Before the District Consumer Disputes Redressal Commission, Rohtak.
Complaint No. : 171.
Instituted on : 20.04.2018.
Decided on : 07.11.2023.
PurushotamKhangwal(age 43 years) s/o Sh.Balwant Singh R/o H.No.327/15, Sanjay Nagar, Rohtak, Haryana-124001.
..............Complainant.
Vs.
- ICICI Lombard General Insurance Company Limited, (Mailing Address)IRDA Reg. No.115 401 & 405, 4th floor, Interface 11, new Linking Road, Malad(West) Mumbai-400064 through its Director/M.D./Manager.
- ICICI Lombard House having its Registered office at 414 Veer Savarkar Marg, Near Siddhi Vinayak Temple Prabhadevi, Mumbai-400025.
- ICICI Lombard General Insurance Company Limited, 2nd floor, AppuGhar Shopping Complex, Civil Road, Rohtak through its Divisional Manager.
Second address:
ICICI Lombard General Insurance Company Limited, Ashoka Plaza AshokaChowk, Delhi Road, Rohtak.
……….Opposite parties.
COMPLAINT U/S 17 OF CONSUMER PROTECTION ACT.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
DR. TRIPTI PANNU, MEMBER.
DR. VIJENDER SINGH, MEMBER
Present: Sh.Pardeep Mittal, Advocate for the complainant.
Sh.Naveen Chaudhary, Advocate for the opposite parties.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Brief facts of the case as per complainant are that he had obtained a cashless Health Insurance policy online from respondentno.3for himself as well as his family including minor child Akshra vide policy no.412i1/iH/127882816/00/000 having plan name iH 2Adults-3child-1year w.e.f. 02.03.2017 to 01.03.2018. On 28.11.2017 the daughter of complainant, Akshra suffered from vomiting and fever problem and thus complainant admitted her daughter to Hooda Hospital situated at GohanaAdda, Rohtak. On 28.11.2017 complainant telephonically gave intimation in this regard to respondents on toll free No.18002666. The daughter of complainant remained admitted in the aforesaid hospital with effect from 28.11.2017 to 03.12.2017 i.e. 5 days and the complainant incurred Rs.15230/- on account of her treatment. He had paid the aforesaid expenses out of his own pocket despite having the aforesaid cashless health insurance policy issued by respondents.The complainant approached to respondentin the second week of December 2017, submitted all the relevant documents and requested them to pass the claim. That on 17.12.2017 the complainant received a massage that aforesaid claim is under process. After that on dated 26.12.2017 he received a letter from respondent's office vide which they asked the complainant to furnish some documents, which were duly submitted by the complainant on 03.01.2018. On 23.01.2018 a person namely SatishDhankharmade telephonic call to complainant and visited the residence of the complainant for settlement of aforesaid claim. He told the complainant that his company was intended to pay expenses only for treatment of four days andassured the complainant that if the complainant will agree to receive claim offour days then the respondents will pass the claim within a week. Upon this the complainant agreed to waive off the claim of one day. The said person wrote a letter for settlement for above said four days and took signature of complainant and click a photograph of complainant with settlement letter. On 30.01.2018 the complainant received a letter and an e-mail sent by respondents vide which theyhad repudiated the claim of complainant on the ground of misrepresentation. The act and conduct of opposite partiesis illegal and amounts to deficiency in service. Hence this complaint and it is prayed that opposite parties may kindly be directed to pay Rs.23,490/- + 15,230/- i.e. amount of policy premium plus treatment expenses to the complainant alongwith interest at the rate of 24% per annum w.e.f. 28.11.2017 till actual realization, Rs. 51,000/- as amount of harassment besides Rs.25,000/- as amount of litigation expenses to the complainant.
2. After registration of complaint, notices were issued to the opposite parties. Opposite parties appeared and filed their reply submitting therein that the complainant has never intimated the answering respondent till date. The said claim was repudiated vide the letter dated 30/01/2018 and the said policy was terminated vide letter dated 06/03/2018 as the claim was based on false facts and mis representation. During the processing of the claim for admission at Hooda hospital the insured gave the false information to the answering respondent and so the said claim was repudiated as per the Standard Exclusion on clause of the insurance policy. The complaint is liable to be dismissed on these score alone. The complainant is not entitled to get any claim and compensation as prayed for from the answering respondents/opposite parties. There is no deficiency in service and negligence on the part of the answering respondents/opposite parties and dismissal of complaint has been sought.
3. Learned counsel for the complainant in his evidence has tendered affidavits Ex.CW1/A, documents Ex.C1 to Ex.21 and has closed his evidence on dated 13.03.2019. Learned counsel for the opposite party has tendered documents Ex. R1 to Ex.R15 and closed his evidence on dated 25.11.2019.
4. We have heard learned counsel for the parties and have gone through material aspects of the case very carefully.
5. In the present case the claim of the complainant has been repudiated by the opposite party vide its letter dated 30.01.2018 on the ground that the claim is not payable for the standard exclusion under the head ‘Remarks’ that:-
“As per the part (iii) of the schedule, exclusion under 12, fraudulent claims- if any claim is in respect fraudulent or if any false statement or declaration is made or use in support there of or any fraudulent means or device are used by the insured or any one acting on his means or devices are used by the insured anyone acting on his behalf to obtain any benefit under this policy not payable"
We have minutely perused the written statement filed by the respondent. In reply the respondent has not mentioned any fact regarding misrepresentation by the complainant, regarding the fraud he committed or not disclosed any wrong declaration. Merely it has been stated that claim cannot be paid because the complainant has misrepresented the facts. No affidavit has been filed. It has been submitted during the arguments that the complainant was admitted in the hospital only for 4 days and he claimed hospitalization for the period 28.11.2017 to 03.12.2017 i.e for 6 days but in fact the complainant only admitted as indoor patient for 5 days. In support of this contention opposite party has placed on record a documents Ex.R4 photocopy of hand written statement of the complainant but this document is not supported with the affidavit of opposite party. We have minutely perused the document Ex.R3. This document is in the form of questionnaire presented by ICICI Lombard Gen. Insurance co. before the treating doctor. The perusal of this document itself shows that the date of admission of patient is 28.11.2017 and discharge 03.12.2017. So as per this document also it has been established that patient was admitted on 28.11.2017 and discharged on 03.12.2017. As such there is deficiency in service on the part of opposite parties and complainant is entitled for the claim under the policy.
6. In view of the facts and circumstances of the case we hereby allow the complaint and direct the opposite parties to pay Rs.15230/-(Rupees fifteen thousand two hundred and thirty only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e. 20.04.2018 till its realization and shall also pay Rs.5000/-(Rupees five thousand only) as compensation on account of deficiency in service and Rs.5000/-(Rupees five thousand only) as litigation expenses to the complainant within one month from the date of decision.
7. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
07.11.2023.
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Nagender Singh Kadian, President
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TriptiPannu, Member.
……………………………….
Vijender Singh, Member
