Punjab

Sangrur

CC/130/2022

Usha Garg - Complainant(s)

Versus

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

Sh. Amit Aggarwal

04 Mar 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SANGRUR .

                                                                         Complaint No. 130

 Instituted on:   18.01.2022

                                                                        Decided on:     04.03.2024

 

Usha Garg wife of Late Sh. Naresh Kumar Garg, resident of H.NO.1/2, Railway Road, Sangrur.

                                                         …. Complainant.     

                                                 Versus

1.             ICICI Lombard General Insurance Company Limited, ICICI Lombard Health Care, ICICI Bank Tower, Plot No.12, Financial District, Nanakram Guda, Gachibowli, Hyderabad-500032 through its Managing Director.

2.             ICICI Lombard General Insurance Company Limited, Registered Office: ICICI Lombard House, 414, Veer Savarkar Marg, Near Sidhi Vinayak Temple, Pravhadevi, Mumbai 400025 through its Director.

                                                        ..Opposite parties.

 

For the complainant    :       Shri Amit Aggarwal, Adv.

For Opp.parties          :       Shri Bhushan Garg, 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 late husband of the complainant Shri Naresh Kumar Garg got himself insured with New India Assurance Company Limited for health insurance in the year 2012 and the policy was got renewed from time to time.  Further the policy was renewed from 24.4.2020 to 23.4.2021 vide policy number 36130034209500000006 for the insured sum of Rs.4,50,000/- in total. Further case of the complainant is that in the year of 2016, Naresh Kumar Garg also obtained another top-up health insurance policy from the OPs in addition to the above said policy of New India Assurance company Limited for Rs.10.00 Lacs after leaving first Rs.4,00,000/-. The first Rs.4,00,000/- of the medical bill would be paid by the New India Assurance Company Limited and the remaining amount upto Rs.10,00,000/- of the total medical bill would be paid by the opposite parties as per the policy. It is further averred that before insuring Shri Naresh Kumar Garg got medically checked from their empanelled hospital and after that the policy bearing number 4113i/XOL/116089273/00/000 dated 11.5.2016 for the period from 29.4.2016 to 28.4.2018 was issued. It is further averred that the said Naresh Kumar Garg paid Rs.500/- as fee for the said medical checkup of which Rs.250/- was reimbursed to him as per its policy. In the said policy, the complainant is the nominee being the wife of said Naresh Kumar Garg. Further case of complainant is that Naresh Kumar Garg renewed the policy from the OPs from to time time and from 29.4.2020 to 28.4.2022 vide policy number 4113i/XOL/116079273/02/000.

2.             Further case of the complainant is that in the month of April, 2021 the insured Naresh Kumar Garg suffered infection with Covid-19 virus and was got admitted in Mayo Hospital, Mohali which is also known as  Chandigarh Health Care Private Limited, Mohali for the treatment of the said disease and remained admitted from 26.4.2021 to 06.05.2021 and on 06.05.2021 he succumbed to the said virus and died, where he spent an amount of Rs.8,75,394/- on his treatment.  Further case of complainant is that after the death of said Naresh Kumar Garg, the complainant being the nominee lodged the claim with New India Assurance Company Limited for the payment of medical claim and the New India Assurance company Limited passed the claim to the tune of Rs.4,50,000/ and the remaining claim amount of Rs.4,25,394/- was to be reimbursed by the OPs as per the policy.  

3.             The grievance of the complainant is that the OPs repudiated the rightful claim of Rs.4,25,394/- on the ground of non disclosure of hypertension, Asthma, which is said to be illegal and without basis. Moreover, the said corona virus has no link with the alleged hypertension and asthma. The said Naresh Kumar Garg was non alcoholic and non smoker during his lifetime. The opposite party also sent a letter dated 08.11.2021 in the name of Naresh Kumar Garg regarding termination of notice of health policy mentioned above by alleging that he has hypertension since 12 years and on medication. 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.4,25,394/- alongwith interest @ 18% per annum and further claimed compensation and litigation expenses.

4.             Record shows that notice was sent to the OPs, but did not appear, as such were proceeded against exparte on 09.09.2022. Further record shows that the learned counsel for the OPs filed an application dated 09.10.2023 for recalling/review of the order dated 9.9.2022 passed by this Commission and to set aside the exparte order dated 9.9.2022 vide which the Ops were proceeded against exparte, but this application was disposed of vide order dated 10.10.2023 and the OPs were permitted to join the proceedings onwards without filing any written reply or evidence and the OPs were accordingly granted opportunity to address arguments in this case.

5.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-22 copies of documents and affidavit and closed evidence. On the other hand, the OPs have not produced any evidence as they were exparte.

6.             We have heard the learned counsel for the parties and have gone through the record on the file. Written arguments were filed by the parties.

7.             It is writ large on the file that husband of the complainant was insured with the OPs under the medical insurance policy in question on top up basis for Rs.10,00,000/-. The contention of the complainant is that during the subsistence of the insurance policy in question, Shri Naresh Kumar Garg died on 6.5.2021 due to Corona Virus. It is further argued that though an amount of  Rs.8,75,394/- was spent on the treatment and out of the said amount, New India Assurance Company Limited paid an amount of Rs.4,50,000/- and the remaining amount of Rs.4,25,394/- was to be paid by the OPs which was withheld by the OPs and the claim was rejected/repudiated on the ground that Shri Naresh Kumar Garg was suffering from hypertension which was not disclosed by him at the time of taking the insurance policy.  Further case of complainant is that after the death of said Naresh Kumar Garg, the complainant being the nominee lodged the claim with New India Assurance Company Limited for the payment of medical claim and the New India Assurance company Limited passed the claim to the tune of Rs.4,50,000/ and the remaining claim amount of Rs.4,25,394/- was to be reimbursed by the OPs as per the policy which was not paid by the OPs illegally and without any basis.  Ex.C-4 is the copy of insurance policy for Rs.10.00 Lacs, which shows that Naresh Kumar Garg was insured by paying the requisite premium of Rs.3800/-. Record shows that the OPs chose to remain exparte and the OPs have not produced iota of evidence as they were exparte.  

8.             Further  Ex.C-5 is the copy of the medical bill of Shri Naresh Kumar Garg issued by Chandigarh Healthcare Pvt. Ltd. Mohali where the patient remained admitted from 26.4.2021 to 06.05.2021 and spent an amount of Rs.8,42,864/- on the treatment. It is worth mentioning here that admittedly an amount of Rs.4,50,000/- has been paid by New India Assurance Company Limited and the remaining amount of Rs.4,25,394/- was to be paid by the OPs which has been withheld illegally and without any basis  on the ground of non disclosure of hypertension and Asthma. Ex.C-7 and Ex.C-8 are the emails where the claim has been rejected on the ground of non-disclosure of hypertension, asthma…… Ex.C-9 is the termination notice wherein it is mentioned that the insured Naresh Kumar Garg has hypertension since 12 years and on medication and the same was not disclosed during the policy inception. Ex.C-10 is the medical checkup appointment letter. Ex.C-11 is the payment slip of Rs.200/- for the M.E.R. and E.C.G. tests. Ex.C-12 is the receipt of Rs.300/- for the laboratory test. Ex. C-13 is the medical examination report form of Naresh Kumar Garg wherein no disease was found out and this form was duly stamped and signed by Dr. Ravinder Bansal of Bansal Hospital and Heart Centre, Sangrur. Ex.C-14 to Ex.C-17 are the medical examination reports. It is clear from the above mentioned medical record that the insured was thoroughly medically examined by the OPs and no disease was found out. Ex.C-22 is the claim form of the OPs wherein it mentioned at page number 3 in the column of Primary Diagnosis Covid-19 Pneumonia and this form was stamped and signed by Dr. Jasmeet Singh. From the above discussion it is clear that insured Naresh Kumar Garg was diagnosed with Covid-19 Pneumonia which has no connection with the alleged disease of hypertension and asthma. Moreover, the above said policy was issued after thorough medical examination of the insured conducted by the insurance company. In Divisional Manager, LIC of India and another versus R.Viji Akila and another Revision Petition No.842 of 2016 decided on 09.06.2022 (National Commission) wherein the case was that the claim was repudiated on the ground of concealment of disease. Medical examination of insured conducted by panel doctor of insurance company. Death claim of insured repudiated on the ground that there was suppression of material information relating to health condition. Held, it is admitted that premium was paid, policy was valid and policy issued after a medical examination of insured conducted by insurance company from a doctor on its own panel. Insurance company had not been able to conclusively establish that there was in fact suppression of material information. Revision was dismissed.   In another case HDFC Standard Life Insurance Co. Ltd. versus Gurkirtan Singh, First Appeal No.356 of 2018 Decided on 31.10.2022 (NC). Concealment. If there is suppression of any medical condition, unless it is shown that concealment of medical illness has any connection with disease with which death occurred, such a concealment is of no consequence.  Death claim repudiated by insurer on the ground that insured was suffering from loose bodies, left knee (Arthroscopic) and underwent treatment for same but did not disclose it in proposal form. Held, insured had not died of any knee disease but died of cardiac arrest. So even there was, any concealment, it was not material and repudiation on this count was not justifiable. Appeal was  dismissed.  

9.             Now, coming to the quantum of compensation payable to the complainant. Admittedly, the insurance policy is for the sum insured of Rs.10,00,000/-.  The complainant has though claimed an amount of Rs.4,25,394/-, but the complainant has produced the treatment bill Ex.C-5 of Chandigarh Health Care Pvt. Ltd. Mohali on record which shows that the amount of Rs.8,42,864/- was spent, out of which the New India Assurance Company Limited has already paid to the complainant an amount of Rs.4,50,000/- and the remaining amount of Rs.3,92,864/- is to be paid by the OPs, which was never paid.  As such, we find it to be a clear cut case of deficiency in service on the part of the OPs by not paying the rightful and legal claim to the complainant. 10.                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.

11.            Accordingly, in view of our above discussion, we allow the complaint and direct OPs to pay to the complainant the claim amount of Rs.3,92,864/- alongwith interest @ 7% per annum from the date of filing of the present complaint i.e. 18.01.2022 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.

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

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

                             Pronounced.

                            March 4, 2024.