Haryana

Yamunanagar

CC/400/2013

Kirpal Singh s/o Sh.Mahinder Singh - Complainant(s)

Versus

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

P.K Punia

16 Feb 2016

ORDER

BEFORE THE PRESIDENT DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, YAMUNA NAGAR AT JAGADHRI.

                                                                                                Complaint No. 400 of 2013.

                                                                                                Date of institution: 29.05.2013

                                                                                                Date of decision: 16.02.2016

 

Kirpal Singh aged about 48 years son of Sh. Mahinder Singh, resident of village Tehi Post Office Harnaul, Tehsil Jagadhri, District Yamuna Nagar.

                                                                                                                                                           …Complainant.

                                    Versus

 

1. ICICI. Lombard General Insurance Company Limited, 528(A), IInd Floor, Gobindpuri Road, Yamuna Nagar, through its Branch Manager.
2. ICICI Lombard, General Insurance Company Limited, Corporate Office:- ICICI Lombard, General Insurance Company limited, ICICI Lombard House 414, veer Savarkar, Near Sidhi Vinayak Temple, Parbha Devi, Mumbai-400025.
3. ICICI Lombard, General Insurance Company Limited, Interfact Building No.11, 401/402, 4^th Floor , New Link Road, Malad(West) Mumbai. 

 

                                                                                                                                               …Respondents.

BEFORE:         SH. ASHOK KUMAR GARG, PRESIDENT.

                        SH. S.C.SHARMA, MEMBER.

                       

Present: Sh. Pawan Kumar Punia, Advocate, counsel for complainant.

              Sh. Parmod Gupta, Advocate, counsel for respondents.  

 

ORDER

 

1.                     Complainant  Kirpal Singh has filed the present complaint under section 12 of the Consumer Protection 1986.  

2.                     Undisputedly, complainant Kirpal Singh had purchased family mediclaim cashless insurance policy bearing No. 4034/FPP/71575274/00/000 valid from 16.05.2012 to 15.05.2013 for a sum of Rs. 3,00,000/- covering the risk for himself, his wife Sudesh Kaur, daughter Lovepreet Kaur and son Dilpreet Singh and paid a premium of Rs. 10837/- to the respondents ( hereinafter referred as OPs Insurance Company) (Annexure C-2) . On 28.7.2012, the daughter of the complainant namely Lovepreet Kaur aged about 6 years felt some problem and she was taken to Gaba Hospital, Yamuna Nagar where she was checked up vide OPD No. 14952 registration No. 18725, Sr. No. 56 dated 28.7.2012 and echocardiography was done. As per report of echocardiography dated 01.08.2012 (Annexure C-3) the final impression was “ A Cyanotic CHD Large Ostium secundum ASD, Lt.-Right Shunt Diated RA & RV with Moderate RV Systolic Dysfunction”, thereafter, the daughter of the complainant was referred to Fortis Hospital Mohali and the complainant had adopted a treatment package in the Fortis Hospital for the treatment of his daughter Lovepreet Kaur and accordingly she was admitted in the Hospital on 13.08.2012 and discharged on 20.08.2012 and spent an amount of Rs. 1,61,458/-. Copy of bill is Annexure C-4. After getting discharge from the hospital, the complainant applied to the OPs for reimbursement of the amount paid by him and forwarded all the bills and documents as required by the OPs. However, despite many requests the OPs did not reimburse the money of the claim insured under Mediclaim Policy whereas at the time of taking mediclaim policy the OPs assured the complainant to indemnify him. Hence, there is a deficiency in service on the part of OPs and the complainant is entitled to get an amount of Rs. 1,61,458/- alongwith interest on account of medical expenses and Rs. 1,00,000/- on account of compensation as well as litigation expenses etc. Hence this complaint.

3.                     Upon notice, OPs appeared and filed its written statement by taking some preliminary objections such as Hon’ble Forum has no jurisdiction to entertain and try the present complaint and on merit it has been submitted that as per the documents supplied by the complainant, it was revealed that there was pre-existing disease on the policy No. 40341/CHC/06058561/00/00 effected from 13.5.2011 to 12.5.2012 and the claim of the complainant was not payable and the same was rejected under part II of the schedule, “Permanent exclusion clause 3.4. (iii & vii)- The treatment was related to Birth defect and internal congenital illness.” Regarding this intimation was sent to the complainant vide letter Annexure R-10. As the daughter of the complainant was treated for Birth defect and internal congenital illness. So, the claim of the complainant has been rightly repudiated by the OPs and there is no deficiency in service on the part of OPs and lastly prayed for dismissal of complaint.

4.                     To prove the case, complainant tendered into evidence his affidavit as Annexure CX and documents such as Photo copy of Insurance policy valid from 13.5.2011 to 12.5.2012 as Annexure C-1, Photo copy of insurance policy valid from 16.5.2012 to 15.5.2013 as Annexure C-2, Photo copy of treatment chart including reports of Gaba Hospital as Annexure C-3, Photo copy of bill of Fortis Hospital as Annexure C-4, Photo copy of rejection/ repudiation letter as Annexure C-5 and closed his evidence.

5.                     On the other hand, counsel for the OPs tendered into evidence affidavit of Inderjeet Singh, Manager ( Legal) as Annexure RW/A and documents such as Photo copy of insurance policy valid from 16.5.2012 to 15.5.2013 alongwith terms and conditions as Annexure R-1, Photo copy of risk assumption letter as Annexure R-2, Photo copy of insurance policy valid from 13.5.2011 to 12.5.2012 as Annexure R-3, Photo copy of customer Information Sheet as Annexure R-4 & R-5, Photo copy of list of hospital as Annexure R-6, Photo copy of history chart of Gaba Hospital as Annexure R-7, Photo copy of Echocardiography report as Annexure R-8, Photo copy of covering letter as Annexure R-9, Photo copy of repudiation letter as Annexure R-10 and closed the evidence on behalf of OPs.                  

6.                     We have heard the learned counsel for both the parties and have gone through the pleadings as well as documents placed on file very minutely and carefully. Counsel for the complainant reiterated the averments mentioned in the complaint and prayed for its acceptance whereas counsel for OPs reiterated the averments made in the reply and prayed for dismissal of complaint.

7.                     Learned counsel for the complainant argued at length that genuine claim of the complainant has been repudiated by the OPs insurance company illegally whereas the claim of the complainant was covered under the insurance policy in question and referred the case law titled as Lakhwinder Singh & Another Versus United India Insurance Company Limited & Others, II (2010) CPJ page 265 U.T.Chandigarh wherein it has been held that Consumer Protection Act 1986-Section 2(1)(g) – Life Insurance- Suppression of material facts- Group Mediclaim Insurance Policy- Expenses claimed- Claim repudiated alleging pre-existing disease- Deficiency in services alleged- Complaint dismissed- Hence appeal- No history of previous treatment of angina- Maladies like diabetes, hypertension being normal wear and tear of life cannot be termed as concealment of pre-existing disease- Various medical conditions causing chest pain- No suppression of facts proved- Repudiation not justified- Order set aside- Relief entitled.

8.                     On the other hand, counsel for the OPs insurance company hotly argued at length that as the daughter of the complainant was suffering from A Cyanotic CHD Large Ostium secundum ASD, Lt.-Right Shunt Diated RA & RV with Moderate RV Systolic Dysfunction. Meaning thereby “ the daughter of the complainant was having congenital heart disease ( CHD) ( hole in heart by birth) and as per the Exclusion Clause under 3.4 (iii)(vii) of the Insurance policy in question Annexure R-1, treatment relating to internal congenital illness and Birth defects and external congenital illnesses, the company shall not be liable to make any payment for any claim directly or indirectly. Learned counsel for the OPs further argued that as the complainant has suppressed these facts that her daughter is suffering from birth disease, so, the claim of the complainant has rightly been repudiated being violations of the terms and conditions of the insurance policy and referred the case law titled as Mrs. Shnyni Valsan Pombally Versus State Bank of India & others, 2014(1) CLT page 356 wherein it has been held that Insurance claim- Repudiation- Pre-existing disease-Held- The deceased was suffering from “diabetes mellitus” for which ailment he was on regular medication for over three years- It was not possible to even comprehend that the insured would not know that he was suffering from diabetes- Undoubtedly, these were “material facts” and being within the knowledge of the insured only, he was obliged to disclose the same correctly- Having suppressed the said facts while answering the questionnaire, we are of the opinion that the Insurance Company was within its rights to repudiate the claim of the complainant- In that view of the matter, there was no question of any deficiency in service on their part.

9.                     After hearing both the parties, we are of the considered view that the claim of the complainant has been rightly repudiated by the OPs Insurance Company as it is evident from the entire record of Gaba Hospital (Annexure C-3) as well as report of Echocardiography (Annexure R-8) that the daughter of the complainant namely Lovepreet Kaur was suffering from Congenital heart disease and treatment which was obtained from the Fortis Hospital Mohali was related to that disease which was not covered as per the terms and conditions of the insurance policy under clause 3.4(iii)(vii) permanent exclusion of the policy in question. It is settled law that the insurance policy is a contract between the parties and both the parties are bound by its terms and conditions. Counsel for the complainant failed to show that exclusion clause 3.4 is not applicable to the case of the complainant and claim of the claimant has been wrongly repudiated.  As per terms and conditions of the insurance policy, insurance company is not liable to pay the medical expenses on account of treatment relating to Birth defects and internal congenital illnesses i.e. congenital heart disease ( CHD) ( hole in heart by birth) as per the Exclusion Clause under 3.4(iii)& (vii) of the Insurance policy Annexure R-1. The law cited by the complainant is not disputed but not applicable to the facts of the present case as in the present case, the daughter of the complainant was suffering from congenital heart disease (CHD) and the complainant has not mentioned in his affidavit or complaint that he was not having any knowledge regarding Birth disease of her daughter.

10.                   After going through the above noted facts and circumstances of the case we are of the considered view that as the claim of the complainant has been rightly repudiated under exclusion clause 3.4 (iii) & (vii)of the Insurance Policy, so, there is no deficiency in service or unfair trade practice on the part of OPs Insurance Company.   

11.                   Resultantly, we find no merit in the present complaint and the same is hereby dismissed with no order as to costs. Copies of this order be sent to the parties concerned free of costs as per rules. File be consigned to the record room after due compliance.

Announced: 16.02.2016

                                                                        (ASHOK KUMAR GARG)

                                                                        PRESIDENT

 

 

                                                                        (S.C.SHARMA    )

                                                                        MEMBER