DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II

Udyog Sadan, C-22 & 23, Qutub Institutional Area

(Behind Qutub Hotel), New Delhi- 110016

Case No.106/16

Ms. Sonia Varma

Wife of Shri Pradeep Varma

37, Golf Links, New Delhi-110003.                               …Complainant

                                                               VERSUS         

ICICI Lombard General Insurance

Company Ltd.  

ICICI Lombard Health Care

ICICI Lombard House

414, Veer Savarkar Marg

Near Siddhi Vinayak Temple

Prabhadevi

Mumbai-400025.

Through The Chief – Underwriting & Claims

And its Delhi office at :

ICICI Towers, NBCC Place

Pragati Vihar, Bhisham Pitamah Marg

New Delhi-110003.                                                      ….Opposite Party

Coram:

Ms. Monika A Srivastava, President

Ms. Kiran Kaushal, Member

Sh. U.K. Tyagi, Member

ORDER

     Date of Institution  :  08.04.2016

                                          Date of Order         :  31.08.2022

Member: Shri U.K.Tyagi

          Complainant has prayed for directing ICICI Lombard General Insurance Company Ltd. (hereinafter referred to as OP) (i) to pay an amount of Rs.90,200/- towards reimbursement of medical expenses incurred by her under Insurance Policy effective during the period 22.12.2014 to 21.12.2015 along with interest @18% per annum from 10.7.2015 till the date of payment; (ii) to pay an amount of Rs. 1 Lac as compensation towards mental agony etc. along with interest @ 18% per annum as per above period in (i) ; (iii)to pay an amount of Rs.1 lac towards litigation cost etc.

          Brief facts of the case are as under:-

The complainant purchased ICICI Lombard General Complete Health Insurance Policy from OP for being customers of American Express Banking Corp.  The policy covered reimbursement of admissible medical expenses upto specified sum insured, hospitalisation expenses of at least 24 hours or more; related to medical expenses incurred 30 days prior to hospitalisation ; medical expenses incurred within 60 days from the date of discharge etc. and pre-existing diseases covered after 2 years.  In 2010, the complainant got herself admitted in Manipal Hospital after having medical tests.  Tumour was surgically removed on 12.4.2010.  On technical grounds, the complainant could not get this reimbursement. 

          In 2015, the complainant missed her menstrual cycles.  On the advice of doctor, she was admitted in hospital i.e. Fortis La Femme Centre for Women Hospital GK.II, New Delhi.  The complainant was operated upon for the removal of fiberoid with Endometrial Polyp.  In the course of treatment, the complainant had incurred expenses of Rs.90,200/-.  She put in this claim with OP on 28.5.2015 for reimbursement.  The lodging of the claim was duly acknowledged by OP.  The OP vide its letter dated 15.10.2015 unlawfully repudiated the claim in accordance with clause 1.13 of part III of Schedule I to the Policy and further on the premise of non-disclosure of material fact in the Proposal Form.

          The complainant maintains that Angiomyolipoma is not a disease but a common benign tumour of kidney and it can not be termed as Pre-existing disease as the said growth was removed 5 years ago surgically.  Pre-existing condition/Disease has been defined in sub-clause 10.28 part II of Terms & Conditions of the policy as meaning thereby – “any condition, ailment, injury or illness for which the insured had developed signs/symptoms were diagnosed/received medical advice/ treatment, 48 months prior to covered period start date”. Be it noted that the complainant underwent surgical operation in 2010 and entered into contract of Mediclaim Insurance on 22.12.2014.  As such, the repudiation is arbitrary and malafide.  The denial of medical expense tantamount to an unfair trade practice, breach of trust & breach of the principle of uberrima fide and deficiency in service on the part of OP.

          OP, on the other hand, while filing its reply, inter-alia took some preliminary objections.  The OP also stated that the complainant had also taken its policy for the period 17.12.2012 to 16.12.2013.  The same was renewed for the currency period 17.12.2013 to 16.12.2014.  The Policy in question was for the period mentioned above.  As such, the subject policy is a renewed policy and fraud has been played upon the OP by not disclosing these facts.  It was also averred by OP that medical record of 19.4.2010, reveals that the complainant was known case of the Hypothyroidism and is on regular medication since last 16 years.  As per medical science, the Hypothyroidism also causes menstrual cycle abnormalities.  The copies of Medical records dated 19.04.2010  and 07.10.2015 are annexed as annexure R-4&5.

          Both the parties have filed written submissions and evidence in-affidavit.  Written statement is on record so is rejoinder. Oral arguments were heard & concluded.

          This Commission has gone into entire material placed on record and due consideration was also given to the oral arguments.  The complainant also placed reliance on the judgement of Hon’ble National Commission the case i.e. the New Indian Assurance Co. Ltd. Vs. Smt. V. Vimla FA No.646/2006 “when there is doubt about the pre-existing disease, the benefit of doubt should be given to the policy holder, favouring the claim”.  The complainant further exhorted that she was operated upon in 2010 whereas the terms & conditions of the above said Policy states that pre-existing disease means disease which is diagnosed 48 months prior to the cover period start-date. However, the angiomyolipoma had been surgically removed i.e. more than 56 months before the instant contract of Insurance was entered.

Attention of the Commission was also drawn to the medical record of the complainant for the year 19.04.2010, where it is shown that the complainant is a known case of Hypothyroidism and is on regular medication since last 16 years. OP also further laid emphasis that as per medical science, the Hypothyroidism also causes the menstrual cycle abnormalities and complainant was diagnosed for the same problem. The OP has tried to prove this fact that the material fact has been concealed by the complainant while entering into contract of Insurance.  The OP also revealed that the instant policy is a renewed one and being renewed since 2012.  The complainant had never tried to expose this fact of medical condition in the Proposal Form.  The OP has relied upon catena of judgment where material facts from the contract of Insurance have been withheld and the insurance companies have repudiated the claims. Hon’ble Courts have held the repudiations.  The OP also referred the case of Satwant Kaur Sandhu Vs. New India Assurance Company Ltd. where Hon’ble Apex Court held that “There was clear suppression of material facts in regard to the health of the insured and therefore the respondent insurer was fully justified in repudiating the insurance contract”.  Also in the case of Bimla Devi Vs. Life Insurance Corp. of India the Hon’ble National Commission in RP No.3806 of 2009 held the repudiation justified as the medical facts in regard to medical condition of the complainant were not brought on record of the insurance contract.

          In nutshell, keeping in view the facts and circumstances   of the instant case, this Commission respectfully following the above judgment, feels that the complainant could not prove its case whereas OP has been able to rebut the claim of complainant with the help of catena of judgments.  Accordingly we reject the claim of complainant and complaint fails.

          No order as to cost.

File be consigned to the record room after giving copy of the order to the parties as per rules.