DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II U.T. CHANDIGARH Complaint Case No.:1480 of 2009 Date of Inst: 09.12.2009 Date of Decision:01.04.2010 Vijay Kumar Verma r/o H.No.5521/3, Modern Housing Complex, Manimajra, Chandigarh. ---Complainant V E R S U S1. ICICI Lombard General Insurance Company, ICICI Lombard Health Care, TGV Mansion, 8th Floor, Plot No.6-2-1012, Khairatabad, Hyderabad-500004 through its Managing Director.2. ICICI Lombard General Insurance Company, Interface Building No.11, 401/402, 4th Floor, New Link Road, Malad (West), Mumbai-400064 through its Manager. 3. ICICI Lombard General Insurance Company, Quite Office No.10, Sector 40-B, Chandigarh through its Branch Manager. ---Opposite PartiesQUORUM SHRI LAKSHMAN SHARMA PRESIDENT SHRI ASHOK RAJ BHANDARI MEMBER SMT.MADHU MUTNEJA MEMBER PRESENT: Sh.Gaurav Bhardwaj, Adv. for complainant Sh.Sandeep Suri, Adv. for OPs. --- PER LAKSHMAN SHARMA, PRESIDENT Sh.Vijay Kumar Verma has filed this complaint under section 12 of the Consumer Protection Act, 1986 praying therein that OP be directed to :- i) Pay a sum of Rs.1,12,994/- along with interest @ 12% p.a. incurred towards treatment. ii) Pay a sum of Rs.3 lacs for mental agony, deficiency in service and unfair trade practice. 2. In brief, the case of the complainant is that he took health insurance policy No.4034i/FPP/ 04886980/00/000 effective from 12.08.2009 to midnight of 11.08.2010. The complainant suffered paralytic attack on 06.09.2009 and as such he was admitted in Fortis Hospital, Mohali for his treatment. The complainant showed his card and policy to the hospital who sent the pre-authorization request through e-mail to OPs for cashless treatment which was declined by OPs. According to the complainant, he spent a sum of Rs.99,969/- during his hospitalization in the Fortis Hospital besides Rs.3025/- towards his follow up treatment. It has further been averred that the doctor also advised a machine to him worth Rs.95000/- for sleeping disorder but he hired the same on rent @ Rs.10000/- per month. The complainant submitted his claim but the same has been repudiated by OPs on the ground that it violates the exclusions clauses No.3.2 of the policy. According to the complainant, the repudiation of the claim on the ground mentioned above, amounts to deficiency in service and unfair trade practice on the part of OPs. In these circumstances, the present complaint has been filed seeking the reliefs mentioned above. 3. In the reply filed by OPs, it has been admitted that the insurance policy in question was issued to the complainant and the same was valid for the period from 12.08.2009 to midnight of 11.08.2010. It has further been pleaded that the policy was taken on 12.08.2009 and the complainant took admission in the hospital on 06.09.2009. According to OPs, the medical expenses for the first 30 days of the policy are not covered as per exclusion clause No.3.2 which reads as under: “Clause 3.2. Medical charges incurred within 30 days of inception date of the policy except those that are incurred as a result of bodily injury caused by an accident. This exclusion does not apply for subsequent renewals with the company without a break”. Therefore, the claim of the complainant was not payable as per the exclusion clause 3.2 of the insurance policy and the same was rightly repudiated vide letter dated 07.09.2009 (Annexure C-3). In these circumstances, according to OPs, there is no deficiency in service on its part and the complaint deserves dismissal. 4. We have heard the learned counsel for the parties and have gone through the entire record including documents, annexures, affidavits etc. 5. Admittedly, the policy in question is effective from 12.08.2009 to midnight of 11.08.2010. It is also admitted fact that the complainant was admitted in the hospital on 06.09.2009 for his treatment. It is also admitted that the complainant suffered paralytic attack which was not result of any bodily injury caused by accident. Annexure C-1 is the copy of the insurance policy along with the terms and conditions placed on record by the complainant himself. Annexure C-3 is the copy of the letter dated 07.09.2009 whereby the claim has been repudiated on the ground that it is not payable in view of clause 3.2 of the policy. As the complainant was hospitalized within 30 days of the inception of the policy, the claim is not payable in view of clause 3.2 of the policy. Admittedly, there was no bodily injury to the complainant. 6. The judgement of the Hon'ble National Commission reported in the case titled as New India Assurance Co. Ltd. Vs. Harbans Singh, 2008(1) CPC-614 (NC) relied upon by the complainant is not applicable to the facts and circumstances to the present case. 7. In view of the above findings, the complainant has failed to make out any case of deficiency in service against OPs. Consequently this complaint is dismissed with no order as costs. 8. Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room. Announced 01.04.2010 Sd/- (LAKSHMAN SHARMA) PRESIDENT cm sd/- (ASHOK RAJ BHANDARI) MEMBER Sd/- (MADHU MUTNEJA) MEMBER
| | MRS. MADHU MUTNEJA, MEMBER | HONABLE MR. LAKSHMAN SHARMA, PRESIDENT | MR. A.R BHANDARI, MEMBER | | 
