Delhi

North East

RBT/CC/154/2022

MOHIT TYAGI - Complainant(s)

Versus

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

06 May 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

                                             RBT/Complaint Case No. 154/22

 

 

 

In the matter of:

 

		Sh. Mohit Tyagi S/o Sh. B.K Tyagi R/o U 160, Upadhyay Block, Shakarpur, Delhi-110092		Complainant
		Versus
		ICICI Lombard General Insurance Co. Ltd. 414, P. Balumarg, Off Veer Sawarkar Marg, Near Siddhivinayak Temple, Prabhadevi, Mumbai-400025		Opposite Party
			DATE OF INSTITUTION:         JUDGMENT RESERVED ON:                           DATE OF ORDER:		16.11.18 25.10.23 06.05.24

 

CORAM:

Surinder Kumar Sharma, President

Anil Kumar Bamba, Member

 

ORDER

Anil Kumar Bamba, Member

The Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986.

Case of the Complainant           

1. The case of the Complainant as revealed from the record is that on 06.09.13 Complainant purchased health plan from Opposite Party vide policy no. BIH/Q0056771/12/09 with premium of Rs. 6,313/- annually for himself and his children namely Bhoumick Tyagi and Ridhi Tyagi from diseases. The daughter of Complainant got suffered from fever and loose motion and was admitted in Max Hospital, Patparganj Delhi on 12.06.17 and got discharged on 15.06.17. The Complainant intimated the Opposite Party and after verification Opposite Party cleared all bills of hospital. There is also a provision of pre and post medical charges of 30 days including medical test injection, Dr. visits and medicinesetc. It is stated that as per policy Complainant submitted all original bills regarding pre and post medical treatment/requirements along with complete medical treatment with including investigation report discharge slip etc.and Complainant got receiving of Opposite Party dated 05.09.17. The Complainant stated that despite completing all the formalitiesregardingdocuments Opposite Party has not passed the claim of Rs. 10,519/- of Complainant and whenever Complainant tried to contact Opposite Party customer care the Opposite Party speculated Complainant on one pretext or another but never passed the claim of Complainant. Hence, this shows deficiency in service on behalf of Opposite Party. The Complainant has prayed for Rs. 10,000/- as the bills of pre and post medical claim and Rs. 50,000/- for mental harassment. He further prayed for Rs. 10,000/- towards litigation expenses.

Case of the Opposite Party

2. The Opposite Party contested the case and filed written statement.It is stated that the pre and post medical charges of 30 days of medical test and injection, Doctor visits and medicine etc. are covered as per policy. It is submitted that there is a general condition in 7.4 and 7.12 of the policy which has to be fulfil by the claimant as per the policy, the claim claimed by the claimant can be reimbursed after fulfilling the general terms and conditions of the policy. The claimant is required to produce the documents i.e. Discharge card with hospital final bill with payments and all investigation reports in support to diagnosis by the hospital for further pre and post medical charges.
3. It is denied that the plaintiff has submitted all original bills regarding pre and post medical treatment/requirement along with complete medical treatment with including investigation report discharge slip etc. It is further denied that the documents were duly received by the Opposite Party on 05.09.17. It is pertinent to mention herein that Opposite Party on various occasions had requested the claimant to produce the required documents and failing to provide the required documents, the claim of the claimant was repudiated vide letter dated 16.03.18 as per general condition 7.4 and 7.12 of the insurance policy It is further submitted that the claimant had concealing the original documents and hiding the true facts from this Hon’ble Forum. Hence, there is no deficiency in service on behalf of Opposite Party.

Rejoinder to the written statement of Opposite Party

4. The Complainant filedrejoinder to the written statement of Opposite Partywherein the Complainant has denied the pleas raised by the Opposite Party and has reiterated the assertions made in the complaint.

 

 

Evidence of the Complainant

5. The Complainant in support of his complaint filed his affidavit wherein he has supported the averments made in the complaint.

Evidence of the Opposite Party

6. In order to prove its case, Opposite Party filed affidavit of Sh. Rishi Kant, AR of Opposite Party wherein the averments made in the written statement of Opposite Party have been supported.

Arguments & Conclusion

7. We have heard theComplainant. We have also perused the file and the written arguments filed by the Complainant. The case of the Complainant is that Complainant purchased health plan policy from Opposite Party vide with premium of Rs. 6,313/- annually for himself and his children from diseases. The daughter of Complainant got suffered from fever and loose motion and was admitted in Max Hospital, Patparganj Delhi on 12.06.17 and got discharged on 15.06.17. The Complainant intimated the Opposite Party and after verification Opposite Party cleared all bills of hospital. There is also a provision of pre and post medical charges of 30 days including medical test injection, Dr. visits and medicines etc. It is stated that as per policy, Complainant submitted all original bills regarding pre and post medical treatment/requirements along with complete medical treatment with including investigation report discharge slip etc. and Complainant got receiving of Opposite Party dated 05.09.17. The Complainant stated that despite completing all the formalities, Opposite Party has not passed the claim of Rs. 10,519/- of Complainant and whenever Complainant tried to contact Opposite Party customer care the Opposite Party speculated Complainant on one pretext or another but never passed the claim of Complainant.
8. The case of the Opposite Party is that there is a general condition in 7.4 and 7.12 of the policy which has to be fulfil by the Complainant as per the policy, the claim claimed by the Complainant can be reimbursed after fulfilling the general terms and conditions of the policy. The Complainant is required to produce the documents i.e. Discharge card with hospital final bill with payments and all investigation reports in support to diagnosis by the hospital for further pre and post medical charges.  The Opposite Party denied that the plaintiff has submitted all original bills regarding pre and post medical treatment/requirement along with complete medical treatment with including investigation report discharge slip etc. It is further denied that the documents were duly received by the Opposite Party on 05.09.17. It is pertinent to mention herein Complainant failed to submit required documents. So, the claim of the Complainant was repudiated.
9. In view of the above, it is clear that Complainant did not lead any evidence regarding supplying of documents as demanded by the Opposite Party to reimburse the claim of the Complainant.  Hence, in our considered opinion, there is no deficiency in service on the part of Opposite Party. Therefore, the complaint is dismissed.
10. Order announced on 06.05.24.

Copy of this order be given to the parties free of cost.

File be consigned to Record Room.

 

(Anil Kumar Bamba)                Member

(Surinder Kumar Sharma) President