Delhi

North East

CC/3/2023

Yogesh Kumar - Complainant(s)

Versus

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

02 Jul 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: NORTH-EAST

GOVT. OF NCT OF DELHI

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

Complaint Case No. 03/23

 

 

In the matter of:

 

 

		Sh. Yogesh Kumar S/o Sh. Naresh Kumar R/o E 280, Guru Govind Gali, Chajjupur, Babarpur Shahdara Delhi 110032		Complainant
		Versus
		ICICI Lombard General Insurance Co. Ltd. Through its Director 414, P.Balu Marg, Off Veer Sawarkar Marg, Near Sidhivinayak Temple, Prabhadevi Mumbai 400025   Also at:- ICICI Lombard General Insruance 3rd Floor Narain Manzil, 23 Barakhamba Road, New Delhi 110001		Opposite Party
			DATE OF INSTITUTION:         JUDGMENT RESERVED ON:                           DATE OF ORDER:		02.01.23 14.02.24 02.07.24

14.02.

CORAM:

Surinder Kumar Sharma, President

Anil Kumar Bamba, Member

Ms. Adarsh Nain, Member

 

ORDER

Ms. Adarsh Nain, Member

The Complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against Opposite Party alleging deficiency in services.

Case of the Complainant                                                                 

1.  The case of the Complainant as revealed from the record is that the Complainant availed three policies from Opposite Party namely Hospital daily Cash Benefit vide Policy no. 4148/237795579/00/000 valid from 25^th Jan 2022 to 24^th Jan 2023, policy no. 4148/239118585/00/000 valid from 09^th Feb 2022 to 08 Feb 2023, and policy no. 4148/239119781/00/000 valid from 10^th Feb 2022 to 09^th Feb 2023, and all the policy papers were delivered to Complainant’s email ID. The Complainant submits that he purchased the above policy through paytm application where it was mentioned that in case the customer is holding three policies, the total liability of ICICI Lombard (Opposite Party ) would be capped at 3 policies. It is further stated that in the month of May 2022, the Complainant suffered from body pain, fever, vomiting, pain in abdomen, cervical pain etc. and got admitted in City Hospital & Trauma Centre on 18.05.22 where he came to know that he has suffered from Malaria fever and got discharged on 24.05.22. Thereafter on 28.05.22 Complainant called ICICI Lombard customer care and registered his hospital daily cash 3 claims under 3 different policy numbers and provided all the required documents. After that, the Complainant contacted Opposite Party several times to settle the claim but the matter was not settled. The Complainant stated Opposite Party rejected 2 claims of Complainant and one claim is still pending with them. Thereafter on 14.07.22 Complainant received call from lady officer and told that claims will be settled and when Complainant contacted Opposite Party and asked about rejection of claim they denied to give any information. The Complainant had also sent legal notice to Opposite Party dated 03.08.22 but of no use. Thereafter on 02.08.22 Opposite Party sent letter to Complainant stating “On further scrutiny and verification of the claim documents it is noted that you were treated on day care basis further you have misrepresented the facts to get the benefit out of insurance”.  The Complainant stated that Opposite Party gave different and false excuses to reject the claim. Hence, this shows deficiency in service on behalf of Opposite Party. The Complainant has prayed to provide the claim of Rs. 36,000/- with 18 % p.a. till date and Rs. 2 lakhs for mental harassment. He further prayed for   Rs. 51,000/- for legal assistance fees.
2. None has appeared on behalf of Opposite Party despite service of notice. Therefore, Opposite Party was proceeded against Ex-parte vide order dated 27.03.23.

Ex-Parte Evidence of the Complainant

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

 

Arguments & Conclusion

4. We have heard the Complainant and Counsel for the Opposite Party. We have also perused the file and the written arguments filed by the Complainant and the Opposite Party.
5. It is the case of the Complainant that Complainant availed three policies from Opposite Party which covered the Complainant for daily hospital cash benefit. The Complainant remained admitted in City Hospital & Trauma Centre and received treatment from 18.05.22 to 24.05.22 for malaria and incurred medical expenses. It is alleged that he filed the insurance claim under all the three policies but two out of three claims were wrongly rejected while the third one is still pending. It is also submitted by the Complainant that other insurer Niva bupa settled the claim. This shows deficiency in service on behalf of Opposite Party. The Complainant alleged deficiency and prays for a claim of Rs. 36,000/- as well as compensation for for mental harassment.
6. The perusal of the material on record shows that the Complainant had remained under treatment City Hospital & Trauma Centre from 18.05.22 to 24.05.22 for malaria and incurred medical expenses. He had filed discharge summary and other documents in support. The Complainant’s grievance is that Opposite Party issued three different policies providing for daily hospital cash in case of inpatient treatment but did not settle his claims. At the same time, the Complainant makes the averment in the complaint itself that other insurer namely Neva Bupa Heath Insurance Co. Ltd. settled his claim for said treatment. The Complainant has filed Copy of Settlement letter/ reimbursement statement which shows that the Insurer Neva Bupa Heath Insurance Co. ltd. had paid the claim of Rs.54,517/- to the Complainant for the treatment at City Hospital for Malarial fever from 18.05.22 to 24.05.22. It shows that the Complainant was also covered under some other policy issued by Neva Bupa Heath Insurance Co. ltd which settled the subject claim.
7. In this context, it is relevant to mention here that Hon’ble Supreme Court in United India Insurance Co. Ltd. v. Levis Strauss (India) (P) Ltd., 2022 SCC OnLine SC 537, decided on 02-05-2022 made observation in respect of cases of Double Insurance- Overlapping policies. The 3 judges bench observed;   
7. “What is in issue in this present case has been characterized as “duble insurance”, i.e., where an entity seeks to cover risks for the same or similar incidents through two different-overlapping policies.”

The Bench opined that a contract of insurance is and always continues to be one for indemnity of the defined loss, no more no less and in the case of specific risks, such as those arising from loss due to fire, etc., the insured cannot profit and take advantage by double insurance.

8. Since in the present matter, there is clear case of double insurance covering similar incidents/risks under two different policies and as per the Complainant’s own admission, the subject claim has already been settled and the Complainant has received the amount, the Complainant cannot be allowed to take the advantage of double insurance and earn profits out of insurance.
9. In view of above, we do not see any merits in the complaint, hence, the same is dismissed with no order as to costs.
10. Order announced on 02.07.24.

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

File be consigned to Record Room.

 

(Anil Kumar Bamba)              Member

(Adarsh Nain)          Member

(Surinder Kumar Sharma) President