Haryana

Ambala

CC/274/2018

Sushil Kumar - Complainant(s)

Versus

ICICI Lombard Gen Inss. - Opp.Party(s)

S.R. Bansal

20 Aug 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMBALA.

 

                                                          Complaint case No.: 274 of 2018.

                                                          Date of Institution         :  27.08.2018.

                                                          Date of decision   :  20.08.2019.

 

Sushil Kumar Kansal, aged about 72 years, resident of #93, Preet Nagar, Jagadhri Road, Ambala Cantt.  

          ……. Complainant.

                                                    Versus

 

1. ICICI Lombard General Insurance Company Limited, ICICI Bank Tower, 9^th Floor, Plot No.12, Financial District, Nanak Ram Guda, Gachi Bowoli, Hyderabad-500032.
2. ICICI Lombard General Insurance Company Limited, GIC, Block-C, Sushant Lok-1, Sector-43, Gurugram, Haryana-122015 through its Authorized Signatory.
3. ICICI Lombard General Insurance Company Limited, Triloki Chamber, First Floor, SCO 4307/4/21, Opposite Municipal Committee Road, Ambala Cantt.– 133001 through its Branch Manager.

             ….…. Opposite Parties.

 

Before:        Smt. Neena Sandhu, President.

                   Smt. Ruby Sharma, Member.

Shri Vinod Kumar Sharma, Member.                 

                            

Present:       Shri S.R. Bansal, Advocate, counsel for the complainant.

Shri Rajesh Kumar, Advocate, counsel for the OPs.

 

Order:        Smt. Neena Sandhu, President

Complainant has filed this complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘OPs’) praying for issuance of following directions to them:-

1. To pay the medi-claim amount of Rs.6.3 lakhs alongwith interest @18% per annum.
2. To pay Rs.5,00,000/- as compensation for the mental agony and physical harassment suffered by him.
3. To pay Rs.55,000/- as litigation charges.
4. To pay miscellaneous expenses of Rs.11,000/-.
   382.  

                   Any other relief which this Hon’ble Forum may deem fit.

 

Brief facts of the case are that the complainant had purchased the Medi-claim insurance policy having No.4129/137051717/00/000 from the OPs for the period from 10.10.2017 to 03.01.2018 under Claim No.IN300020594 UHID 822397812 interaction ID2018032201267. He visited his son at Singapore to reside with him. There he enjoyed very healthy life having no problem. On 21.11.2017, early in the morning, he was having pain in the chest and was taken to Ng Teng Fong General Hospital, Singapore by his son. Intimation in this regard was given to the insurance company through email. After investigation, Poay Huan LOH Heart, Primary Percutaneous transluminal Coronary Angioplasty for ST-Elevation myocardial Infarction surgery was conducted and was discharged on 23.11.2017. A medical bill dated 23.11.2017 of 13720.03 Singapore Dollars approximately Rs.6,30,000/- were paid to the said hospital. The hospital sent his medical bill for payment to the OPs, but they did not paid the same, rather repudiated his genuine claim vide letter dated 24.01.2018. In the letter dated 24.01.2018, it is clearly mentioned that in case the complainant is not satisfied with the resolution, then he may raise objection within 08 weeks, to the OPs. After receiving the letter dated 25.02.2018, he raised the objection on 10.03.2018, but the OPs again taken the same stand. He sent a registered notice dated 07.05.2018 to the OPs as well as the Branch Incharge of Ambala Cantt., but neither any reply nor the payment was ever received from the OPs. By not paying the claim amount, the OPs have committed deficiency in service. Hence, the present complaint.

2.                 Upon notice, OP appeared through counsel and filed written version, raising preliminary objections regarding maintainability and jurisdiction. On merits, it is stated that at the time of taking the policy, the complainant concealed the material facts about the illness, from which, he was suffering for the last many years and on 27.09.2016, he had taken treatment from the Healing Touch Hospital, Ambala City i.e. much prior to taking the policy in question. The policy shall be null and void and no benefit shall be payable in the event of untrue or incorrect statement, misrepresentation, mis-description or on non disclosure. The complainant had not disclosed his past medical history of suffering from hypertension and diabetes. After receiving the information, the OP immediately issued the letter Ref.:IN0300020594 dated 24.01.2018, wherein, it was clearly mentioned that no payment could be made as the complainant has suppressed the material fact about his heath and obtained the policy by way of making the wrong statement and prayer has been made for dismissal of the present complaint.

3.                The ld. counsel for the complainant tendered affidavit of complainant as Annexure CA along with documents as Annexure C-1 to C-12 and closed the evidence on behalf of complainant. On the other hand, learned counsel for OPs tendered affidavit of Shri Nishant Gera, Authorized Officer/Manager Legal, ICICI Lombard General Insurance Company Limited as Annexure RA alongwith documents Annexure R1 to R4 and closed the evidence on behalf of OPs.

4.                We have heard the learned counsel of the parties and carefully gone through the case file and also the written arguments filed by the learned counsel for both the parties.

5.                 The learned counsel for the complainant has argued that the complainant had purchased the policy in question from the OPs for the period from 10.10.2017 to 03.01.2018. The complainant visited his son at Singapore and on 21.11.2017, early in the morning, he was having pain in the chest and was taken to Ng Teng Fong General Hospital, Singapore, where, Poay Huan LOH Herart, Primary Percutaneous transluminal Coronary Angioplasty for ST-Elevation myocardial Infarction surgery was conducted and had paid 13720.03 Singapore Dollar approximately Rs.6,30,000/- vide bill dated 23.11.2017, to the said hospital. He lodged the claim with the OPs, but they by repudiating his genuine claim vide letter dated 24.01.2018, have committed deficiency in service.  

6.                On the contrary, the learned counsel for OPs has argued that the OPs have rightly repudiated the claim, because, at the time of taking the policy, complainant concealed the material fact about his health from the OPs and had violated the terms & conditions of the policy in question, thus no amount is payable under the policy.

7.                From the perusal of questionnaire (Annexure C-9), it is evident that to the question No.7, “Since when you are suffering from Heart Disease. When it was diagnosed first time? Kindly provide the details and documents?”, the complainant had answered that “it was diagnosed/treated on 21.11.2017 only by the Ng Tang Forg General Hospital, Juroong (Singapore)”. The plea of the OPs is that at the time of taking the policy in question, the complainant had concealed the material facts about his health. To corroborate this fact, they have placed reliance on the prescription slips of Healing Touch Hospital, Ambala (Annexure R-1). From the perusal of said prescription slips, it is evident that the complainant was diabetic and hypertensive and was taking medicine for the same. There is no mention that the complainant disclosed any previous history of heart problem. The only fact established by the above referred prescription slips is that the complainant prior to obtaining policy, was having history of diabetes and hypertension. In the case of Satish Chander Madan Vs. M/s Bajaj Allianz General Insurance Co. Ltd. decided on 11.01.2016, the Hon’ble National Commission has held that hypertension is a common ailment and it can be controlled by medication and it is not necessary that person suffering from hypertension would always suffer a heart attack. Treatment for heart problem cannot be termed as a claim in respect of pre existing disease. Claim was wrongly repudiated. The Hon'ble Delhi State Consumer Disputes Redressal Commission, New Delhi in the case of Life Insurance Corporation of India Vs. Sudha Jain 2007(2) CLT 423, has drawn conclusions in para 9 of the order and the relevant clause is 9(iii), which is reproduced as under:-

                   "9(iii) Malaise of hypertension, diabetes occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is full of tension at the place of work, in and out of the house and are controllable on day-to-day basis by standard medication and cannot be used as concealment of pre-existing disease for repudiation of the insurance claim unless an insured in the near proximity of taking of the policy is hospitalized or operated upon for the treatment of these diseases or any other disease." Taking into consideration the facts of the present case and the law laid down by the Hon’ble Superior Fora in the above referred cases, we are of the view that OPs were not justified in repudiating the claim of the complainant and are thus liable to pay the amount which the complainant had incurred on his treatment. From the Tax Invoice dated 23.11.2017 of Jurong Health Services Pvt. Ltd., Singapore (Annexed alongwith the written arguments, which is marked as “A”), it is evident that the complainant had incurred 13720.03 Singapore Dollars on his treatment, therefore, the OPs are liable to pay the medical expenses of 13720.03 Singapore Dollars to the complainant. They are also liable to compensate the complainant for the mental agony and physical harassment suffered by him alongwith litigations expenses.

8.                 In view of the aforesaid discussion, we hereby allow the present complaint and direct the OPs in the following manner:-

1. To pay the claim of 13720.03 Singapore Dollars in Indian rupees by taking the currency value as on 24.01.2018 (i.e. the date of repudiation of claim).
2. To pay Rs.5,000/- as compensation for mental agony and physical           harassment suffered by the complainant.
3. To pay Rs.3,000/- as litigation expenses.

 

                   The OPs are further directed to comply with the aforesaid directions within the period of 30 days from the date of receipt of the certified copy of this order, failing which, the awarded amount shall carry interest @ 9% per annum for the period of default. Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.

Announced on :20.08.2019.

 

 

 

          (Vinod Kumar Sharma)           (Ruby Sharma)               (Neena Sandhu)

              Member                                  Member                       President