IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM
Dated this the 20th day of July 2023
Present: Sri.Manulal.V.S, President
Smt.Bindhu.R, Member
Sri.K.M.Anto, Member
CC No.79/2022 (Filed on 13/04/2022)
Complainant : Sherry Mathew,
Pullolickal House,
Kothala P.O, Pampady,
Kottayam - 686 564.
(By Adv: M.C Scariah)
Vs.
Opposite parties : 1.The Assistant Vice President(Health Claim),
ICICI Lombard General Insurance Company,
ICICI Lombard Health Care,
ICICI Bank Tower, Plot No.12,
Financial District, Nanakram Guda,
Gachibowli, Hyderabad - 500 032,
Telangana.
2. The Senior Manager,
ICICI Lombard General Insurance Company,
Kottayam Branch,
Ist Floor, Trade Centre,
Sasthri Road, Kottayam.
(Both by Adv: Agi Joseph)
O R D E R
Smt.Bindhu.R, Member
The complainant was at first insured with National Insurance Company to a medi-claim policy. The 2nd opposite party under the direction of the first opposite party promised that if the medi-claim policy with National Insurance Company was transferred to ICICI Lombard, the opposite parties were ready to give all the medical benefits which the complainant get from the National Insurance Company. Believing this the complainant transferred his medi-claim policy with National Insurance Company to the ICICI Lombard and the opposite parties have issued policy certificate no.4128/P-HSHA/229135409/000 to the complainant. The present policy is valid from 11-10-2021 to 10-10-2022. The 2nd opposite party acted as the agent of the 1st opposite party. As per the terms of the said policy the complainant and his family members are entitled to get medical reimbursement for their treatment. His son Reyan Sherry Mathew was hospitalised at Rajagiri Hospital, Ernakulam and the claim of Rs.33,632/- was settled for Rs.32,264/- on 16-11-2021 by the opposite parties. Thereafter the said Reyan Sherry Mathew was admitted to Matha Amruthanandamayi Hospital, Kochi in connection with certain other diseases and he was treated there for the period from 06-11-2021 till 18-11-2021. The respondents are liable to compensate the complainant for the medical bill for the said treatment. Since there was no agreement between the opposite party and the said hospital for cashless transaction, the complainant had to pay the entire bill amount of Rs.2,11,769/- and he submitted a claim before the opposite party for the said amount. But on 16-12-2021 the opposite parties rejected the claim on flimsy grounds. The rejection of claim by the opposite parties is mal administration and deficiency of service on the part of the opposite parties which is to be compensated, hence the complaint is filed for realising Rs.2,11,769/- along with compensation of Rs.1,00,000/- from the opposite parties.
Notice was received by the opposite parties and they filed joint version through the Manager, Legal of ICICI Lombard General Insurance Company Limited. National Insurance Company and ICICI General Insurance Company are two different legal entities. Therefore a contract between the first opposite party and the complainant will not bind the second one. If policy holder of the first company opt for a policy with the second company, will not get continuing benefit of the policy conditions. The treatment expenses of Reyan Sherry Mathew is not correct. The petitioner has not spent Rs.2,11,769/- for the treatment of his son. The policy issued to the complainant starts only from 11.10.2021. As per the policy conditions the policy expenses related to the treatment of any illness within 30 days from the first policy commencement date shall be excluded. The date of admission of the petitioner’s son is on 6.11.2021. Hence the said treatment will not be covered under the terms and conditions of the policy. As per the terms and conditions of the policy the petitioner is not entitled to get the reimbursement. So the repudiation of the policy is correct and there is no deficiency of service on the part of the opposite parties. The complaint is liable to be dismissed.
The complainant filed proof affidavit along with documents which were marked as Exhibits A1 to A11. The opposite party also filed evidence affidavit and marked Exhibit B1 to B3.
Based on the rival contentions of the parties and evidence on record, we are of the view that the main issue to be resolved is whether the repudiation of the policy by the opposite party is lawful and if not so, what are the reliefs the complainant is entitled to?
POINTS 1 & 2 :-
The case of the complainant is that he being a policy holder of the opposite party by porting the previous policy with National Insurance Company, claimed for refund of the amount incurred for the treatment of his son Reyan Sherry Mathew who is also an insured under the policy with the opposite party. But the opposite party repudiated the claim for the reason that the claim was within 30 days of the inception of the policy which comes under the exclusion clause. The opposite party denying all allegations justifies the repudiation as it was within 30 days.
Now, we have given a thoughtful consideration on the evidence on record. Exhibits A2, A3 and A8, A10 and A11 are the discharge card and the bills from Amritha Hospital which prove that the insured Reyan Sherry Mathew was under treatment in the hospital from 06.11.2021 to 18.11.2021.The policy is admitted by the opposite party and Exhibit A1 is the policy schedule and Exhibit B1 is the terms and conditions. Exhibit A4 is the repudiation letter sent by the opposite party to the complainant dated 16.12.2021 in which the reason for the repudiation is stated as “30 days waiting period”. “As per review of documents it is seen that the insured Rayan Mathew has been covered under policy since 11-OCT-2021 which is first year policy for him without any previous year continuity and date of admission 06/11/2021 falls in 30 days waiting period. As per policy schedule Part II 3.4 Code-Exc103:30-day waiting period –a) Expenses related to the treatment of any illness within 30 days from the first policy commencement date shall be excluded. Hence rejected.”
The reason for the rejection of the claim is that the date of admission of the insured for the treatment was within 30 days from the inception of policy ie., 11.10.2021 to 11.10.2022. Upon a detailed reading of Exhibit A1, we find that there is a column for previous policy No. and it is recorded as 570600502010000724. Though the opposite party has stated in the version that they were not bound by the conditions of another insurance company, from this policy schedule it is inferred that the policy has been ported from another company. It is evident from another column in which it is written as portability waiver period (yrs) 2 for complainant and 2 for his wife and 0 for his son. Next column is Portability date of joining 11.10.2019 for the complainant and his wife and for the child it is 08.10.2021. So the contention of the opposite parties that they were not bound by the conditions of policy issued by National Insurance Company is not admissible as from the documents it is evident that the policy was ported from National Insurance Company to the opposite party company.
The reason for the repudiation as per the opposite party is that the treatment was within 30 days from the date of inception of the policy. But Exhibit A5 which is the claim settlement letter sent by the opposite party to the complainant dated 16.11.2021 settling the claim of the same Reyan Sherry Mathew, for the expenses incurred on a treatment in Rajagiri Healthcare and Education Trust. The date of the said admission was 18-10-2021 and an amount Rs.32,264/- was awarded to the complainant towards the settlement. For this claim the admission was within 10 days and the claim amount was given. Now the second claim is for the period from 6-11-2021 to 18-11-2021 which is within 26 days of the inception of the policy is rejected for the 30 days exclusion. We find that by approving the first claim of the complainant under the policy, the opposite party has estopped their right to use the exclusion clause of 30 days.
“Estoppel is a legal doctrine that precludes a party from contradicting its own previous actions if those actions have been reasonably relied on by another party.” (Oriental Insurance Company Ltd. Vs. Baby Komal & Anr. on 27 November, 2012) The Supreme Court in Chaggan Lal Keshav Lal Mehta vs. Patel Narain Dass Hari Bhai AIR 1982 SC 121 held that the plea of breach of the terms and conditions of policy having not been taken in the earlier Claim Petitions at Shahpura, the Appellant was estopped from raising a plea of breach of terms and conditions of the policy in this case as it cannot be permitted to shift stands in different Claim Petitions. Thus, the Claim Petitions were allowed and various amount of compensation were awarded in different Claim Petitions.”
Thus the opposite party cannot take different views in two claims having the same situations and we find that the complainant is eligible to get the hospital expenses reimbursed by the opposite parties.
So we allow the complaint and the 2nd opposite party is directed to give Rs.2,11,769/- (Rupees Two Lakhs Eleven Thousand Seven Hundred and Sixty Nine only) towards the claim amount with an interest of 9% p.a. from the date of filing of the complaint and Rs.20,000/- (Rupees Twenty Thousand only) as compensation towards the mental agony to the complainant.
The order shall be complied within 30 days from the date of receipt of copy of this order. If not complied as directed, the compensation amount will carry 9% interest from the date of order till realisation.
Pronounced in the Open Commission on this the 20th day of July, 2023
Smt.Bindhu.R, Member Sd/-
Sri.Manulal.V.S, President Sd/-
Sri.K.M.Anto, Member Sd/-
APPENDIX :
Exhibits from the side of the Complainant :
A1 - Copy of Policy Schedule/Certificate No.4128/P- HSHA/
29135409/ 00/000
A2 - Copy of Inpatient Collection & Appropriation Receipt with
inpatient detailed bill dated 18/11/2021 for Rs.2,27,210/-
issued from Amritha Institute of Medical Science, Kochi
A3 - Copy of ICICI Lombard Health Care Claim Form for
reimbursement
A4 - Copy of Repudiation letter dated 16/12/2021
issued by the Ist opposite party
A5 - Copy of Claim Settlement letter dated 16/11/2021
issued by the Ist opposite party
A6 - Copy of lawyer notice dated 03/01/2022 issued by the
complainant to the Ist opposite party
A7 - Postal Receipt dated 05/01/2022
A8 - Copy of material issue Report dated 18/11/2021
A9 - Copy of Premium Certificate issued by the opposite
party for tax purpose
A10 - Copy of Discharge Summary dated 18/11/2021
issued from Amritha Institute of Medical Science, Kochi
A11 - Copy of Pharmacy Issue Report dated 08/12/2022
Exhibits from the side of Opposite parties :
B1 - Copy of Policy with terms and conditions
B2 - Copy of Repudiation letter dated 16/12/2021
issued by the Ist opposite party
B3 - Copy of Claim Form
By Order,
Sd/-
Assistant Registrar
