Punjab

Sangrur

CC/400/2022

Puneet Sharma - Complainant(s)

Versus

ICICI Lombard General Insurance Company Limited - Opp.Party(s)

Sh. Ritesh Jindal

11 Nov 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SANGRUR .

                                                                         Complaint No. 400

  Instituted on:   12.04.2022

                                                                          Decided on:     11.11.2024

Puneet Sharma aged about 25 years son of Ramesh Kumar, resident of House No.110, Near PWD Rest House, Ward No.2, Sunam, Tehsil Sunam, Distt. Sangrur.

                                                         …. Complainant.     

                                                 Versus

1.             ICICI Lombard General Insurance Company Limited, Branch Office: SCO-26, 1^st Floor, Kaula Park, Sangrur through its Branch Manager/ Authorised Signatory.

2.             ICICI Lombard General Insurance Company Limited, Registered Office: ICICI Lombard Health Care, ICICI Bank Tower, Plot No.12, Financial District, Nanakram Guda, Gachibowli, Hyderabad, Telangana-500032 through its Managing Director/Authorised Signatory.

                                                        ..Opposite parties.

 

For the complainant    :       Shri Ritesh Jindal, Adv.

For Opp.parties          :       Shri G.S.Sibia, Adv.

 

Quorum                                           

Jot Naranjan Singh Gill                   : President

Sarita Garg                                        : Member

Kanwaljeet Singh                               :Member

 

ORDER

JOT NARANJAN SINGH GILL, PRESIDENT

 

1.             Complainant has preferred the present complaint against the opposite parties  on the ground that complainant obtained online health insurance  policy bearing number 4148/234154037/00/000, namely, Group Safeguard Insurance policy which was valid for the period from 08.12.2021 to 07.12.2022 by paying the requisite premium of Rs.249/- to the OPs. Under the said scheme, complainant is insured for a sum of Rs.50,000/- and was entitled to get treatment from any of the hospital cashless by showing his card, but no separate terms and conditions were supplied to the complainant.  Further case of complainant is that on 25.01.2022, the complainant felt fever and was immediately taken to Mata Kaushlaya Memorial Centre and Polyclinic, Sangrur for treatment and after checking the complainant was found to be a case of dengue fever with thrombocytopenia and the complainant remained admitted in the hospital from 25.1.2022 to 30.1.2022 for treatment. Though the complainant showed the insurance policy to the doctor of the hospital, but he told to pay the expenses in cash, as such the complainant paid the amount of Rs.41383/- to the hospital authorities from his pocket being the treatment expenses.  Further case of complainant is that thereafter the complainant submitted the claim alongwith the documents and the OPs assured that it will be settled within a period of 30 days and thereafter the complainant received letter dated 31.01.2022 demanding documents and the complainant supplied the same to the OPs. Further case of complainant is that he received a letter dated 10.03.2022 whereby the claim of the complainant was repudiated on the false ground that “specific reports signed and attested by registered pathologist which confirm following diagnosis and laboratory finding positively” so the claim was rejected, which is said to be wrong and illegal on the part of the OPs. Thus, alleging deficiency in service on the part of the Ops, the complainant has prayed that the Ops be directed to pay to the complainant the claim amount of Rs.41,383/- alongwith interest and further claimed compensation and litigation expenses.

2.             In reply filed by OPs, preliminary objections are taken up on the grounds that the complaint is not maintainable, that the complainant has filed the complaint by concealing true and material facts from this Commission, that the complainant has dragged the OPs into uncalled litigation and that the complainant has not come to this Commission with clean hands. On merits, the issuance of the policy in question is admitted and it is further averred that the terms and conditions were duly supplied to the complainant. It is admitted further that the complainant lodged the claim with the OPs. It is stated that since the claim of the complainant was not genuine, as such the same was repudiated.  Lastly, the OPs have prayed that the complaint be dismissed with costs.

3.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-25 copies of documents and affidavit and closed evidence. On the other hand, the learned counsel for the OPs has produced Ex.OPs/1 to Ex.OPs/4 copies of documents and affidavit and closed evidence.

4.             We have gone through the pleadings put in by the parties along with their supporting documents with their valuable assistance. 

5.             It is an admitted fact between the parties that complainant was insured with the OPs under the health insurance policy in question, copy of which on record is Ex.C-2 by paying the requisite premium of Rs.249/- and the sum insured was to the tune of Rs.50,000/-.  The learned counsel for the complainant has argued vehemently that during the subsistence of the insurance policy the complainant suffered with dengue fever and remained admitted in Mata Kaushlaya Memorial Centre and Polyclinic, Sangrur for treatment from 25.1.2022 to 30.1.2022 as is evident from discharge summary Ex.C-7, where he spent an amount of Rs.41,383/- as claimed by the complainant in the complaint, but the claim of the complainant was repudiated by the OPs vide letter dated 10.3.2022 Ex.C-23 on the ground that the complainant was treated for Dengue fever with TCP and the given report is not from pathologist, which is said to be wrong and illegal for repudiation of the claim and the complainant has prayed for acceptance of the complaint.  On the other hand, the stand of the OPs is that the claim of the complainant has rightly been repudiated as the claim was not genuine one as mentioned in the reply of complaint as well as by Shri Amandeep Singh, Legal Manager in the affidavit Ex.OPs/1. Ex.OPs/2 is the copy of risk assumption letter dated 08.12.2021 addressed to the complainant Puneet Sharma. Ex.OPs/3 is the copy of Group Safeguard Insurance, wherein the learned counsel for the OPs has showed that specific reports should be signed and attested by registered pathologist which confirm diagnosis and laboratory findings positively, but we are unable to go with this contention of the learned counsel for the OPs as the Ops have produced nothing on record to show that such terms and conditions were ever supplied to the complainant or explained to the complainant at the time of issuance of the insurance policy.  The complainant has produced on record the copy of insurance policy number 16932533109 dated 5.12.2021 Ex.C-2, wherein the policy starts from 8.12.2021 and it also contains terms and conditions, but it nowhere contains such a clause that specific reports should be signed and attested by registered pathologist which confirm diagnosis and laboratory findings positively.  Moreover, the complainant has produced on record the copy of certificate Ex.C-24, issued by Dr. Mohit Goyal of Mata Kaushalya Memorial Centre and Polyclinic, Sangrur, wherein it has clearly been stated that laboratory reports of complainant Puneet Sharma dated 25.01.2022 for dengue antigen were conducted in his hospital under his supervision.  Again Ex.C-25 is another certificate issued by Dr. Mohit Goyal showing that Dengue NS1 Ag test was done in this laboratory on 25.01.2022. Under the circumstances all this clearly proves that all the tests of Dengue were conducted under the supervision of Dr. Mohit Goyal in his hospital and laboratory which is situated inside Mata Kaushalya Hospital as is evident from Ex.C-25. These certificates were duly stamped and signed by Dr.Mohit Goyal. The claim of the complainant has wrongly and illegally been repudiated by the OPs without applying the mind, as such, the repudiation letter dated 10.03.2022 Ex.OP/4 is illegal and the same is not binding upon the complainant. 

6.             Now, coming to the quantum of compensation payable to the complainant. Admittedly, the insurance policy is for the sum insured of Rs.50,000/-.  The complainant has  claimed an amount of Rs.41,383/-. After perusal of the bills Ex.C-3 to Ex.C-5, we find that the complainant has spent an amount of Rs.41,383/- on the treatment. Further final bill Ex.C-6 also shows that the complainant paid an amount of Rs.41,383/- to hospital authorities for the treatment. Ex.C-7 is the discharge summary which again clearly shows that the complainant was suffering from dengue fever. Further Ex.C-8 to Ex.C-21 are the copies of clinical laboratory reports, which shows that various tests were conducted in the laboratory inside Mata Kaushalaya Hospital, Opp. Civil Hospital Sangrur under the supervision of the treating doctor Shri Mohit Goyal. Accordingly, we find that justice shall be met if the OPs are directed to pay to the complainant the claim amount of Rs.41,383/- alongwith interest from the date of filing of the present complaint. 

7.             The insurance companies are in the habit to take these type of projections to save themselves from paying the insurance claim. The insurance companies are only interested in earning the premiums and find ways and means to decline claims. The above said view was taken by the Hon’ble Justice Ranjit Singh of Punjab and Haryana High Court in case titled as New India Assurance Company Limited versus Smt. Usha Yadav and others 2008(3) R.C.R. 9 Civil) 111.

8.             Accordingly, in view of our above discussion, we allow the complaint and direct OPs to pay to the complainant the claim amount of Rs.41,383/- alongwith interest @ 7% per annum from the date of filing of the present complaint i.e. 12.04.2022 till realisation. Further OPs are directed to pay to the complainant an amount of Rs.5000/- as compensation for mental tension, agony and harassment and further an amount of Rs.5000/- on account of litigation expenses. This order be complied with within a period of sixty days of receipt of copy of this order.

9.             The complaint could not be decided within the statutory time period due to heavy pendency of cases.

10.            Copy of this order be supplied to the parties free of cost. File be consigned to the records after its due compliance. 

                             Pronounced.

                             November 11, 2024.