D.O.F:28/06/2022     

                                                                                                            D.O.O:30/10/2024

IN THE CONSUMER DISPUTES  REDRESSAL COMMISSION KASARAGOD

                                 CC.137/2022

Dated this, the 30^th   day of October 2024

PRESENT:

SRI.KRISHNAN.K                                              : PRESIDENT

SMT. BEENA. K.G                                            : MEMBER

1. Haseena P K aged 44 years,

W/o Ibrahim. N,

Sulthana Mahal,

Soorambail, Kasaragod District       671321                      : Complainant

2. Ibrahim. N,aged 46 years,

S/o K.V. Aamu,

Sulthana Mahal,

Soorambail, Kasaragod District   671321

(Adv. Shrikanta Shetty.K)

                                                      And

ICICI Lombard General Insurance C. Ltd,

ICICI Lombard Health Care,

ICICI Bank Tower, Plot No. 12,

Financial District, Nanakram Guda,

Gachibowli, Hyderabad – 500032                                 : Opposite Party

Telangana. Represented by

Associate Vice President – Health claims.

ORDER

SRI. KRISHNAN.K : PRESIDENT

          The case of the complainant is that they obtained a health insurance policy for the period 17/08/2021 to 16/08/2022.  On 18/02/2022 complainant No:1 admitted for the treatment of abnormal uterine bleeding Dr. Veena Manjunath conducted surgery of laparoscopic Hysterectomy followed by Salphingectomy on 21/02/2022 and discharged on 24/02/2022.  Total bill comes to Rs. 75,355/- opposite party denied cashless service.  The complainant therefore claiming Rs. 75, 355/- with interest and compensation.

          The Opposite party set exparte.  The opposite party filed petition to set aside exparte order but dismissed as per order in IA 152/2023 dated 23/08/2023.  But still Opposite party participated in the proceedings and filed argument notes.

          The complainant filed chief affidavit and cross examined as Pw1.  Ext A1 to A5 documents filed on his behalf Ext A1 denial letter by Opposite party.  Ext A2 discharge summary, Ext A3 extract bill, Ext A4 insurance policy, Ext A5 bill series 25 in number.

          The opposite party filed argument notes submitted that as per exclusion clause 3.2 therein a waiting period of 2 years hence not entitled to insurance benefits.

          The following points arised for consideration in the case:

1. Whether complainant is entitled to insurance benefits as per policy conditions and whether repudiations is valid and justifiable
2. Whether complainant is entitled to compensation and if so for what reliefs?

     In the present case opposite party admitted the Insurance policy.  But the claim rejected for the reason that claim is made within 2 year of issue of policy.

          On going through the documents Ext A1 to Ext A5 series it is seens that complainant No:1 admitted in the hospital for treatment during the period 18/02/2022 and 24/02/2022 within the policy period.

          The contention of opposite party is that there is waiting period of start date of policy for getting coverage.  Hence not eligible for insurance benefits.  This is the only reason to repudiate the policy.

          The opposite party has no case that any information is suppressed by complainant while obtaining the policy.  Here is a case that opposite Party collected the premium, accepted it and entered in to agreement to the insurance company cannot withdrawn from its liability.  There is no case that false information is given to get insurance policy.

          There is no justifiable reason or justification to deny insurance benefits opposite party has not adduce any evidence or documents in this case.

          In this circumstances commission holds that repudiation of Insurance benefits is not justifiable on the ground of waiting period of two year and we allows the claim of the complainant.

Since the payment of insurance benefits is not made as per conditions of insurance policy there is deficiency in service hence opposite party liable to pay compensation.

          In the result complaint is allowed in part directing opposite party to pay sum of Rs. 75,355/- (Rupees Seventy five thousand three hundred and Fifty five only) with 8% interest from date of complaint till payment and   Rs. 25,000/- (Rupees Twenty five thousand only) for deficiency in service and             Rs. 5,000/-(Rupees Five thousand only) as cost of litigation within 30 days of the receipt of the order.            

      Sd/-                                                                                                 Sd/-

MEMBER                                                                                   PRESIDENT  

Exhibits    

A1- Letter of the Opposite Party denial of cashless access.

A2- Discharge Summary

A3- Discharge estimate bill

A4- Insurance Policy

A5- series- Bills

   Sd/-                                                                                            Sd/-

MEMBER                                                                                        PRESIDENT

Forwarded by Order

Ps/                                                                 Assistant Registrar