescence, limitation, non-joinder and mis-joinder of necessary parties.
2. That, the present complaint is concocted, frivolous and vexatious and liable to be dismissed as per the provision of section 26 of the consumer protection Act.
3. That, the complaint does not come under the purview of consumer protection Act, hence liable to be rejected.
4. That the contents of the complaint petition are not true and not admitted. The averments made, contention raised and inference tried to be drawn, which are not specifically admitted here in below, are here by denied. The contents are neither maintainable in Law nor in facts hence liable to be dismissed.

SPECIFIC PLEADINGS

1. That, based on the information received from complainant, this Opponent had issued an Optima Restore Individual Policy bearing no. 110103/111 19/AA01265980 for the period 30" Nov 2019 to 29 Nov 2020 subject to the term/s and/or condition/s incorporated and to the extent of limits mentioned in the said Policy. Copy of Policy along with Term & Conditions is annexed herewith as Annexure A and Annexure B respectively. Subsequently during renewal, the complainant had requested for reduction of the sum insured to Rs 5 Lakh and based on such request, policy bearing number 2805 2035 5354 0501 000 was renewed from 30 Nov 2020 to 29th Nov 2021 with reduced Sum Insured. Copy of the Renewed Policy is annexed hereto and marked as Annexure C.
2. That, the Policy Kit containing all relevant documents were duly received by the policy holder thereby giving him an Opportunity to verify and examine the benefits, terms and conditions thereof obtained by him with the Policy Bond. It is pertinent to mention herein that the complainant/proposer never approached the Company stating that any information given in the documents contained within the Policy Kit was incorrect, incomprehensible or unacceptable to him within the free look up period, i.e. 15 days from receipt of the policy document. Considering that no objection was received from Complainant during such time, he is strictly bound by the terms and conditions of the Insurance Contract.
3. That, on 29" Nov 2021 a claim for reimbursement was received by this OP Insurance Company from Complainant vide Reimbursement ID RR-FC21–12734614 for his health check up procedures dated 27" Nov 2021. It is pertinent to mention herein that the insured had undergone blood tests and all such investigative procedures required for a general routine health check up. Copy of the Claim Form and Medical Records are annexed hereto and marked as Annexure D and Annexure E respectively.
4. That, upon receipt of such claim intimation, this OP had scrutinized complete records in respect of the claim and it was gathered that the present policy had not completed a period of 2 years on the date of investigation. Considering that policy terms and conditions under an Optima Restore Individual Policy render very clearly that any claim for preventive health check-up claim will be payable at Rs.1500 wherein Sum Insured is 5 Lakh only once and at the end of every 2 continuous policy years. As the present policy end date was on 29" Noy 2021 and the investigative procedures were done on 27" Nov 2021 and claim was lodged on 29" Nov 2021, claim was inadmissible as per policy terms and conditions.
5. This OP draws the attention of this Ld Forum towards the relevant clauses from the Policy Wording;
   When is benefit under Preventive Health Check Up available to Insured/Member;
6. That in light of aforesaid findings, this OP Insurance Company was constrained to repudiate the claim vide letter dated 09" Dec 2021 declaring the same. Copy of the Repudiation letter is annexed hereto and marked as Annexure F.
7. That, following the repudiation, the Complainant instituted the aforesaid grievance along with another dispute with respect to eligibility of discount on renewing his policy with this OP at 8%, Both disputes were brought before the Hon’ble Ombudsman at West Bengal which were carefully scrutinized by the Insurance Ombudsman in depth. Upon evaluation of contents of the dispute along with complete documents from both parties, the Hon’ble Ombudsman upheld that the decision of this OP was in order, in respect of both aforesaid disputes. This OP would like to submit that the Complainant was eligible for 0% discount. as he had completed around 3433 steps against a minimum step count of 5000. As the Complainant had not completed the required step count, he was not eligible for the discount under the policy and this fact was ascertained before the Ombudsman too by this OP. Copy of the Award passed by the Hon’ble Ombudsman is annexed hereto and marked as Annexure G.
8. That, despite the decision from the Insurance Ombudsman which was quite clear and within the four corners of the policy terms and conditions and IRDA Guidelines, the Complainant has continued to harass this OP vide legal notices, registering complaints and has left no stone unturned to malign this OP Insurance Company’s reputation on social media platforms too.
9. That, this OP is not legally obliged to honor the Complainant’s claim and there cannot be any further deliberation on the grounds of rejection as the matter has already been taken up before a competent judicial authority prior to institution of the present complaint before this Ld. Forum, and a justiciable award has been passed too after careful evaluation of his claim.
10. That this OP Insurance Company, once again repudiates the Complainant’s repeated statements and representations as absolutely false, ingenuously fabricated and maliciously concocted.
11. That the defamation committed by the Complainant and disseminated through print and electronic media were directed to tarnish the reputation of this OP in professional capacity. These statements have tended to only injure and lower the Company’s reputation in the estimation of right and fair minded members of the society and have exposed this OP to unjust criticism, ridicule, dislike and irreparable damage.
12. That, at the outset, there is no deficiency in service on the part of Opponent. An act of repudiation of a claim is done by company after considering all the material and relevant facts. This can by no stretch be termed as “deficiency in service” on the part of opponent. To determine an act of “deficiency in service” the court must consider what specific acts of an Insurance Company would amount to deficiency of service? when does the limit of such deficiency in service end? and when the limits of an inquiry into facts and evidence akin to that of a civil court commence?. It is respectfully submitted that there is no body of Indian law on the point and the only pronouncement of law by the Hon’ble Supreme Court on the test to be applied is found in the judgment of “Ravneet Singh Bagga vy. KLM Royal Dutch Airlines (2000) 1 SCC 66” where the Hon’ble Supreme Court laid down that the test of deficiency in service lay in the Complainant proving that there was some fault, imperfection, shortcoming or inadequacy in the manner of the Insurance Company and further such fault etc. must be willful. More importantly the Hon’ble Supreme Court has held that where there is a bona fide dispute between parties and where the service provider has after considering all the material with them and the relevant facts has acted in a particular manner, then such acts will not amount to deficiency in service. Thus, as there is no “deficiency in service” on the part of this respondent, the complaint is liable to be dismissed on this count alone.
13. That, the averments made and / or allegations levelled by petitioner in the claim petition against this respondent, if not specifically admitted by this respondent hereinafter, be hereby deemed to have been reproduced and denied in toto. The Petitioner/s be put to strict proof of all such averments and / or allegations.
14. That, the petition is not maintainable either in law or on facts and the same is liable to be rejected in limine.
15. That, in reply to Para 14 of the complaint petition, it is submitted that the alleged claim/compensation is frivolous, vexatious and devoid of merits and hence, the question of payment of alleged compensation for no fault of Opposite Parties do not arise at all.
16. This OP craves leave of the Hon’ble commission to file additional or amended written statement as and when necessary or on filing of any documents by the complainant.

The response has been received on 17 Jan 2023 during the court hearing from the opposite party HDFC ERGO. The document contains Annexure of Insuree Policy Documents and Insurance Policy Terms & Conditions. The link contains all the pages in sequence. https://photos.app.goo.gl/o4KZVKMgYBb2WDEx8

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