Punjab

Ludhiana

CC/18/692

Abha Khanna - Complainant(s)

Versus

ICICI Lombard Gen.Ins.Co.Ltd - Opp.Party(s)

Amarjot Singh adv

13 Jul 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No: 692 dated 14.11.2018.                                                        Date of decision: 13.07.2022.

 

Abha Khanna, aged about 37 years wife of Shri Gaurav Khanna, resident of 58-R, Model Town, Ludhiana.                                                                                                                                                              ..…Complainant

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1. ICICI Lombard General Insurance Company Ltd., having its registered office at ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai-400025, through its Director/Managing Director/Manager.  
2. ICICI Lombard General Insurance Company Ltd., having its Branch Office at TF 1-5, 3^rd Floor, 88, Kunal Tower, The Mall Road, Ludhiana, through its Branch Manager.                                                                                                                                                 …..Opposite parties 

Complaint under Section 12 & 14 of the Consumer Protection Act, 1986.

QUORUM:

SH. K.K. KAREER, PRESIDENT

SH. JASWINDER SINGH, MEMBER

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Amarjyot Singh, Advocate.

For OPs                          :         Sh. Rajeev Abhi, Advocate.

ORDER

PER K.K. KAREER, PRESIDENT

1.                In brief, the case of the complainant is that in the year 2011, she purchased a cashless insurance policy from the OPs on 08.09.2011 which was renewed from time to time and lastly the complainant was holding policy No.4128i/HP/107083197/02/000 which was valid from 21.09.2017 to 20.09.2019. The policy covered the complainant, her husband and minor children. A premium of Rs.25,397/- was paid at the time of renewal of the said policy.

2.                It is further alleged that on 06.08.2018, the complainant was admitted in Dayanand Medical College and Hospital, Ludhiana  due to pain in the chest. The complainant applied for the cashless treatment but the OPs rejected the same vide email dated 06.08.2018 on false and frivolous grounds and on the ground that the complainant was a known case of diabetes for the last 8 years which was prior to inception of the policy. In fact, the complainant was not suffering from diabetes from last 8 years. Rather the complainant suffered  from diabetes only for the last 8 months and has also been provided a medical certificate by the family physician of the complainant. The complainant requested the OPs for the review of the cashless claim but to no avail. As a result, the complainant had to incur expenses of Rs.27,381.91 on her hospitalization from 06.08.2018 to 08.08.2018.  

3.                It is further alleged that on 11.08.2018, the complainant was admitted in Medanta The Medicity  Global Health Pvt. Ltd. Hospital, Ludhiana. The complainant again lodged cashless claim with the OPs which was rejected on the same ground. The complainant was discharged on 13.08.2018. Due to rejection of the cashless claim, the complainant had to pay the treatment expenses of Rs.2,87,507.31.

4.                To add an insult to the injury, the OPs sent letter dated 29.08.2018 and canceled the policy on false and frivolous grounds though they have been accepting the insurance premium continuously for 7 years. The complainant was never a patient of diabetes prior to inception of the policy. The OPs did not consider the certificate dated 06.08.2018 issued by the family physician i.e. Dr. Ashwani Sharma and also the letter sent by DMC Hospital, Ludhiana to the OPs whereas also it was clearly mentioned that the complainant was suffering from diabetes only for the last 8 months. The complainant was admitted in DMC Hospital, Ludhiana on 06.08.2018 and the period of diabetes was mentioned by mistake as 8 years instead of 8 months. However, the OPs did not consider all these facts and cancelled/terminated the policy on the ground of non-disclosure of material facts. In fact, the complainant never concealed any facts while taking the policy.

5.                It is further alleged that the complainant is under regular follow up treatment of Medanta The Medicity Hospital and has incurred expenses of Rs.8,707/- on her follow-up treatment. The rejection of the claim and cancellation of the policy amounts to deficiency of service on the part of the OPs. In the end, it has been requested that the OPs be directed to pay the afore mentioned claims amounting to Rs.3,23,596.22 along with interest @ 18% per annum along with compensation of Rs.2,00,000/- and costs of Rs.11,000/-. It has further been requested that the OPs be further directed to restore the policy on the same terms and conditions.  

6.                The complaint has been resisted by the OPs. In the written statement filed on behalf of the OPs it has been, inter alia, pleaded that the complaint is not maintainable. According to the OPs, as per part III of schedule 1 of the policy, no benefits are payable in the event of untrue or incorrect statement, misrepresentation, mis-description or non-disclosure of any material particular is found in the proposal form, personal statement, declaration and connected documents. The OPs have further pleaded that Hero DMC Heart Institute had lodged  pre-authorization request with provisional diagnose DM, HTN, CAD, ACS, trop (+ve). On receipt of the pre-authorization request, additional information request form was sent on 06.08.2018 calling upon the hospital to supply the information as to when the patient was diagnosed for the first time of diabetes, heart disease in terms of month and year. The hospital was further requested to provide first consultation with all past treatment papers including investigation reports. Hero DMC Heart Institute sent reply to the request form dated 06.08.2018 vide their letter dated 06.08.2018 itself clearly stating that the patient had a history of diabetes for 8 years and CAD was diagnosed on 02.08.2018. After the receipt of the information, cashless authorization request was declined on the ground that the patient was a known case of diabetes for 8 years i.e. prior to the policy inception but this fact was not disclosed at the time of taking the policy. The OPs have further pleaded that termination notice of the policy vide letter dated 29.08.2018 was also issued.

7.                As regards the pre-authorization request for admission at Medanta The Medicity City-Global Health Pvt. Ltd. dated 11.08.2018, the same was also rejected on the ground that the complainant had history of diabetes for the last 8 years as per the documents of Hero DMC Heart Institute, Ludhiana. Thus, there has been no deficiency of service on the part of the OPs. It has also been denied if the OPs were liable to pay the claims of Rs.27,381.91 and Rs.2,87,507.31 in respect of hospitalization of the complainant at DMC, Ludhiana and Medanta, The Medicity. The other allegations made in the complaint have been denied as wrong and a prayer for dismissal of the complaint has also been made.

8.                In evidence, the complainant submitted her affidavit as Ex. CA along with documents Ex. C1 to Ex. C21 and closed the evidence.

9.                On the other hand, learned counsel for the OPs tendered affidavit Ex. RA of Sh. Aditya Sharma, Manager Legal along with document Ex. R1 to Ex. R19 and closed the evidence.

10.              We have heard the learned counsel for the parties and have also gone through records.

11.              During the course of arguments, the counsel for the OPs has argued that the complaint is without any merits. He has further contended that only pre-authorization requests have been declined while the complainant has not submitted regular claims in respect of her hospitalization with DMC Hospital, Ludhiana and Medanta, The Medicity Hospital. The counsel for the OPs has further contended that notice of cancellation of the policy has been rightly issued taking into consideration the terms and condition part III of policy document Ex. R1 which clearly provides that the policy shall be null and void and no benefit shall be payable in the event of untrue or incorrect statements, misrepresentation, mis-description or on non-disclosure in any material particular in the proposal form etc. In this regard, the counsel for the OPs has further contended that the complainant was a known case of diabetes mellitus prior to the inception of the policy as is evident from the document Ex. R9 of DMC Hospital, Ludhiana and, therefore, cashless claim has been rightly rejected. The counsel for the OPs has further pointed out that cashless claim received from Medanta The Medicity Hospital was also rejected on the same grounds the counsel for the OPs has further pointed out that the complainant has procured false certificate from the family doctor and on the basis of that certificate, they have got a certificate from DMC Hospital which is Ex. R18 and in the certificate Ex. R18 also, it is mentioned that the history of diabetes of the patient was recorded as 8 year at the time of her admission but as per the statement and certificate issued by the family physician of the complainant, actual history is 8 months for diabetes mellitus. In this regard, the counsel for the Ops has further pointed out that the certificate Ex. R18 is meaningless as the hospital authorities have not affirmed on its own that the patient had history of diabetes for only 8 months and the certificate Ex. R18 has been issued on the basis of the certificate issued by the family physician of the complainant. In support of his arguments, the counsel for the OPs has relied upon I (2019) CPJ 295 (NC) in Tarun Beriwal and another Vs Oriental Insurance Company Limited and another whereby it has been held by the Hon’ble National Consumer Disputes Redressal Commission, New Delhi if the insured failed to disclose that he was suffering from hypertension and diabetes for the last 4/5 years, the repudiation of the claim was justified. The counsel for the OPs has further relied upon 2003 CPJ 91 (NC) in LIC of India Vs Smt. Shashi Bala whereby it has been held by the Hon’ble National Consumer Disputes Redressal Commission, New Delhi that nexus between diabetes mellitus and heart attack well established and, therefore, the repudiation of the claim was justified. The counsel for the OPs has further relied upon I (2017) CPJ 256 (NC) in LIC of India Vs Jyothi Sudhir whereby it has been held by the Hon’ble National Consumer Disputes Redressal Commission, New Delhi that had the assured disclosed that he was suffering from hypertension and diabetes mellitus, the corporation would have asked for special medical reports which would have been placed before a medical reference and based upon the medical report.  It was further held that false and inaccurate statement by the assured was on material aspect which influenced the decision of the insurer and, therefore, the repudiation of the claim was justified. The counsel for the OPs has further relied upon II (2012) CPJ 191 (NC) in United India Insurance Co. Ltd. Vs Kanta Gupta whereby it has been held by the Hon’ble National Consumer Disputes Redressal Commission, New Delhi that the diabetes mellitus from which the insured was suffering from and was treating for at the hospital was a complication of long standing diabetes mellitus and the chronic renal failure was also the result of the same long standing disease and, therefore, he insurance company could not held guilty of rejection of the claim.

12.              We have thoughtfully considered the above contentions raised by the counsel for the counsel for the OPs.

13.              Primarily, in this case, only the pre-authorization request for cashless treatment of the complainant at Dayanand Medical College and Hospital, Ludhiana from 06.08.2018 to 08.08.2018 and at Medanta The Medicity Global Health Pvt. Ltd. Hospital from 11.08.2018 to 13.08.2018 have been declined on the ground that the complainant was suffering from and was a known case of diabetes mellitus for the last 8 years i.e. prior to the inception of the policy in the year 2011 and this fact was  not disclosed in the proposal form at the time of taking the policy in the year 2011. However, the OPs have relied upon a document Ex. R4 of Dayanand Medical College and Hospital wherein it is stated that the patient had a history of diabetes mellitus for 8 years and CAD (Chronic Artery Disease) was diagnosed on 02.08.2018. In this regard, the complainant has relied upon medical certificate Ex. C6 issued by her family physician Dr. Ashwani Sharma  wherein it is stated that the complainant has been suffering from diabetes mellitus for the last 8 month. The OPs themselves have placed on record certificate Ex. R18 issued by DMC and Hospital, Ludhiana which is also based upon the certificate issued by the family physician of the complainant. The policy was admittedly obtained in the year 2011. Apart from a mere observation in Ex. R4, no other tangible evidence has come on record which could conclusively show that the complainant was suffering from diabetes mellitus since prior to the inception of the policy in the year 2011. Therefore, merely on the basis of an observation in Ex. R4 which has later on had been altered by the hospital authorities in the certificate ex. R18, the OPs should not have repudiated the pre-authorization request. 

14.              The complainant on her part has not chosen to file the regular claims for reimbursement of expenses incurred for her hospitalization with DMC and Hospital, Ludhiana from 06.08.2018 to 08.08.2018 and for Medanta, The Medicity Hospital from 11.08.2018 to 13.08.2018. The rejection of pre-authorization request is not final as candidly admitted by the counsel for the OPs at the time of arguments. In the given facts and circumstances of the present case, in our considered view, it would be just and proper if the complainant is directed to submit the claims in respect of her hospitalization with DMC and Hospital, Ludhiana from 06.08.2018 to 08.08.2018 and for Medanta, The Medicity Hospital from 11.08.2018 to 13.08.2018 within a period of 30 days from the date of receipt of copy of this order following which the OPs shall consider and reimburse the same strictly in accordance with terms and conditions of the policy within a further period of 30 days. The cancelation of the policy is also not justified on the part of the OPs.

15.              As a result of above discussion, the complaint is disposed of with direction to the complainant to  partly allowed with direction to submit the claims in respect of her hospitalization with DMC and Hospital, Ludhiana from 06.08.2018 to 08.08.2018 and for Medanta, The Medicity Hospital from 11.08.2018 to 13.08.2018 within a period of 30 days from the date of receipt of copy of this order following which the OPs shall consider and reimburse the same strictly in accordance with terms and conditions of the policy within a further period of 30 days. Keeping in view the peculiar circumstances, there shall be no order as to costs. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

16.              Due to rush of work and spread of COVID-19, the case could not be decided within statutory period.

                             (Jaswinder Singh)                            (K.K. Kareer)

                    Member                                           President

Announced in Open Commission.

Dated:13.07.2022.

Gobind Ram.

Abha Khanna Vs ICICI Lombard GIC                           CC/18/692

Present:       Sh. Amarjyot Singh, Advocate for complainant.

                   Sh. Rajeev Abhi, Advocate for OPs.

 

                   Arguments heard. Vide separate detailed order of today, the complaint is disposed of with direction to the complainant to  partly allowed with direction to submit the claims in respect of her hospitalization with DMC and Hospital, Ludhiana from 06.08.2018 to 08.08.2018 and for Medanta, The Medicity Hospital from 11.08.2018 to 13.08.2018 within a period of 30 days from the date of receipt of copy of this order following which the OPs shall consider and reimburse the same strictly in accordance with terms and conditions of the policy within a further period of 30 days. Keeping in view the peculiar circumstances, there shall be no order as to costs. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

 

 

                             (Jaswinder Singh)                            (K.K. Kareer)

                    Member                                           President

 

Announced in Open Commission.

Dated:13.07.2022.

Gobind Ram.