DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION CAMP COURT AT LUDHIANA

                                          RBT/Consumer Complaint No.23 of 2018

                                              Date of institution: 09.01.2018

                                              Date of Decision:07.04.2022

Saroj Rani widow of Sh. Ashok Mago, resident of House No.1539, Sector 39, Urban Estate, Chandigarh Road, Ludhiana, Punjab  

….Complainant

Versus

1. ICICI Lombard General Insurance Company Limited, TF-1-5, 3^rd Floor, Kunal Tower, 88, The Mall Road, Ludhiana, Punjab 141001 through its authorized signatory/MD/Authorized Representative/General Manager
2. ICICI Lombard General Insurance Company Limited, Mailing Address 401 and 402, 4^th Floor, Interface 11, New Linking Road, Malad (West) Mumbai 400064 through its authorized signatory/MD/authorized representative/General Manager
3. ICICI Lombard General Insurance Company Limited, registered office at ICICI Lombard House, 141, Veer Savarkar Marg, Near Sidhu Vinayak Temple, Prabhadevi Mumbai, through authorized signatory/MD/authorized representative/General Manager
4. Max Health Care Super specialty Hospital, Near Civil Hospital, Phase 6, Mohali Punjab 160055, through authorized signatory/MD/authorized representative/General Manager
5.  Max Health Care, registered office, Max House , 1, Dr. Jha Marg, Okhla, New Delhi 110 020, through its authorized signatory/MD/Authorized representative/General Manager.                                                       ……..Opposite Parties

Complaint under Consumer Protection Act.

Quorum:   Shri Ranjit Singh, President.

                       Mrs. Ranvir Kaur, Member

Present:    Sh.Sandeep Sethi, Advocate, for complainant  

Sh. Rajeev Abhi, Advocate, for OPs No.1 to 3

Sh.G.S.Saini, Advocate, for Ops No.4 & 5

Order dictated by Sh. Ranjit Singh, President & Smt. Ranvir Kaur, Member              
 

 Order

The present order of ours will dispose of the above complaint filed under Consumer Protection Act, received by way of transfer from District Consumer Disputes Redressal Commission, Ludhiana, by the complainant against the Opposite Parties On the ground that in the month of February 2017, the complainant was having pain in both knees and difficulty in walking from last 5/6 months and after consulting with senior doctors and taking opinion of Senior Doctor suggested him for both knees replacement b

iltaterial advanced osteoarthritis knee and after conducting all the tests, complainant was got admitted on 3.3.2017 at Max Super Specialty Hospital, Mohali, i.e. with OP No.4 and got discharged on 09.03.2017. The complete record of complainant was also submitted with OPs No.1 to 3. The complainant, who was holding policy with OP since 2013 and after admitting with the hospital, complainant had also be given Pre Authorization Request No.110100307827 for admission at Max Super Specialty Hospital, Mohali. It is further averred that complainant had also disclosed about her complete medical health but the nursing staff mistakenly mentioned case of complainant as hypertension since last 8 years and diabetes, mellitus sine 8 years and hypothyroidism since 4 years. The above information was never given by the complainant regarding hypertension rather it was mentioned wrongly by the staff of the Max Super Specialty Hospital, Mohali. The complainant got replace her knee after taking approvals from OPs No.1 to 3 and the time of discharge the official of opposite parties refused to clear the bills on the pretext of giving some false reasons. The complainant and her relative also informed them that the complainant was not suffering from hypertension from last 8 years rather the officials of the Max Hospital also issued one certificate addressing that history of 8 years is mentioned in error rather the complainant Saroj Rani aged about 58 years is c/o DM Type II and hypertension since 3 months and history of 8 years mentioned in error. Even after issuance of certificate and by repeated requested by the complainant and her family members and relatives opposite party had rejected cashless claim of complainant and under compulsion circumstances complainant was forced to pay huge amount of Rs.5,06,800/- through RTGS transfer. The complainant also requested them through various written applications to reconsider the case and policy after furnishing certificate from senior doctors of Max Hospital who admitted their mistake that it was clerical mistake and complainant also several times officials of their local office. But the officials did not listen to the genuine request of complainant. Complainant had also send them various emails but again they had not clear the dues of complainant. Even complainant had submitted every document and had completed all the formalities as asked by them by time to time. It is further averred that the staff members and senior doctors are also equally liable for the mistake done by them while sending and making false reports, mentioning 8 years hypertension of complainant whereas complainant and her relatives never given such any information to the staff members and to the doctors of Ops No.4 & 5. Vide instant complaint, the complainant has sought the following reliefs:-

1. To pay Rs.5,06,800/- i.e. claim lodged by the complainant against claim No.220100391772 claim of Saroj Rani UHID 101245181, policy No.41281/HPR84352301/03/000 coverage period 25.11.2016 to 24.11.2017 date of admission 2.3.2017
2. To pay follow up treatment expenses for Rs.60,000/- (Including medicines) 
3. To pay Rs.1,00,000/- for mental harassment, mental pain and agony faced by the complainant and trauma
4. To pay Rs.50,000/- as litigation expenses

2.     In reply, the OPs No.1 to 3 has taken various objections on the ground of maintainability and jurisdiction also. On merits, it is stated that since immediately on the receipt of the claim it was duly registered and entertained. The complainant has obtained the insurance policy from OPs No.1 to 3. The insurance policy is contract in itself and the parties are bound by the terms and conditions of the policy. Nothing can be added or subtracted out of it as per the law laid down by the Apex Court. It is further stated that M/s Max Super Specialty Hospital has lodged pre authorization request with answering OPs. Immediately on the receipt of pre authorization request additional information request was sent vide letter dated 1.3.2017 calling upon the said hospital to supply/furnish past medical history of asthma HTN, DM, CAD, Stroke, Cancer, arthritis, HIV, Alcohol/drug abuse and any other ailmement since how long the patient was having these ailments and furnish the details of treatment taken till date. The cashless authorization was declined vide declaration of cashless access dated 14.3.2017 on the ground of pre existing disease which is based on the documents submitted in support of the claim which clearly proves that the complainant was suffering with HTN and DM prior to the policy commencement and the complainant has not disclosed the same at the time of policy commencement and as such the claim stands rejected due to nondisclosure in terms and policy terms part III clause 1 of the policy schedule. The complainant had lodged the claim  with the OPs. After the receipt of all the documents which were material and required for processing of the claim and after due application of mind by the officials of the OP in terms of the insurance policy the claim of the complainant was repudiated as no claim as per part III clause I of the policy terms and conditions under the Head “Standard Exclusions i.e. incontestability and Duty of Disclosure which clearly states that “the policy shall be null and void and no benefit shall be payable in the event of untrue and incorrect statement, misrepresentation, mis description or on non disclosure in any material particular in the proposal form, personal statement, declaration and connected documents, or any material information having been withheld, or a claim being fraudulent or any fraudulent means or devices being used by you or any one acting on your behalf to obtain any benefit under this policy. Rest of the allegations leveled by the complainant has denied by the answering OPs. 

3.     In reply, the OPs No.4 & 5 has taking various preliminary objections that the complainant is having no locus standi to file the present complaint; that the present complaint is false, frivolous, vague and vexatious;; that the complainant has filed the present complaint just to harass the answering OPs. On merits, it is stated that OP4 has wrongly mentioned as Max Healthcare Super specialty Hospital by the complainant out of his sheer ignorance. OP4 is Max Super specialty Hospital and not max Healthcare Super specialty Hospital. The present complaint has been filed by the complainant against the answering OPs without any reason and probable cause. There is no deficiency on the part of the answering OPs. Moreover, the complainant was admitted in the hospital of the OPs No.4 & 5 on 2.3.2017 and was discharged in stable condition on 10.3.2017 for TKR and the complainant was issued with the bill dated 10.3.2017 amounting to Rs.5,06,800/-. The OP4 has processed for the cashless claim of the complainant along with all the required documents to the insurance company on 4.3.2017 but the claim has been rejected by the insurance company on the ground of non entitlement of the complainant. After verifying the records, it was found that there was some typographical mistake in the documents of OP4 and OP4 immediately amended the said documents and processed for the claim of the complainant for cashless treatment, but despite repeated follow up by the OP4, no response has been received from the insurance company. Rest of the allegations have been made by the complainant has denied and prayed for dismissal of the present complaint.  

4.     In support of his evidence, the learned counsel for the complainant has tendered certain documents. On the other hand, the learned counsel for the OPs No.1 to 5 have also tendered documents in the shape of evidence.

5.     We have heard the learned counsel for the parties and have gone through the record of the file, carefully and minutely. 

6.     Briefly the claim of the complainant is that she has been continuously paying the premium without any failure since the insurance agreement in the year 2017. She suffered with knee failure of both the legs and incurred an expenditure of Rs.5,06,800/-. In her complaint, she has claimed Rs.7,21,800/- including compensation, medicine expenses and litigation expenses.

7.     On the other hand, the OPs has tried to rebut the claim of the complainant on the basis of that in her statement, earlier to the insurance she had concealed the factum of being a patient of hypertension for last 8 years that is much prior to the date of contract of insurance. 

8.     Perusal of the pleadings the evidence and the submission of the argument of both the parties, has revealed that the allegation by the OP regarding the complainant being patient of hypertension was just a bonafide mistake of the Max Super specialty Hospital, Mohali, which stands duly rectified on the record.         

9.     It is not out of relevance to discuss here that just for the sake of arguments of equity and natural justice the insurance company should have subjected the insurance holder to the Medical Test of hypertension of any before executing the insurance agreement and incase of the result coming positive should not have executed the insurance agreement. There does not appear any logic in the rejection of the claim on the basis of any test/statement after the application of the claim when the complainant has regularly paid all the premiums and has already put her claim in the pipeline. 

10.   It is pertinent to mention here that the discussion made above said para is just for the sake of arguments because here showing the victim a patient of hypertension was just a bonafide mistake in fact it being of three months instead of eight years and further the same having been duly rectified under the due process of law. 

11.   In the light of aforesaid facts/ discussion the complainant has succeeded to prove her claim while the arguments of the OP do not behold. Conclusively the case of the complainant succeeds and she is entitled to amount of Rs.5,66,800/-. She is also entitled Rs.20,000/- as compensation and Rs.10000/- as litigation expenses.  

12.   In view of the discussion made above, present complaint is allowed against opposite parties and directed to pay Rs.5,66,800/- to the complainant  alongwith Rs.20,000/- for harassment and Rs.10,000/- as litigation expenses. This order is directed to be complied with within a period of thirty days from the date of receipt of copy of this order. Free certified copies of this order be sent to the parties, as per rules. The files be consigned to record room.

Announced

April 07, 2022

                                                                                                           (Ranjit Singh)

                                                 President

                                      (Ranvir Kaur)