ORDER

(Per Sri Karanam Kishore Kumar, President on behalf of the Bench)

CONSUMER COMPLAINT No.82/2025

1. This complaint is filed under section 35 of the Consumer Protection Act, 2019, praying to direct the opposite parties jointly and severally:-

a. To pay medical expenditure of Rs.10,17,772/- incurred by the complainant.

b. To pay compensation of Rs.1,00,000/- for mental agony suffered by the complainant.

c. To pay Rs.25,000/- for legal expenses.

And

d. To grant such other reliefs as the Hon’ble Commission deems fit and proper in the circumstance of the case.

2. The case of the complainant in brief runs as follows:- The complainant is a resident of Pathur Street, Allagadda Town and Mandal, Nandyal District. Opposite Party No.1 is HDFC ERGO General Insurance Company Ltd, represented by its Authorized Signatory. Opposite Party No.2 is Continental Hospitals, represented by its Managing Director.

The complainant, a Software Engineer and native of Allagadda, has been holding an “Energy Silver Insurance Policy” (Accident and Health Insurance) issued by Opposite Party No.1 since 2019, covering the medical expenses of his father, Sri Atla Vijaya Bhaskar Reddy. The policy was periodically renewed. For the relevant period, Opposite Party No.1 collected a premium of Rs.42,750/- and issued Policy No.2814203683272504000 dated 07.03.2024, valid from 25.03.2024 to 24.03.2025.

The complainant’s father had no history of smoking or alcohol consumption. On 25.06.2024 at about 6:30 PM, the complainant’s parents were allegedly attacked by certain relatives and unidentified persons armed with knives and iron rods. During the incident, chilli powder was reportedly thrown, and both were assaulted indiscriminately. In the said attack, the complainant’s mother, Smt A.Sreedevi, died on the spot, while his father sustained multiple grievous injuries and went into severe shock. The injured was initially taken to Government Hospital, Allagadda, where first aid was administered. Considering his critical condition, including shock, drowsiness, chronic kidney disease, anemia, and the need for haemodialysis, he was advised to be shifted to a higher medical centre.

Accordingly, on 27.06.2024, he was admitted to Opposite Party No.2 hospital, a network hospital under the policy. At opposite party No.2 hospital, the patient (ID No.CH20016501) was diagnosed with a closed left lower limb comminuted un-displaced proximal one-third tibia shaft fracture, along with abrasions, contusions, and uremic encephalopathy. He was treated in ICU from 27.06.2024 to 06.07.2024 and again from 31.07.2024 to 08.08.2024. During the course of treatment, a closed reduction with above-knee moulded fibre cast was performed. He was discharged on 06.07.2024. The complainant incurred medical expenses of about Rs.5,45,000/-.

When a cashless claim was submitted on 03.08.2024, Opposite Party No.1 raised queries through an Additional Information Request (CCN: RC-HS24-14367867), seeking clarification regarding an alleged history of “Alcohol Withdrawal Psychosis.” The complainant contends that the said query was baseless, as his father had no history of alcohol consumption. Accordingly, he submitted a clarification on 03.08.2024 denying any such history. On 08.08.2024, the treating doctor issued a clarification stating that the patient’s drowsiness was due to anemia, chronic kidney disease, haemodialysis, and the severe physical and psychological shock caused by the incident, and not due to any alcohol-related condition. The hospital also issued a revised discharge summary removing the reference to “Alcohol Withdrawal Psychosis.”

Despite the above clarifications, Opposite Party No.1 repudiated the claim and cancelled the policy without proper justification, thereby denying reimbursement of the medical expenses incurred. Aggrieved thereby, the complainant issued a legal notice dated 03.10.2024 to both opposite parties, alleging that due to the incorrect recording of medical information by Opposite