Chandigarh

DF-II

CC/822/2022

SAROJ KUMAR SHARMA - Complainant(s)

Versus

ICICI LOMBARD GENERAL INSURANCE COMPANY LIMITED - Opp.Party(s)

DEVINDER KUMAR

07 Oct 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II, U.T. CHANDIGARH

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Consumer Complaint  No	:	822 of 2022
Date  of  Institution	:	17.12.2022
Date   of   Decision	:	07.10.2024

 

 

 

 

Saroj Kumar Sharma (S K Sharma) son of Sh.Harbans Lal Sharma, aged about 82 years, resident of H.No.3137, Sector 37-D, Chandigarh.

             … … … Complainant

 

Versus

ICICI Lombard General Insurance Company Limited, The Statement, Plot No.149, 4^th Floor, Industrial Area, next to Hometel Hotel, Phase-I, Chandigarh through its Managing Director.

   … … … Opposite Party

 

BEFORE:  MR.AMRINDER SINGH SIDHU,       PRESIDENT

                MR.SURESH KUMAR SARDANA,       MEMBER

                               

Argued by:    Sh.Devinder Kumar, Counsel for Complainant.

OP ex-parte.

 

 

ORDER BY AMRINDER SINGH SIDHU, M.A.(Eng.),LLM,PRESIDENT

 

1]       The complainant has filed the present complaint pleading that he purchased a Mediclaim Policy from the OP by paying premium of Rs.12,308/- and OP issued Policy (Annexure C-1). The complainant Mr.Saroj Kumar Sharma is policy holder and Mr.Sumit Sharma(Son), Ms.Richa Sharma(Daugher-in-law), Ms.Tinishka Sharma (Grand Daughter) & Mr.Akshat Sharma(Grand Son) were the insured persons. The policy was valid from 25.01.2022 to 24.01.2023.

    It is submitted that in the month of November 2022, complainant’s daughter-in-law namely Ms.Richa Sharma faced some health problem and visited to Max Hospital, Phase 6, Mohali. After conducting some tests and under the advise of Doctor, complainant admitted his daughter-in-law in the said hospital on 01.11.2022 and after treatment discharged on 05.11.2022. It is submitted that Max Hospital raised a bill of Rs.79,625/- for the treatment of daughter-in-law of the complainant and due information was given to OP by Max Hospital to provide the cashless facility. It is submitted that Max Hospital provided all the required documents to the OP with the request to release the bill amount of Rs.79,625/-, but the OP approved only amount of Rs.25,000/-. The complainant raised objection about the approval of short amount and requested the OP to explain the reason, but OP failed to explain it. The OP released short amount of Rs.25,000/- instead of complete bill amount of Rs.79,625/- to the hospital, thus having no other option, complainant paid the balance bill amount of Rs.53,079/- to the hospital from his own pocket.    

    It is submitted that against the unlawful act of the OP, complainant sent letter dated 17.11.2022 to the OP through speed post with a request to release the balance claim amount of Rs.53,079/-, but all in vain. Hence, this complaint has been filed alleging deficiency in service and unfair trade practice on the part of OP with a prayer to direct the OP to pay balance treatment charges of Rs.53,079/- along with interest, compensation for mental agony and harassment, litigation expenses.

2]       The OP did not turn up despite service of notice, hence, OP was proceeded ex-parte vide order dated 20.01.2023.    

3]       Complainant led evidence in support of his contention.

4]       We have heard the learned counsel for the complainant and have gone through entire documents on record.

5]       It is observed from the record that the complainant’s daughter in law was treated in Max Hospital, Phase 6, Mohali, from 01.11.2022 to 05.11.2022 for which the said Hospital raised a bill of Rs.79,625/- out of which Rs.25,000/- was paid by the OP and balance amount of Rs.53,079/- was paid by the complainant.

6]       The main grouse of the complainant is that in spite of having mediclaim policy (Annexure C-1), his total claim for Rs.79,625/- was only partially reimbursed by the OP for Rs.25,000/- and the OP has failed to reimburse the balance amount of Rs.53,079/- and also failed to explain any reason for approval of short amount.

7]       The OP did not appear to contest the claim of the complainant and preferred to be proceeded ex-parte. This act of the OP draws an adverse inference against it. The non appearance of the OP shows that it has nothing to say in its defence against the allegations made by the complainant. Therefore, the assertions of the complainant go unrebutted and uncontroverted. As such, the same are accepted as correct and the deficiency in service and unfair trade practice on the part of OP is proved.

8]       Not only this, it is usual with the insurance company to show all types of green pastures to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sorts of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation.  This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible. It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims.

9]       In similar set of facts the Hon’ble Punjab & Haryana High Court, Chandigarh in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others, 2008(3) RCR (Civil) Page 111 went on to hold as under:-

“It seems that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy.  The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.

 

10]      In the light of above observations & findings, the present complaint deserves to succeed against the OP. The complaint is partly allowed. OP is directed to pay balance claim amount of Rs.53,079/- to the complainant along with interest @6% per annum payable from 05.11.2022, i.e. the date of discharge from the hospital till the date of its actual realization.       

        The above said order shall be complied with by the OPs within a period of 45 days from the date of receipt of certified copy of this order.

 

11]      The pending application(s) if any, stands disposed of accordingly.

        The Office is directed to send certified copy of this order to the parties, free of cost, as per rules & law under The Consumer Protection Rules & Act accordingly. After compliance file be consigned to record room.

Announced

07.10.2024                                                               

Sd/-

 (AMRINDER SINGH SIDHU)

PRESIDENT

 

 

Sd/-

 (SURESH KUMAR SARDANA)

MEMBER

as