DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi-110016.
Case No.524/2009
Sh. Tarun Aggarwal
S/o Sh. M. K. Aggarwal
R/o 1515 Green Filed Colony,
Near NHPC Chowk, Surj Kund Road,
Faridabad, Haryana-121003 ….Complainant
Versus
ICICI Lombard General Insurance Co. Ltd.
K-18, Lajpat Nagar-II,
New Delhi-110024
Also at:
ICICI Bank Towers
Bandra-Kurla Complex,
Mumbai-400051 ……Opposite Party
Date of Institution : 02.07.09 Date of Order : 15.03.16
Coram:
Sh. N.K. Goel, President
Ms. Naina Bakshi, Member
O R D E R
Briefly stated, the case of the Complainant is that he obtained family medical insurance policy for himself, his wife Smt. Srishti Aggarwal and his son Sh. Bharat Aggarwal by paying a premium of Rs.15,000/- to the OP on 15.02.08. The OP accepted the proposal form and issued the policy in the joint name of the Complainant and his wife and also issued two Health Cards vide acceptance letter dated 20.03.08. The policy No.4063/HAP/03468019/ 00/000 was issued for a sum of Rs.3 lacs for the period from 20.03.08 to midnight of 19.03.2009. The Complainant did not receive Health Card for his son, namely, Bharat Aggarwal. Accordingly, he lodged a complaint with the OP on 26.06.2008 for non inclusion of his son in the policy but the Complainant did not receive any reply from the OP. Subsequently, the Complainant submitted mediclaim claim for Rs.34,759/- on medical treatment and raised the bill for the same. The details of the bills, documents and amount incurred by the Complainant is annexure J (Colly). The Complainant was informed by the OP that the claim was processed only for Rs.5000/- which was resisted by the Complainant. However, according to the Complainant, he received a cheque of Rs.7,500/- dated 14.05.09 with the remarks “Encashment of cheque discharges the liability of insurer under the said claim” and hence the complainant did not present the cheque for encashment. The Complainant further states that he renewed the policy on 07.03.2009 while making the payment of Rs.15,000/- by a cheque for the period 20.03.2009 to 19.03.2010. However, the policy was renewed for the period from 27.03.2009 to 26.03.2010. He immediately lodged complaints on 02.04.09 & 23.04.09 about taking the premium in advance and issuing the policy for a later date. Accordingly, he asked the OP to refund the whole amount paid as renewal premium but the OP sent a cheque of Rs.11,250/- dated 04.05.09 to the Complainant without explaining deductions made by the OP from Rs.15,000/-. Pleading deficiency in service on the part of the OP, the Complainant has filed the present complaint with the following prayers:-
- Direct the OP to pay the mediclaim to the tune of Rs.34,759/- alongwith interest to the Complainant.
- Direct the OP to refund the renewal premium of Rs.15,000/- alongwith interest to the Complainant.
- Direct the OP to pay Rs.10,000/- as compensation for harassment and mental agony suffered by the Complainant.
- Direct the OP to pay Rs.5,500/- as litigation charges.
Resisting the complaint, OP in the written statement has taken a plea that “encashment of cheque discharges liability of insurer under the said claim”. Therefore the OP stands discharged under the contract of insurance. OP has further stated that there has not been hospitalization event. Basic hospitalization is covered under benefit A whereas benefit B covers OPD expenses; that the table given in HAP policy clearly mentions that the person with a sum assured of Rs.3 lacs under benefit A would be entitled to benefit B (OPD expenses) corresponding to the age band in which he/she falls into. Since the case of the Complainant falls in the age band of 19-35 years, OPD expenses came out to be Rs.7500/- which is clearly mentioned in Part I of the schedule (copy Annexure-A). It is stated that the complainant has already been paid Rs. 7500/- which the complainant has acknowledged and received. As regards the complaint regarding refund of Rs.11,250/- out of Rs.15,000/- towards renewal policy, the OP has stated that the Complainant has admitted payment of Rs.11,250/- which was paid by applying the refund grid and refunded the amount of Rs.11,250/- to the Complainant. Accordingly, OP has prayed for dismissal of the complaint.
Complainant has filed rejoinder to the written statement of OP by reiterating the averments made in the complaint. It is stated that the OP is liable to pay the medical expenses, whether the person is hospitalized or not.
Complainant has filed his own affidavit in evidence. He has relied upon the documents which have not been marked exhibit numbers as per the exhibit numbers given to them in the affidavit of complainant.
On the other hand, affidavit of Sh. Ms. Pooja Sharma, Manager Legal has been filed in evidence on behalf of the OP. Reliance has been placed on Exhibit A and some judgments but exhibit number is not marked on the document nor copies of judgments filed.
Written arguments have been filed by the Complainant.
We have heard the arguments on behalf of the parties and have also gone through the file very carefully.
We straightaway come to the question, whether the complaint is maintainable and what relief is admissible to the Complainant?
As regard the claim of the Complainant for Rs.34,759/- we have perused the Annexure-A (marked for the purpose of identification) of the policy wherein it is clearly mentioned that for OPD a person in the age of 19-35 years under benefit B is entitled for Rs.7,500/-. It is the wife of the complainant (aged about 30/34 years) who fell sick. We have perused the Annexure J (Colly) (marked for the purpose of identification) and we find that the claims submitted by the Complainant are pertaining to outpatient treatment only. Therefore, he has been correctly paid a sum of Rs.7500/- vide cheque. It is pertinent to point that the Complainant has not adduced any evidence to show that this cheque was not received by him.
The complaint regarding refund of premium of Rs.15,000/- with interest for the renewal of the premium amount is exaggerated as OP has already paid Rs.11,250/- towards refund. However, the OP has not given the break up of difference amount of Rs.15,000/- minus Rs.11,250/-.
Hence, the OP is to be blamed for deficiency of service to the extent of withholding amount of Rs.3750/- (Rs.15000 – Rs. 11,250/-) without giving any cogent reason for such unilateral action.
We, therefore, partly allow the complaint and direct the OP to pay Rs.3,750/- in lieu of balance amount without giving any cogent reason for withholding this amount with simple interest of 5% per annum from 04.05.2009 i.e. the date of payment of Rs.11,250/- till the date of payment.
The order shall be complied within 30 days of receipt of copy of this order failing which OP shall become liable to pay interest @ 8% per annum from the date of filing of the complaint till its realization.
Let a copy of this order be sent to the parties as per regulation 21 of the Consumer Protection Regulations. Thereafter file be consigned to record room.
Announced on 15.03.16.
(NAINA BAKSHI) (N.K. GOEL) MEMBER PRESIDENT
Case No. 524/09
15.3.2016
Present – None.
Vide our separate order of even date pronounced, the complaint is allowed. OP is directed to pay Rs.3,750/- in lieu of balance amount without giving any cogent reason for withholding this amount with simple interest of 5% per annum from 04.05.2009 i.e. the date of payment of Rs.11,250/- till the date of payment. The order shall be complied within 30 days of receipt of copy of this order failing which OP shall become liable to pay interest @ 8% per annum from the date of filing of the complaint till its realization. Let the file be consigned to record room.
(NAINA BAKSHI) (N.K. GOEL) MEMBER PRESIDENT
