BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I, U.T. CHANDIGARH ======== Consumer Complaint No | : | 759 of 2010 | Date of Institution | : | 13.12.2010 | Date of Decision | : | 12.05.2011 |
Sh.Jang Bahadur Singh r/o H.No.14, Sector 4-A, Chandigarh. ….…Complainant V E R S U S 1. ICICI Lombard General Insurance Co. Ltd., ICICI Lombard Health Care, ICICI Bank, SCO No.1-2, Sector 9, Madhya Marg, Chandigarh. 2. ICICI Lombard General Insurance Co. Ltd., ICICI Lombard Health Care, TGV Mansion, 6th Floor, Plot No.6-2-1012, Khairatabad, Hydrabad-500004. ..…Opposite Parties CORAM: SH.P.D.GOEL, PRESIDENT SH.RAJINDER SINGH GILL, MEMBER DR.(MRS) MADANJIT KAUR SAHOTA MEMBER Argued by:Sh. Ravi Kant Sharma, Adv. for complainant. Sh.R.S.Dhull, Adv. for OPs --- PER P.D.GOEL, PRESIDENT The complainant namely Sh.Jang Bahadur Singh has filed the present complaint under section 12 of the Consumer Protection Act (as amended upto date) “hereinafter referred to as the Act”. In short, the facts of the case are that the complainant got mediclaim insurance policy No.40631/HAP/04637408/00/000 from OP which was valid from 16.04.2009 to 19.04.2010. It is the case of the complainant that he was hospitalized on 23.03.2010 at Fortis Hospital, Mohali and was treated for 10 days. The complainant was discharged on 01.04.2010 and thereafter he remained under the supervision and treatment of the doctors for a period of three month. The complainant was treated for the ailment “sub acute intestinal obstruction-tubercular”. According to the complainant, Fortis Hospital, Mohali is one of the approved hospitals by the OP for cashless access and as such the complainant had the right to get the treatment by showing his identity card issued by OP without paying any amount. The complainant informed OPs as well as the hospital authorities about his hospitalization for availing cashless access. The complainant alleged that vide letter dated 26.03.2010 (Annexure C-3), the cashless facility was declined by the OP on the probability of pre-existing disease. The complainant had to arrange funds from his friends and relatives to make the payment to the hospitalization. It is further the case of the complainant that he incurred Rs.1,66,585/- on his treatment. Thereafter, the complainant got served a legal notice dated 06.11.2010 (Annexure C-5) upon the OPs to refund Rs.1,66,585/- but to no effect, hence, this complaint. 2. OPs No.1 and 2 filed written statement and took some preliminary objections vis-vis maintainability and jurisdiction. On merits, the averments of the complainant made in the complaint were denied. It is admitted that the complainant had obtained the mediclaim insurance policy in question from OPs. It is also admitted the cashless facility was denied to the Fortis Hospital, Mohali vide letter dated 26.03.2010. It is denied that the payment of the claim was denied as an excuse to deprive the complainant from payment of the claim. It is further replied that OPs are not liable to pay the claim as the complainant was suffering from Diabetes Type-1 since 25 years, fatty liver grade-III and hypertension and its concealment amounts to suppression of material facts. So, the cashless facility was rightly denied to the complainant as per the terms and conditions of the insurance policy. Denying all the material allegations of the complainant and pleading that there has been no deficiency in service or unfair trade practice on their part prayer for dismissal of the complaint has been made. 3. Parties led evidence in support of their contentions. 4. We have heard the learned counsel for the parties and have also perused the record. 5. Learned counsel for the OPs referred to Annexure C-2 wherein under the “heading past history”, it has been recorded as under:- K/C/O Type-2 Diabetes Mellitus on OHA’s K/C/O Hypertension. 6. Learned counsel for the OPs argued that from the past history referred to above, it is proved that the complainant was suffering from pre-existing diseases i.e. diabetes mellitus and hypertension and the said fact has been concealed by him at the time of taking the insurance policy. On the other hand, the learned counsel for the complainant made a reference to letter dated 27.03.2010 (Annexure C-3) wherein in the column of “remarks”, it is categorically recorded by OPs that as the probability of the disease being pre-existing cannot be ruled out, cashless facility cannot be extended. 7. Although under the heading “past history” referred to above, it has been stated that the complainant was suffering from diabetes mellitus and hypertension but it is not proved that on whose instance the past history of the complainant was recorded. More so the doctor who recorded the past history has not supported the said fact with his affidavit. The matter does not rest here. In the letter dated 27.03.2010 (Annexure C-3) in the column of remarks, it has been stated by OPs that as the probability of the disease being pre-existing cannot be ruled out, cashless facility cannot be extended. Under these circumstances, it can legitimately be concluded that the OPs are not paying the claim on mere assumptions, conjectures and surmises. In our considered view, the OPs have no right to disallow the present claim. 8. Besides this, the OPs have placed on record the proposal form (Annexure R-1) which contains Note-1 and the same is reproduced as under:- “Note-1) Individual (s) proposed for insurance whose age is 58 years or above have to compulsorily undergo medical tests at ICICI Lombard designated diagnostic centres”. The age of the complainant at the time of obtaining the policy was between 61-65 years as is evident from the proposal form (Annexure R-1). So the conditions contained vide note-1 referred to above are fully applicable to the present case. Thus, it is clear that the complainant had undergone medical tests at the diagnostic centre of the OPs prior to obtaining/issuance of the insurance policy. 9. Now it is established on record that the complainant had compulsorily undergone medical tests at the diagnostic centre of OPs prior to obtaining the insurance policy. So the plea of OPs that probability of the diseases being pre-existing goes to ground. 10. The complainant has produced on record the bill dated 01.04.2010 (Annexure C-4) qua which he was asked by Fortis Hospital, Mohali to pay the amount of Rs.1,66,585/-. The details of amount qua Annexure C-4 go un-rebutted and un-controverted. Hence, the complainant is held entitled to Rs.1,66,585/- on account of the expenses incurred on his treatment. 6. As a result of the above discussion, this complaint is accepted and OPs are directed to pay Rs.1,66,585/- to the complainant along with interest @ 9% p.a. from the date of filing of the complaint till realization along with Rs.25,000/- as compensation for mental agony and harassment and Rs.5000/- as costs of litigation within one month from the date of receipt of the certified copy. 7. The certified copies of this order be sent to the parties free of charge. The file be consigned. | Sd/- | | Sd/- | Sd/- | 12.05.2011 | [ Madanjit Kaur Sahota] | | [Rajinder Singh Gill] | (P.D.Goel) | cm | Member | | Member | President |
| | MR. RAJINDER SINGH GILL, MEMBER | HONABLE MR. P. D. Goel, PRESIDENT | DR. MRS MADANJIT KAUR SAHOTA, MEMBER | | 
