The National Consumer Commission, while modifying an order from the state consumer commission, has directed HDFC ERGO General Insurance Company Ltd. to pay a reduced mediclaim amount to a resident of Thane. The state commission had initially awarded ₹50.91 lakh to the resident.
The national commission referred to a clause in the policy which stated that in the case of a co-applicant, the benefits of the sum insured were limited to 50 percent for each insured individual. It directed that 50 percent of the sum insured (₹25.45 lakh) should be paid with nine percent interest. The earlier report by FPJ on April 28 had highlighted the state consumer commission's directive for HDFC Ergo to pay ₹50.91 lakh as mediclaim.
Rs 1 lakh compensation from state govt
Additionally, the state government provided ₹1 lakh as compensation for mental agony, along with nine percent interest from the date of the claim. The national commission set aside the compensation for mental agony, stating that the state commission had not provided any findings to justify the award. The national commission clarified that compensation cannot be claimed under multiple categories. The interest will be calculated from March 2020 until the date of payment.
The order, dated June 23, was issued by Justice Ram Surat Ram Maurya, the presiding member of the National Consumer Disputes Redressal Commission (NCDRC). The order was in response to an appeal filed by HDFC ERGO General Insurance Company Ltd. against Thane resident Sarbendu Bagchi. Bagchi had obtained a Home Suraksha Plus policy while applying for a home loan. During the policy period, he underwent treatment with a nephrologist. However, in August 2019, his creatinine levels unexpectedly rose, leading to his hospitalization and subsequent diagnosis of acute and chronic renal failure.
Ex-parte order against HDFC Ergo
When the policyholder submitted an insurance claim under two policies - the Sarva Suraksha Claim for ₹1 lakh and the Home Suraksha Plus Policy for ₹50.91 lakh - only the Sarva Suraksha policy was settled, while the claim of ₹50.91 lakh under the Home Suraksha Plus Policy was denied. The state commission had issued an ex-parte order against HDFC Ergo. During the hearing, the commission noted that Ergo raised a brief issue during the arguments, stating that in the Home Suraksha Plus policy, one of the coverages under Section III was for "Major Medical Illness and Procedures," with a sum insured of ₹50.91 lakhs. However, in the paragraph following that table, it was mentioned that "'in case of co-applicant, benefits under section III & IV (Major Medical Illness and Procedure & personal accident) were limited to 50% of the sum insured for each insured.'"
Justice Maurya, in his order, stated, "I have considered the arguments of the counsel for the parties. A perusal of the insurance policy clearly shows that the sum insured for Major Medical Illness and Procedure was ₹5091080/- and 50% of that amount has to be awarded as per the terms and conditions of the policy, considering that there were two insured individuals. However, the State Commission overlooked the terms and conditions of the policy. Therefore, the order of the State Commission is liable to be modified." The commission further mentioned that regarding the payment, "admittedly there is a bank clause, and the payment has to be made to the bankers. It shall be open to the appellant to make the payment to the banker."