District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.608/2021
Date of Institution: 30.11.2021
Date of Order: 26.10.2022.
Smt. Bharti Bhatia, W/o Shri Mahesh Bhatia, R/o House No. 1930, Jawahar Colony, NIT, Faridabad, Haryana – 121005.
…….Complainant……..
Versus
1. ICICI Lombard General Insurance Company Limited having office: SCO No. 17, Ist floor, Sector-16, Faridabad, Haryana.
2. ICICI Lombard General Insurance Company Limited, Having office: B-1, 1-2, Mohan Cooperative Industrial Estate, Mathura Road, Block E., New Delhi – 110 044.
…Opposite parties……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Sh. Ravi Nagpal, counsel for the complainant.
Sh. Rakesh Dabaas, counsel for opposite parties Nos.1 & 2.
ORDER:
The facts in brief of the complaint are that the complainant had availed the Family Health Insurance Policy bearing No. 4128i/P-Ihn/205819020/00/000 in the name of her husband i.e. Mahesh Bhatia for a period of 21.09.2020 to 20.09.2021. On 05.05.2021 the complainant was admitted to the hospital namely Krishna Nursing Home, Sector-10, Faridabad, suffering from fever & cough and shortness of breath and remained there upto 07.05.2021. The total bill of the hospital was Rs.58,350/-. Even after the lapse of time opposite party fails to give the reason of repudiating the claim of the complainant and after running form pillar to post complainant tracked her claim and got to know the reason of the repudiation of the claim “as per the part iii of the schedule. Exclusion under 12. Fraudulent claims – if any claim is in any respect fraudulent. OR if any false statement or declaration is made or used in support thereof or any fraudulent means or devises are used by the insured or anyone 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”. The complainant alongwith her husband approached to the concerned doctor i.e. Dr. Surendra Kumar Meena at Krishna Nursing Home, sector-1, Faridabad and asked about the details of the patient then Dr. Surendra Kumar Meena, assured the complainant and her husband that all the treatment done during hospitalization were relevant and necessary for etiology of disease and for management. And issued a letter on dated 03.08.2021 on Krishna Nursing Home, letter head, in which the patient was admitted “ This is to certify that Mrs. Bharti Bhatia was admitted in our hospital with complaint of a fever & cough and shortness of breath. Then HRCT chest was done in emergency which suggested LRTI with atypical pneumonia with CT Score 14/25, patient was having
low SP02 and her condition did not allow us to wait further to confirm atypical pneumonia or RTPCR testing, we considered this case of atypical viral pneumonia (suspected Covid-19), so on the basis of CT findings, we treated patient for above disease, kindly consider her for cashless facility. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) pay a sum of Rs.58,350/- towards the hospital bills and other expenses alongwith interest @ 24% p.a.
b) pay Rs. 2,00,000/- as compensation for causing mental agony and harassment .
c) cost of present proceedings.
2. Opposite parties put in appearance through counsel and filed written statement wherein Opposite parties refuted claim of the complainant and submitted that at the very threshold the present complaint, the complaint of the complainant as to his treatment was not maintainable reason being, it was established from the claim documents as well as investigation report so got conducted by the opposite parties that the claim of the complainant was a fraudulent claim as defined under PART III of the policy General Terms & Condition NO.12 so incorporated in the insurance policy. The complainant neither had any cause of action nor locus standi to file the present complaint. The complainant had submitted claim form dated Nil alongwith relied upon documents with regards to indoor treatment w.e.f. 05.05.2021 to 07.05.2021 from Krishna Nursing Home, Faridabad. After scrutiny of the claim papers, an independent investigator was depute dot verify the treatment record as well as ascertain the status of the hospital in question. After verification, the said investigator had prepared and submitted his report by incorporating the all facts and circumstance therein as well as annexing the Xerox
of indoor treatment record, questionnaire of the patient. Since it had been established form the claim documents as well investigation report so got conducted by the opposite parties that the claim of the complainant as to his treatment was a fraudulent claim as defined under Part iii of the policy. Thus , the insurance company had treated the subject claim as “No claim” by closing the file in terms of letter of intimation dated 22.08.2021 which decision cannot be termed unconscionable at all. Opposite parties denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite parties– ICICI Lombard Gen. Insurance co. & Others with the prayer to: a) pay a sum of Rs.58,350/- towards the hospital bills and other expenses alongwith interest @ 24% p.a. b) pay Rs. 2,00,000/- as compensation for causing mental agony and harassment . c) cost of present proceedings.
To establish his case the complainant has led in his evidence, Ex.CW-1/A – affidavit of Bharti Bhatia,, Ex,C-1 – insurance policy for the period 21.09.2020 to 20.9.2021, Ex. C-2 – In patient bill,, Ex.C-3 – Discharge summary, Ex.C-4 – prescription dated 03.08.2021 issued by Dr. Surendra Kumar Meera, Ex.C-5 – Track your claim.
On the other hand counsel for the opposite parties strongly agitated
and opposed. As per the evidence of the opposite parties Ex.RW1/A – affidavit of Shri Rohan Mishra, Manager (Legal), M/s. ICICI Lombard General Insurance
Company Ltd. 4th floor, Red Fort Capital Parsvnath Tower, Bhai Veer Singh Marg, Gole Market, New Delhi, Ex.R-1 – Policy Schedule (policy certificate). Ex.R-2 – claim form, Ex.R-3 – Discharge summary, Ex.R-4 – In patient bill, Ex.R-5 – questionnaire, Ex.R-6 - Individual reimbursement.
6. In this complaint the complaint was filed by the complainant with the prayer to pay a sum of Rs.58,350/- towards the hospital bills and other expenses alongiwth interest @ 24% p.a. The claim of the complainant was repudiated by the opposite party on the ground of fraudulent. In this regard, the opposite parties have examined Ex.R1 to R7.
7. After going through the evidence led by the parties, the Commission is of the opinion that as per ICLM Conclusion Details vide Ex.R-6 in which it has been mentioned that DOJ: 21 Sep. 2020 insured stated that she was admitted in Krishna Nursing Home in single private room from 5 May 21 to 7 May 21 with C/o Chest pain since 2nd May which increase don5the May 21, Pre admission consulted to Dr. Atul. As per ICP C/o with cough, difficulty in breathing, fever, weakness since 10 days HRCT dated 2 May 21 chest shows GGO with interlobular septal thickening and fibrosis involving B/L lungs, CT score shows 14/25. Treating Dr. Surender Kumar Meena as Covid package in bill that too very high, as per tariff single room charge is Rs.3,000/- per day but 25,000 per day charge, inflation of Rs.44,000 in room rent, as pharmacy bill inj. Meropenem charged of Rs.12,390/- but as per ICP not advised and not given in medication chart. Hence, recommended as repudiation under MOF inflation in bill of Rs.56,390/-. Ex.R5 is only the questionnaire which was asked by the investigator from the complainant which does not prove any kind of fraudulent done by the complainant. Hence, the complaint is allowed.
8.. Opposite parties are directed to process the claim of the complainant within 30 days of receipt of the copy of order and pay the due amount to the complainant along with interest @ 6% p.a. from the date of filing of complaint till its realization. The opposite parties are also directed to pay Rs.2200/- as compensation on account of mental tension, agony and harassment alongwith Rs.2200/- as litigation expenses to the complainant. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 26.10.2022 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
