Orissa

Cuttak

CC/349/2023

Bibek Sahoo - Complainant(s)

Versus

ICICI Lombard General Insurance Co Ltd - Opp.Party(s)

Ms Dipti Dhal

24 Apr 2024

ORDER

IN THE COURT OF THE DIST. CONSUMER DISPUTES REDRESSAL COMMISSION,CUTTACK.

C.C.No.349/2023

 

Bibek Sahoo,

S/o: Jagu Sahoo,

Chauliaganj Madan Mohan Market,

Main Road Nayabazar,Cuttack,

Near Madan Mohan Market,Cuttack,

                    Orissa-753004.                                                                          ...Complainant.

 

          Vrs.

 

1.        ICICI Lombard GIC,ICICI Bank Tower,

Plot No.12,Financial District,

                  Nanakaramguda,Gachibowli,

                   Hyderabad-500032,Telengana,India.

 

2.        ICICI Lombard Nibhaya Vaade having

Registered office and Branch Office

At Plot No.29, Third Anuj Building,

Satyanagar, Bhubaneswar, Orissa-751007,

Represented through its Branch Manager.                                  … Opp. Parties.

 

Present:         Sri Debasish Nayak,President.

                      Sri Sibananda Mohanty,Member.

 

Date of filing:    13.10.2023

Date of Order:  24.04.2024

 

For the complainant:             Ms. Dipti Dhal,Advocate.

For the O.Ps no.1 & 2:           Mr. R.K.Pattnaik,Adv. & Associates.

 

Sri Debasish Nayak,President                                           

Case of the complainant as made out from the complaint petition in short is that he had availed a Health Insurance for himself and his family members from the O.Ps vide policy no.4193/HAER/253468909/00/000 on 26.7.2022 which was effective from 26.7.2022 to 25.4.2023.  As because the complainant suffered from Dengue fever, he was treated at Maa Sarala Hospital,Nayabazar,Cuttack being admitted on 25.6.2023 and had to incur a sum of Rs.1,61,484/- towards his treatment there.   Being discharged from the said hospital on 2.7.23, he had applied for reimbursement from the O.Ps of the medical expenses as borne by him.   But surprisingly, his claim was repudiated by the O.Ps.  Being aggrieved, the complainant has filed this case before this Commission seeking reimbursement of the expenditure as incurred by him to the tune of Rs.1,61,484/- from the O.Ps together with a sum of Rs.2,00,000/- from them towards compensation for his mental agony and harassment.  He has also prayed for a sum of Rs.1,38,516/- towards the cost of his litigation.

          Together with the complaint petition, the complainant has filed copies of several documents in order to prove his case.

2.       Both the O.Ps have contested this case and have jointly filed their written version wherein they have admitted that the complainant had obtained “Health Advantage Edge” Policy from them bearing Policy number 4193i/HAER/253468909/00/000 which was effective from 26.7.2022 till 25.7.2023 and the sum assured therein was Rs.5,00,000/-.  As per the terms and conditions therein the complainant did not fall within the ambit and scope of the policy since because Misrepresentation of material fact i.e. As per policy wordings, PART III OF THE POLICY General Terms and Conditions, Fraudulent Claims If any Claim is in any respect fraudulent, or if any false statement, or declaration is made or used in support thereof, or if any fraudulent means or devices are used by you or anyone acting on your behalf to obtain any benefit under this Policy.  As we have observed discrepancy in current hospitalization, and therefore the claim stands rejected.  Accordingly, the claim of the complainant was repudiated which was justified and for the said reason, the O.Ps through their written version have urged to dismiss the complaint petition as filed.

          Together with the written version the O.Ps also have annexed copies of several documents in order to support their stand.

          The complainant has filed evidence affidavit also but the contents of the said evidence affidavit when perused is noticed to be a reiteration of the contents of his complaint petition.

3.       Keeping in mind the averments as made in the complaint petition and the contents of the written version of the O.Ps, this Commission thinks it proper to settle the following issues in order to arrive at a definite conclusion here in this case.

i.          Whether the case of the complainant is maintainable?

ii.         Whether there was any deficiency in service on the part of the O.Ps ?

iii.        Whether the complainant is entitled to the reliefs as claimed by him?

Issue no.II.

Out of the three issues, issue no. ii being the pertinent issue is taken up first for consideration here in this case.

After perusing the complaint petition, the written version, written notes of submissions as filed from both the sides, evidence affidavit filed by the complainant as well as the copies of documents available in the case record, it is noticed that admittedly, the complainant had obtained a Health Insurance policy from the O.Ps bearing Policy No. 4193/HAER/253468909/00/000  which was effective from 26.7.2022 to 25.7.2023 and the sum assured therein was of Rs.5,00,000/-.  The O.Ps  have mentioned in their written version that the claim of the complainant when made before them was repudiated since because they had observed discrepancy in his hospitalisation.  In the repudiation letter dated 31.8.2023 as sent by the O.Ps to the complainant, they had mentioned  therein that “As per policy wordings, PART III OF THE POLICY General Terms and Conditions, Fraudulent Claims If any Claim is in any respect fraudulent, or if any false statement, or declaration is made or used in support thereof, or if any fraudulent means or devices are used by you or anyone acting on your behalf to obtain any benefit under this Policy.  As we have observed discrepancy in current hospitalization, and therefore the claim stands rejected”.  But they have not mentioned anywhere nor had they filed any document to apprise this Commission that as to what was the discrepancy noticed by them for which they had repudiated the claim of the complainant.  On careful scrutiny of all the copies of documents as available in the case record, it goes to show that the complainant Bibek Sahu suffered from Dengu fever was admitted as an indoor patient at Maa Sarala Hospital at Nayabazar,Cuttack with effect from 25.6.2023 and was discharged on 2.7.2023.  The complainant has produced copies of all his medical treatment documents alongwith the medical bills as paid by him.  The O.P also do not dispute the hospitalisation of the complainant.  But their sole contention is that there was discrepancy in the hospitalisation of the complainant for which they had repudiated the claim which appears to be without any basis.  Considering the facts and circumstances of the case in hand, when there is no cogent evidence or any iota of proof as regards to the cause of repudiation, such act of the O.Ps here in this case appears to be whimisical,unilateral and arbitrary.  When the O.Ps are unable to justify the reason of repudiation properly, such act clearly indicates deficiency in their service as alleged by the complainant.  Accordingly, this issue goes in favour of the complainant.

Issues no.i & iii.

From the discussions as made above, the case of the complainant is definitely maintainable and he is entitled to the reliefs as claimed by him from the O.P here in this case.  Hence it is so ordered;

ORDER

The case is decreed on contest against the O.Ps who are found to be jointly and severally liable here in this case. The O.Ps are thus  directed to pay the complainant an amount of Rs.1,61,484/- towards his treatment forthwith.  The O.Ps are also directed to pay a sum of Rs.2,00,000/- to the complainant towards compensation for his mental agony and harassment as well as cost of his litigation.  This order is to be carried out within a period of 30 days from the date of receipt of copy of this order.

Order pronounced in the open court on this the 24^th day of April,2024 under the seal and signature of this Commission.         

                                                                                      

                                                                                      Sri Debasish Nayak

                                                                                              President

 

 

                                                                                          Sri Sibananda Mohanty

                                                                                                      Member