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BEFORE THE HON’BLE DISTRICT CONSUMER DISPUTE REDRESSAL

COMMISSION, KOLAKATA UNIT-II

COMPLAINT CASE NO.287 OF 2021

LALIT DHANUKA, son of Late Shyam

Sundar Dhanuka, residing at Flat no. BE
1002, Beta Block, Siddha Xanadu
Condominium, Rajarhat Main Road,
Kolkata – 700 013;
…Complainant

-VERSUS-

HDFC ERGO HEALTH INSURANCE

LIMITED (formerly known as Apollo
Munich Health Insurance Company
Limited) having its branch office at 2/1,
4th Floor, KankariaCenter, Russell Street,
Kolkata – 700 071 and also at P-256
Scheme VI-M, PhoolBagan,
Kankurgachi, Kolkata- 700 054;

…..Opposite Party

BRIEF NOTES OF ARGUMENTS FILED BY THE COMPLAINANT

1. That the complainant herein had renewed its medical insurance policy being

Optima Restore Floater Insurance Policy bearing policy no.

150100/11121/AA01107579-01 with Opposite Party herein through their

insurance agent Mr. Vishal Agarwal, upon payment of lump sum premium

amount of Rs.39449.76/- only.

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2. That the aforesaid policy was valid on and from 20 th May, 2020 to 19th May,

2021 and the said policy covers benefit for the complainant and his wife as

spouse. A copy of the said insurance policy is already annexed herewith the

petition of complaint and is marked with letter “A”.

3. That upon renewal of the said insurance policy, the Opposite Party herein

through their insurance agent had informed the complainant that in the trying

time of COVID-19 pandemic, the Opposite Party herein is extending their

support to their valued customer by adding “Home Care Expenses” benefit to

their existing policy. A copy of the said intimation extending “Home Care

Expenses” benefit to the existing policy is already annexed with the petition of

complaint and is marked with letter “B”.

4. That it would appear form the said intimation, which has been widely

advertised and circulated by the Opposite party, that the said “Home Care

Expenses” benefit will cover the cost of treatment of COVID-19 incurred by

the insured person on availing treatment at home and such benefit will also

cover expenses incurred on account of –

a. Diagnostic tests underwent at home or diagnostic centre

b. Medicines prescribed in writings
c. Consultation charges of the medical practitioner
d. Nursing charges related to medical staff
e. Medical Procedures limited to parenteral administration of
medicines
f. Cost of Oximeter, Oxygen cylinder and Nebulizer.

It was further mentioned in the said intimation that the said additional benefit

by way of alteration would inter alia apply to “OPTIMA RESTORE” policy

and said additional benefit would be valid for the period between 1 st July 2020
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to 30th September, 2020 at no extra cost. It is relevant to mention that said

benefit was extended to meet the difficult times faced by the insured due to

Covid-19. Further the fact that this intimation has been issued by the opposite

party has not been disputed nor that it will not apply to the policy taken by the

complainant.

5. That in or around 10th and 11th July, 2020, both the Complainant and his wife

were suffering from fever and as such they were advised to undergo Swab Test

for COVID-19 by Doctor Probodh Ranjan Shil.

6. That on the basis of such advise being made by the medical practitioner, the

complaint and his wife had requested Pulse Diagnostic for Swab Test for

COVID-19 and the report of such test (prepared by the Dr.Lal Path Lab) was

made available to the complainant on 14 th July, 2020 wherefrom it appears that

both the complainant and his wife were suffering from COVID -19. A copy of

the said report dated 14th July, 2020 is already annexed the petition of

complaint and is marked with letter “C”.

7. That be it noted that Dr. Saswata Mukherjee (Senior Doctor at B.M Birla

Hospital) was contacted for further treatment. Due to non-availability of

Hospital bed and further considering their situation and the fact that both the

complainant and his wife are senior citizen and had co-morbidities like

diabeties, said Dr. Mukherjee advised both the complainant and his wide to

undergone treatment from home under him with 24*7 medical observation by

medical attendant vide nursing support of “PROTEA Health Care Ltd” a

company providing nursing support at home.

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8. That it is imperative to note that on basis of such advice the complainant and

his wife underwent active line of treatment from Dr. Saswata Mukherjee who

on a regular basis monitored the health status of the patients with the aid of the

nursing staff of Portea Health Care Ltd. The nursing stuffs of Protea were

present throughout during the period of active line of treatment by Dr. Saswata

Mukherjee in order to aid and assist him. The Nurse would take all the vitals of

the patients thrice a day and report it to the Doctor continuously.

9. That during the aforesaid period, the complainant and his wife suffered from

High Fever, Breathlessness & Dehydration and along with these COVID

Symptoms. The blood pressure issues were noticed for the complainant

whereas his wife being highly diabetic had suffered from highly fluctuating

glucose level. All these were immediately taken care by the Dr. Saswata

Mukherjee with the aid of nursing staff of the Protea. The doctors had

prescribed several medicine, oxygen, nebuliser, blood pressure machine and the

same were purchased for the complainant and his wife. Photocopies of the

prescription, bills are already annexed with the petition of complaint and

collectively marked with letter “D”.

10. The petitioner states that ultimately the patients were recovered and discharged

on 27.02.2020. The certificate issued by said Dr. Saswata Mukherjee in respect

of the complainant and his wife are already annexed with the petition of

complaint and collectively marked with letter “E”.

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11. That thereafter, the complainant through its agent Mr. Vikash Agarwal had

made his claim to the opposite party for himself and his wife to the tune of

Rs.1,64,179 (one Lakh Sixty Four thousand one Hundred and Seventy Nine

Only) along with the supporting documents, prescription and bills.

12. That by a letter dated 28.08.2020, the claim of the wife of the complainant was

repudiated stating “The submitted claim is for quarantine and isolation without

any treatment in Hospital. Hence we regret to inform you that your claim is

repudiated under V C xii h of the policy” whereas by another letter dated

30.08.2020, the claim of the complainant was repudiated by stating “The

submitted claim is for management of an aliment which was done on out-

patient basis without any hospitalization . Hence we regret to inform you that

the claim is repudiated”. Photocopy of the letter dated 28.08.2020 and

30.08.2020 are already annexed with the petition of complaint annexed

herewith and collectively marked with letter “F”.

13. That surprisingly, no clarification whatsoever was sought form the

complainant to understand the claim and its coverage under the policy. It is

relevant to state that aforesaid repudiation was vague and the same has been

made without event looking into the terms of “Home Care Benefit” which has

been issued by the opposite party themselves.

14. That in such circumstances a review of the aforesaid repudiation letter was

made. The receipt of such review request was confirmed by the agent of the

said Opposite Party, however, no steps were taken for reviewing the said
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repudiation despite request. In such circumstances, approach was made to the

grievance rederessal cell against the opposite party by way of email and in

response to such email, the grievance redressal cell informed the complainant

that the claims of the complainant shall remain repudiated in as much as the

submitted medial documents indicated that the member had submitted a claim

for home quarantine when member had a history of fever and cough and as per

medical documents, the member was managed through Oral medication with

no active line of treatment. In the said email, they also provide considerable

amount of education as to different kind of Covid symptoms. It may be noted

that the grievance cell instead of resolving the issue has tried to improvise on

the reasons of repudiation given by the opposite party for repudiating the claim.

A copy of the email to the grievance redressal cell and the reply of the said

grievance redressal cell are already annexed with the petition of complaint and

collectively marked with letter “F”.

15. That upon careful perusal of the finding of the opposite party reveals such

finding is perverse, illegal and arbitrary. The ground of rejection is not in

conformity with the policy for “Home Care Benefit”. Further even the clause of

the policy mentioned above for repudiation could not be found in the policy. It

may be further noted that the Opposite Party has failed to provide their services

to the complainant who is a bona fide customer of the opposite party and it is a

clear case of deficiency of service and mental harassment to the complainant

who are senior citizens.

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16. That it is imperative to note that the complainant and his wife underwent active

line of treatment and constant monitoring of health status by Dr.Saswata

Mukherjee with the aid of Protea health Care Limited and has experience all

the covid 19 symptoms requiring active line of treatment at Home. The fact that

they were under active line of treatment has been certified by the Doctor. It

may be further noted that the doctors fees is paid for the entire period of

treatment and not on OPD basis and also almost 75% of the claim amount is

towards the medical attendants charges by Protea health care which also

confirms active line of treatment. Kindly note here that while repudiating claim

both on first and second occasions, the Opposite Party has arbitrarily did not

consider the purport of the said Home Care Benefit and thus they have

deliberately failed to render services to the complainant and his wife despite

receipt of payment for service.

17. The complainant states that the complainant had approached appropriate

authority under the Department of Consumer Affairs, Government of West

Bengal for Settlement, however, the Opposite Party did not turn up for

settlement proceedings and accordingly, by a Memo no 448 CA/G

/CA/ESTT/IG-547/20 dated 08-04-2021, the said settlement proceedings have

been closed by advising the complainant to approach this Forum. A copy of the

said Memo dated 08-04-2021 is already annexed the petition of complaint and

is marked with letter “H”.

18. That being aggrieved by and dissatisfied with the conduct of the OPs for

adopting unfair trade practices and deficiency in rendering service, the

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complainants, finding no other alternative have sought to initiate the instant

complaint case being no. CC/278/2021 before this Ld. Commission.

ALLEGATIONS AGAINST THE OPS :-

1. Despite clear terms and conditions mentioned in the Insurance Policy (HOME
CARE BENEFIT), the OPs have failed to provide service to the complainants.

2. Despite providing all medical records, the OP had repudiated the claim of the
complainant;

3. The OP Insurance Company has failed to provide such Home Care Benefit
Claim to the insured, the complainant herein, despite providing all the
necessary papers/documents. Due to the above laches and negligence on the
part of the OPs, the complainant along with wife is undergoing tremendous
financial constraints at their old-age.

4. The OP insurance company adopted unfair trade practice for repudiating the
claim and as such the complainants entitled to get compensation along with
interest, damages on account of mental harassment and agony and litigation
cost.

COUNTER ARGUMENTS TO THE CONTENTIONS OF THE OP NO.1

The specific contentions of the OPs are :-

1. The claim of the complainant has been repudiated as the said complainant along
with his wife was treated at their house not at the hospital;

2. Home Care Expenses benefit is not included in the policy agreement of the
complainant;

3. The complainant has failed to mention that such expenses coverage is payable
only if there is active line of treatment with monitoring of the health status by a
medical practitioner for each and every day.

4. The complainants are not eligible to get any relief.


COUNTER ARGUMENTS
The claim of the complainant has
been repudiated as the said
complainant along with his wife was
treated at their house not at the
hospital. Home Care Expenses
benefit is not included in the policy
agreement of the complainant
The complainant has failed to
mention that such expenses
coverage is payable only if there is
active line of treatment with
monitoring of the health status by a
medical practitioner for each and
every day.
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REPLY BY THE COMPLAINANT
In this context it may be noted that the OP
Insurance Company by making such
statement/averment has tried to mislead this
Hon’ble Commission. Careful perusal of the
terms and conditions stipulated in Home Care
Benefit, it revealed that such benefit has been
provided to the customers including the
complainant to their existing policies.
Moreover, such home care benefits cover the
medical expenses for COVID 19 treatment at
home. So, it is crystal clear that the policy has
been provided those insured person who has
taken medical treatment at their home for the
period between 01/07/2020 and 30/09/2020.
Infact, such policies have not been designed
for those people who have admitted at the
hospital. Despite clear terms and conditions,
the OP, for reason best known to them, has
repudiated the claim of the complainant.
In this context, it is imperative to note that the
complainant had furnished all the documents
in relation to their treatment. Infact, the OP
has not repudiated their claim on the grounds
that the complainant is not at all eligible to
claim the Home Care Expenses Benefit.
Infact, nowhere had the OP ever stated that
the complainant did not provide any
documents in relation to the medical
treatment. The OP Insurance Company has
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repudiated the claim on the grounds that the

treatment has been provided to the
complainant at their house not at the hospital.
Upon careful perusal of the treatment records,
it would clearly reveal that the complainant
along with his wife was advised for home
quarantine for 2 weeks. During that time they
have availed services from the Nurse. Further
many testes were done and finally the doctor
has been issued a certificate wherefrom it
revealed that they were in continuous active
line of treatment. Despite providing all the
medical documents, they have repudiated the
claim showing vague ground.

The complainants are not eligible to Kindly note that for such deficiency in
get any relief.
service on the part of the OPs, the
complainants have incurred financial loss. It
is imperative to note that such act and
conduct of the OPs would clearly speak of the
OP’s interest in indulging round dealing with
the complainants herein and their approach
and conduct further speaks of total deficiency
in service on their part. As such the
complainants are eligible to get compensation
from the OPs.

PRAYER :-

Under the aforesaid circumstances, it is most humbly prayed that Your Honour

would graciously be pleased to pass the following order:-

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a) Direction be given upon the Opposite Party to pay a sum of Rs. 1,64,179/- to
the Complainant on account of expenses incurred by him for home treatment
of COVID -19 of himself and his wife together with 18 % per interest on and
from 28.08.2020 till the disposal of the present case.

b) Direction be given upon the Opposite Party to pay a sum of Rs. 5,00,000/- to
the Complainant on account of compensation, legal expenses, mental agony
and harassment suffered by the complainant and his wife;

c) Pass such other or further order as Your Honour may deem fit and proper for
the ends of justice.