District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.115/2023.
Date of Institution:15.02.2023.
Date of Order: 23.10.2024.
Mamta Mourya wife of Shri Umesh Mourya, resident of house NO. 6053, Sanjay Colony, Sector-23, Faridabad.
…….Complainant……..
Versus
ICICI Lombard General Insurance Company Limited, mailing Address: Interface Building No. 16, 601/602, 6th floor, Near Link road, Malad (West) Mumbai through its Branch Manager.
Branch Office: ICICI Lombard General Insurance Company Limited, S.C.O-17, Ist floor, Sector-16, Faridabad, Haryana- 121002 through its Branch Manager.
…Opposite party……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma………..Member
Indira Bhadana………….Member.
PRESENT: Shri Shamim Ahmed, counsel for the Complainant.
Shri Rakesh Dabaas, counsel for opposite party .
ORDER:
The facts in brief of the complaint are that the complainant obtained mediclaim policy vide policy No.4128i/iHA/200534492/02/000 which was valid from 2.6.2022 to 19.6.2023 The complainant is the holder of the mediclaim policy since the last 5 years. For the above said policy the complainant has paid premium. The complainant namely Mrs. Mamta Mourya was suffering from fever since 3-4 days associated with chills and rigors, no rashes, no diurnal variation, not relieved on medication, sever headache (retro orbitral), body pain, back pain, productive cough, nausea, vomiting since 3-4 days and went to Sarvodaya Hospital and Research Center, Sector-8, Faridabad where the Doctors diagnosed the disease of the complainant and got her admitted in the Hospital on 17.10.2022 and got discharged on 20.10.2022. That complainant as well as the official of the Sarvodaya Hospital, Faridabad intimated the respondent. The respondent had given approval to the complainant and the respondent had declined the same on 18.10.2022 and wrote that Unable to ascertain liability of claim. As per the information available at this stage (cashless level), they were unable to ascertain liability of claim, hence cashless stands denied and they requested insured to come for reimbursement with all proper documentation. Inconvenience caused was highly regretted. The hospital raised the bill amounting to Rs.41188/- which was paid by the complainant. After the discharge the complainant submitted claim form for Rs. Rs.41188/- (the expenses incurred on the treatment, Hospitalization, medicines etc. of the complainant) with the opposite party and sent all the original documents asked by the opposite party but the opposite party had not paid any amount of the treatment of the complainant. The complainant applied in the reimbursement and sent so many emails to the respondent but the opposite party even after receiving the said emails did not pay the amount which was paid by the complainant on the treatment of complainant and had refused to the legitimate request of the complainant The complainant demanded the original documents which was sent by her but the respondents refused to handover the documents to the complainant. The aforesaid act of opposite party amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite party to:
a) Pay Rs. Rs.41188/- which was paid by the complainant for the treatment of his wife.
b) pay Rs.1,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 11,000 /-as litigation expenses.
2. Opposite party put in appearance through counsel and filed written statement wherein Opposite party refuted claim of the complainant and submitted that at the very threshold the present complaint, the complaint of the complainant as to her treatment was not maintainable, reason being, it was established from the claim documents as well investigation report so got conducted by the opposite party that the claim of the complainant was a "fraudulent claim" as defined under PART III OF THE POLICY General Terms & Condition No. 12 so incorporated in the insurance policy. The complement neither had any cause of doors and in lodging of the present compliant before this Hon’ble Commission, reason being, the complainant had submitted claim form dated 22.10.2022 alongwith relied upon documents with regards to indoor treatment w.e.f 17.10.2022 to 20.10.2022 from Sarvodaya Hospital, Sector-8, Faridabad. After scrutiny of the claim papers, an independent investigation was deputed to verify the treatment record as well as ascertain the status of the hospital in question. After verification, the said investigator had prepared and submitted his report by incorporating the all facts and circumstances therein as well as annexing the xerox of indoor treatment record, questionnaire of the patent provided by him Since it had been established from the claim documents as well as investigation report so got conducted by the opposite party that the claim of the complainant as to her treatment was a fraudulent claim as defined under PART III OF THE POLICY General Terms & Condition No. so incorporated in the insurance policy. Thus, the insurance company had treated the subject claim as “No Claim” by closing the file in terms of letter of intimation dated 21.11.2022 which decision could not be termed unconscionable at all.Opposite party denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite party– ICICI Lombard General Insurance Co. Ltd.with the prayer to: a) pay Rs. Rs.41188/- which was paid by the complainant for the treatment of his wife. b)pay Rs.1,00,000/- as compensation for causing mental agony and harassment . c) pay Rs. 11,000 /-as litigation expenses.
To establish his case, the complainant has led in his evidence Ex.PE1/A – affidavit of Mamta Mourya, Ex.P-1- claim form – hospitalization, Ex.P-2 – discharge summary, Ex.P-3 – Summary Taxable Invoice-cum-bill, Ex.P-3 – denial of cashless access, Ex.P-4- email dated 28.10.2022, Ex.P-5 – email dated 28.10.2022,, Ex.P-6 – rejection claim, Ex.P-7 – email dated Jan.4,2023, Ex.P-8 – email dated Jan. 10,2023 regarding returning of original documents,, Ex.P-9 – adhaar card.
On the other hand counsel for the opposite party strongly agitated and opposed. As per the evidence of the opposite party Ex.RW1/A – affidavit of Rohan Mishra, Manager (Legal), M/s.ICICI Lombard General Insurance Co. Ltd., 4th floor, red Fort Capital Parsvnath Tower, Bhai Veer Singh Marg, Gole Market, New Delhi, Ex.R-1 – Policy certificate alongwith terms & conditions, Ex.R-2 – claim form, Ex.R-3 – discharge summary, Ex.R-4 – Summary Taxable invoice cum bill of supply, Ex.R-5 – Individual reimbursement,, Ex.R-6 – statement paper,, Ex.R-7 – Initial Nursing Assessment Form-Emergency & Trauma, Ex.R-8 – Test, Ex.R-9 - repudiation letter dated 21.11.2022.
6. In this case, the complaint was filed by the complainant with the prayer to pay Rs. Rs.41188/- which was paid by the complainant for the treatment of his wife. To prove his case, the complainant led in his evidence Ex.P-1 to P-9. On the other hand, opposite party led in their evidence Ex.R-1 to R-9.
7. As per discharge summary vide Ex.P-2, the complainant admitted in Sarvodaya Hospital on 17.10.2022 and discharged on 20.10.2022 with the diagnosis of Lower Respiratory Tract Infecton Acute Vascular Headache. Opposite party repudiated the claim of the complainant vide letter dated 18.10.2022 vide Ex.R-9 on the ground that “As per the policy wordings, Part III of the Policy General Terms and Conditions 12, 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 devises are used by you or anyone acting on your behalf to obtain any benefit under this policy, or if a claim is made and rejected and no court action or suit is commenced within twelve months after such rejection or in case of arbitration taking place as provided therein, within 12 calendar months after the Arbitrator or Arbitrators have made their award, all benefits under this policy shall be forfeited.”
8. During the course of arguments, the counsel for the complainant stated at Bar that the repudiation was done on the basis of the treatment of the patient can be done as an outdoor patient and the admission of the patient was not necessary. On the other hand, counsel for the opposite party argued at length and sated at Bar that it is a case of fraudulent.
9. After going through the evidence led by the both the parties, the Commission is of the opinion that the opposite party has failed to prove the fraudulent case as per the repudiation done by the opposite party.. Hence, the repudiation done by the opposite party is not justified. Opposite party can deduct room charges amounting to Rs.12,600/- from the total amount of Rs.41,188/- as per Ex.P3. Resultantly, the complaint is allowed.
10 Opposite party is directed to process the claim of the complainant after deduction room charges amounting to Rs.12,600/- from the total amount of Rs.41,188/- and the pay the balance amount to the complainant alongwith interest @ 6% p.a. from the date of filing of complaint till its realization. Opposite party is also directed to pay Rs.3300/- as compensation for causing mental agony & harassment alongwith Rs.2200/- as litigation expenses to the complainant. Compliance of this order be made within 30 days from the date of receipt of copy of this order. Copy of this order be sent to the parties concerned free of costs. File be consigned to the record room.
Announced on: 23.10.2024. (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
