PRESIDENT, DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SAMBALPUR

CONSUMER COMPLAINT NO. 39/2021

Present-Dr. Ramakanta Satapathy, President,

  Sri. Sadananda Tripathy, Member

Bishnupriya Pattanayak,

W/O-Sri. Jatindra Kumar Pattanayak,

R/O-Infront of SSI Computer, Pradhanpara, Budharaja,

Po-Budharaja, PS-Ainthapali,

Dist-Sambalpur-768004,

Mob-9437220475.                                                 .……….......Complainant.

Vrs.

1. Branch Manager, ICICI Lombard General Insurance Company Limited,

Near Church, G.M. University Road, Sambalpur, PO-Sambalpur, Ps-Town,

Dist-Sambalpur-768001.

2. Branch Manager, Serving Branch, ICICI Lombard General Insurance Company Limited, Plot No.29, Third Anuj Building, Satya Nagar, Bhubaneswar, Orissa-751007,
3. Managing Director, ICICI Lombard General Insurance Company Limited, ICICI Lombard House, 414 Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai-400025.             ....……….Opp. Parties

Counsels:-

1. For the Complainant           :-       Sri. R.L Sharma, Adv. & Associates
2. For the O.P.s                     :-       Sri. B.K. Purohit, Adv.

Date of Filing:10.08.2023,  Date of Hearing :04.09.2023  Date of Judgement : 17.10.2023

Presented by Sri Sadananda Tripathy, Member.

1. The case of the Complainant is that the Complainant consulted the agent of the OP No. 1 and as per advice, took an International Insurance Policy under the OP No. 1 under plan name 4129 International travel for 60 days period of Trip particular was 06.02.2020 to 05.04.2020. Due to Covid-19, Pandemic corona virus, the Complainant could not returned from USA and hence she further extended/renewed the said policy from 06.02.2020 to 05.05.2020. Due to worldwide Lockdown and shut-down, for Covid-19, the Complainant could not return from USA and hence she contacted the OP No. 1 for further extension/renewal of the said policy but the official of the OP No. 1 told that the office is shut-down due to Covid-19 and under such circumstances it is not possible to renew the policy and advised her to take fresh policy online and accordingly the Complainant took the said policy for 11.05.2020 to 09.09.2020. Due to world-wide lockdown and shutdown the Complainant was forced to reside there with her family in USA and further in order to extent the policy, contacted the OP No. 1 on 09.09.2020, the official of the OP No. 1 did not respond the Complainant and remain silent and on 17.09.2020 the OP No. 1 advised the Complainant to take a fresh policy and accordingly the Complainant took a fresh policy for 17.09.2020 to 26.12.2020. While the Complainant was in USA, she fell ill and was under treatment of the doctors in different dates of Mercy Hospital, the Complainant was advised for several biological tests, prescribed medicines. During treatment at Mercy Hospital, USA total expenses bill from the period 02/10/2020 to 30/10/2020 and 29.10.2020 to 26.11.2020 was $ 5,248.42. The Mercy Hospital USA submitted bill before the OPs Company as agreed but they did not pay medical expenses. The Complainant consulted the OP No. 1 over phone but the OP No. 1 did not co-operate the Complainant and at last advised her to pay the medical expenses/bill and the matter will be settled within few day. The Complainant returned to India on 15.12.2020 and approached and contacted the OP No. 1 several times, but they did not take any fruitful action and every time assured that they will settle the matter as soon as possible. At last with no alternative, the daughter of the Complainant gave complaint through mail on dtd. 24.02.2021 to the customer support of the OPs, which was received by them. On receipt of the mail the Customer Service Desk, ICICI Lombard GIC Ltd. gave vague reply on the complaint and refused to process the claim and repudiated the claim of the Complainant. The Complainant is suffering due to financial loss, mental agony and harassment, without her fault and due to fault of the OPs. The OPs have failed to provide proper services to the Complainant and hence the OPs are liable to pay compensation for deficiency in service and unfair trade practice.
2. The Written Version of the O.Ps is that the claim was received by the Insurance Company that the insured was hospitalized at Mercy Clinic on 16.09.2020 and remained there till 22.09.2020. The claim was received by the Insurance Company and since the policy commenced from 17.09.2020 and the admission of the insured at the Hospital was on 16.09.2020, the claim was repudiated on the ground of Policy Exclusion & Condition-Out of Policy period. As per the available records, the petitioner consulted the Doctor of the USA with complains of pain in stomach and bowel movement on 16.09.2020 where she was diagnosed with rheumatoid arthritis with rheumatoid factor of multiple sites wthout organ or systems involvement; essential (primary hypertension); hypothyroidism, unspecified. Hence, the claim was repudiated.  
3. From the Written Statements of the both the parties, it is observed that the Complainant took an International Insurance Policy under the OP No. 1 under plan name 4129 International travel for 60 days period of Trip particular was 06.02.2020 to 05.04.2020. Thereafter due to Covid-19, the Complainant could not return and as per the advise of the OP No. 1, the Complainant took the said policy freshly from 06.02.2020 to 05.05.2020, 11.05.2020 to 09.09.2020 and lastly on 17.09.2020 to 26.12.2020. The Complainant/insured was hospitalized at Mercy Clinic on 16.09.2020 and remained there till 22.09.2020. Since the policy commenced from 17.09.2020 and the admission of the insured at the Hospital was on 16.09.2020, the claim was repudiated by the OPs on the ground of Policy Exclusion & Condition-Out of Policy period.
4. The policy commenced from 17.09.2020 and the admission of the Complainant/insured at the Hospital was on 16.09.2020, the Complainant is entitle to get the treatment expenses from 17.09.2020 onward but the OPs repudiated the entire claim. Due to Covid-19 situation as per advice of the O.P. no.1 the Complainant has extended the policies and from 17.09.2020 as the policy was valid repudiation made by the O.Ps is non-application of mind. Hence deficiency in service Established against the OPs. Accordingly it is ordered.

ORDER

The case is allowed of on contest. The O.Ps are directed to pay the claim amount in between the period of 17.09.2020 to 26.12.2020 towards medical expenses as the policy was valid from 17.09.2020 to 26.12.2020 on proper calculation to the Complainant, Rs. 25,000/- towards financial loss, mental agony and harassment as compensation and further Rs. 10,000/- towards cost & litigation expenses within 30 days from the date of order, failing which the amount will further carry 9% interest per annum till realization.

Order pronounced in the open Court today on 17^th day of Oct, 2023.

Free copies of this order to the parties are supplied.