Order by:

Smt.Priti Malhotra, President

1.       The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that complainant alongwith her husband namely Khem Chand has been availing the Joint Family Health Insurance policy namely ICICI Lombard Complete Health Insurance from the Opposite Parties at Moga since 23.08.2019 and the same was renewed from time to time. At present policy bearing no.4128i/HSRN/178412380/03/000 with sum insured of Rs.50 lakhs alongwith bonus and recharge benefit valid from 23.08.2023 to 22.08.2024 issued by the Opposite Parties in favour of the complainant and her husband. Unfortunately, complainant has suffered problem of Fever, Joint Pain, Back Pain and Headache, Leg pain and AFI and went to Delhi Heart Institute and Multispecialty Hospital, Moga and remained admitted in the hospital for the period 29.11.2023 to 02.12.2023 and complainant spent Rs.51,387/- on her treatment at the said hospital. The hospital authorities duly informed the Opposite Parties. Thereafter the complainant approached the Opposite Parties and submitted her claim of medical reimbursement alongwith original medical record of said hospital and bills to the Opposite Parties and Opposite Parties also issued claim/Cashless Authorization Request Note no.110100682060-1 to complainant. But complainant was in shock when she received a information from the Opposite Parties that “as per the claim document it has been observed that patient suffering from Diabetes since prior to policy inception and the same was not disclosed at the time of policy inception, hence case is rejected on ground of incontestability of disclosure. Alleged that the complainant was again shocked when she received a letter dated 31.12.2023 from the Opposite Parties, vide which Opposite Parties informed that “as per ICP dated 29 November, 2023 insured Amita Rani is known case of Diabetes since 5 years which is not disclosed at policy inception i.e. 23 August, 2019” and due to such reason they are going to cancel the said policy w.e.f 15.01.2024 i.e. 15 days from the date of letter dated 31.12.2023. Submitted that the complainant has not concealed any material facts from Opposite Parties and Opposite Parties cancel/reject the claim of the complainant on flimsy grounds. Complainant also issued legal notice dated 16.01.2024 to Opposite Parties with a request to settle the above said claim and not to terminate the above said health policy and if terminated then restore the same but to no effect. Due to such act and conducts of the Opposite Parties, the complainant has suffered mental tension and harassment. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-

a)       Opposite Parties may be directed to pay a sum of Rs.51,387/- alongwith interest @ 12% p.a.  from the date of filing of present complaint till realization.

b)      To restore the above said health policy of complainant which was cancelled by the Opposite Parties w.e.f 15.01.2024.

c)       To pay an amount of Rs.50,000/- as compensation on account of mental tension and harassment and for deficiency in service.

d)      To pay an amount of Rs.5500/- as litigation expenses.

2.       Opposite Parties appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the intricate question of law and facts are involved in the present complaint which require voluminous documents and evidence of determination which is not possible in the summary procedure under C.P. Act; the complainant has concealed material facts and document from this Commission as well as from the Opposite Parties, therefore, the complainant is not entitled to any relief. Moreover, she has not disclosed about the disease of diabetes at the time of taking the policy in question which is clear cut violation of the policy. Averred that till today no claim form has been furnished and even not applied for medical reimbursement and there is no claim form on the file, so complaint is pre mature one and is liable to be dismissed. The complainant is not the consumer of Opposite Parties and moreover Proposer of this policy has not filed the complaint and Amita Rani has no right to file the present complaint as she is only insured under the policy issued in the name of Khem Chand her husband; the complainant has no locus standi or cause of action to file the present complaint against Opposite Parties; the complaint is not maintainable in the present form; the complainant has violated the terms and conditions of the policy; this Commission has no jurisdiction to try and decided the present complaint as no branch office of Moga issued policy in this case; there is no repudiation letter on the court file; there is no provision in C.P. Act to restore the policy which has already been cancelled after giving prior notice of 15 days as per policy terms and conditions. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.

3.       In order to prove the case, the complainant has placed on record her affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C20.

4.       On the other hand, Opposite Parties have placed on record affidavit of Sh.Amandeep Singh, Legal Manager, ICICI Lombard GIC Ltd. as Ex.OP-1 alongwith copies of documents Ex.OP-2 & Ex.OP3.

5.         We have heard the ld. counsel for both the parties and also gone through the record.

6.       It is well proved on record that the complainant alongwith her husband availed a health insurance policy namely “ICICI Lombard Complete Health Insurance” having no.4128i/HSRN/178412380/03/000 for the period 23.08.2023 to 22.08.2024. It is also proved that during the policy period, the complainant suffered T2DM, HTN, CAD-Moderate LV Dysfunction, PIVD-1.5-S1 Radiculopathy and Acute Febrile Illness and got admitted in Delhi Heart Institute & Multispeciality Hospital, Moga and remained admitted in the hospital for the period 29.11.2023 to on 02.12.2023. From the perusal of the record it transpires that at the time of taking the treatment, the complainant requested the Opposite Parties for cashless authorization and on receiving the cashless authorization, the Opposite Parties vide email dated 02.12.2023 rejected the cashless request of the complainant. It is the allegations of the complainant that the claim filed with Opposite Parties for reimbursement of the expenses incurred on the above said treatment has not been paid by the Opposite Parties illegally. It is also proved on record vide letter dated 31.12.2023, the Opposite Parties cancelled the policy in question of the complainant.

7.       At the time of arguments, counsel for the Opposite Parties has moved an application for dismissal of the complaint claiming it to be premature. Parties were duly heard on the same. Giving due consideration to the submissions we are of the concerted view that the present complaint is not premature complaint, as the same has duly been filed by the complainant having cause of action accrued in his favour, when the Opposite Parties cancelled the policy in question without any intimation and without any prior notice to the complainant. Thus in our considered opinion the present complaint is not pre mature and is well maintainable. Hence, the application stands disposed of.

8.       Now, we come to the merits of the complaint. It is the allegation of the complainant that Opposite Parties failed to pay the genuine claim of the complainant and also ingenuinely cancelled the policy in question. In the present complaint, the complainant sought relief qua the reimbursement of the expenses incurred by her on the treatment as well as for the restoration of the policy in question. Perusal of the record reveals that during the hospitalization, the complainant applied for preauthorization for cashless treatment, but the said request of complainant was denied by the Opposite Parties, vide  letter dated 24.03.2024. The contents of said letter are reproduced as under:-

          The denial of cashless treatment of the complainant by Opposite Parties on the ground that complainant is suffering from Diabetes since prior to the policy inception is not genuine, as besides discharge summary there is no other document been referred or placed on record by the Opposite Parties establishing that complainant was suffering from said Diabetes before inception of the policy. Furthermore, in the discharge summary nowhere duration of the said ailment is mentioned. Further the denial of cashless claim on account of Diabetes is also not genuine, as Diabetes Mellitus and Hypertension are common life style diseases and repudiation of claim on the basis of these diseases is not justified. Reliance in this regard is placed on RP No. 4461 of 2012, Neelam Chopra Vs. Life Insurance Corporation of India & Ors., decided on 08.10.2018, (NC), wherein it has been held by the Hon’ble National Commission that:

"11. From the above, it is clear that the insurance claim cannot be denied on the ground of these life style diseases that are so common. However, it does not give any right to the person insured to suppress information in respect of such diseases. The person insured may suffer consequences in terms of the reduced claims.

14. Moreover, the non-disclosure of information in respect of this life style disease of diabetes, will not totally disentitle the complainant for indemnification of the claim in the light of the judgment of Hon'ble High Court of Delhi in Hari Om Agarwal Vs. Oriental Insurance Co. Ltd., (supra)."

In view of the judgement (supra), the denial of cashless claim on ground of insured was suffering from Diabetes is unjustified.

9.       During the course of arguments, ld. counsel for the complainant contended that before issuing the policy medical tests of the complainant got conducted by empanelled doctors of the Opposite Parties and after being satisfied and after completing all the formalities the policy was issued to complainant. Due reference is given to the emails (Ex.C3) as placed on record. Perusal of said emails reveals that before issuing the policy complainant was asked to get the medical tests conducted and after satisfying, the Opposite Parties issued the policy to complainant. Hence, we are of the considered view that if the policy was issued to complainant after getting her medically examined, so at this stage, when the complainant has claimed the amount of medical expenses, the objection raised by the Opposite Parties that she is suffering from Diabetes prior to inception of policy is not legal and ingenuine.  If for the sake of arguments, it is presumed that complainant did not get the medical examination done, then in that case also the fault is on the part of the Opposite Parties, as why they issued the policy in question in favour of the complainant without getting her medically checked when her age was above 45 years at the time of inception of the policy in question. Further perusal of the policy document (Ex.C3) placed on record by the complainant reveals that in the said document, the complainant has mentioned her date of birth as 05.05.1967 and in the said document date of joining of policy is mentioned as 23.08.2019, meaning thereby that at the time availing the first policy, the age of the complainant was more than 45 years, so it was the bounden duty of the Opposite Party-Insurance Company to get the life assured medically examined before issuing the policy in his/her name who was above 45 years of age. It is thus reiterated that not only the claim rejection is wrongly been made but also the cancellation of the policy in question is illegal and unjustified without giving any notice to the complainant.                                                                                        

10.     The other technical issue raised by the Opposite Parties is that the present complaint is pre mature, as till date the complainant has not filed any claim form nor lodged the claim for medical reimbursement. Perusal of the record reveals that immediate after the denial of the cashless request of the complainant, the Opposite Parties cancelled the policy of the complainant, also the complainant was not given any opportunity to lodge the claim. The issue so raised by the Opposite Parties certainly can be determined with directions to the complainant to lodge the formal claim for reimbursement with Opposite Parties. Hence we order accordingly.

11.     From the above discussion, we allow the instant complaint in part and complainant is directed to lodge the claim with Opposite Parties alongwith medical records pertaining to treatment taken by her and thereafter Opposite Parties are directed to settle and pay the claim of the complainant next within 15 days from the receipt of copies of the documents from the complainant. Further Opposite Parties are directed to restore the policy of the complainant, which was cancelled by Opposite Parties wrongly and illegally. Opposite Parties are also directed to pay compository costs of Rs.7,000/-(Rupees Seven Thousand only) as compensation and litigation expenses to the complainant. The pending application(s), if any also stands disposed of. The Opposite Parties are directed to comply with the order within stipulated period, failing which, they are further burdened with additional cost of Rs.10,000/-(Rupees Ten Thousand only) to be paid to the complainant for non compliance of the order. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.

Announced on Open Commission