BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 317 of 2020
Date of Institution : 18.12.2020
Date of Decision : 13.03.2024
Jitin Goyal (aged about 37 years) son of Sh. Kailash Goyal, House No.12, HUDA, Sec. 20, Sirsa- 1250055.
……Complainant.
Versus.
1. ICICI Lombard General Insurance Company Ltd., ICICI Lombard House, 414 Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi Mumbai- 400025 through its General Manager/ authorized signatory.
2. ICICI Lombard General Insurance Company Ltd., Unit No. 5-7F, Fifth Floor, Metro Polis Mall, Opposite Vidyut Sadan, Delhi Road, Hisar- 125005 through its Divisional Manager/ Authorized Signatory.
3. ICICI Lombard General Insurance Company Ltd., ICICI Lombard Health Care, ICICI Bank Tower, Plot No.12, Financial District Nanak Ram Guda, Gachi Bowli, Hyderabad- 500032 Telangana through its Associate Vice President, Email ID- …….Opposite Parties.
Complaint under Section 35 of the Consumer Protection Act, 2019.
Before: SH. PADAM SINGH THAKUR……. PRESIDENT
MRS.SUKHDEEP KAUR……………MEMBER.
Present: Sh. Ravinder Monga, Advocate for the complainant.
Ms. Amandeep Kaur, Advocate for opposite parties.
ORDER
The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred as Ops).
2. In brief, the case of complainant is that complainant purchased a health insurance policy No. P/211121/01/2018/002582 for the period 30.12.2017 to 29.12.2018 with the basic floater of sum insured amount of Rs. five lacs from Star Health and Allied Insurance Company Ltd. The Incharge of the said company got complete medical check up of the complainant and his other family members from their approved doctors before issuing the policy. That thereafter insurance policy was renewed in the next year i.e. w.e.f. 30.12.2018 to 29.12.2019. It is further averred that thereafter op no.4 also acting on behalf of ops no.1 to 3 persuaded the complainant to purchase another health insurance policy of ops no.1 to 3 stating that in their policy every family member becomes entitled to avail the risk up to sum insured amount whereas in the policy of Star Health, the limit of risk was Rs.5.00 lakh only concerning all the family members. That complainant stated to op no.4 that he does not want to breakdown the continuation of his policy obtained from Star Health and Allied Insurance Company Ltd. but op no.4 undertook and assured that ICICI Lombard is the only company which treats the previous period under any other policy to be in continuation for covering the risks under the policy issued by it. The op no.4 also insisted him to opt/ switch over to the ICICI Lombard Insurance company after completing of the running policy period of 29.12.2019 under the policy issued by Star Health. It is further averred that in this manner complainant purchased Medical Health Policy No. 41281/P-IHN/191983163/00/000 commencing from 17.01.2020 to 16.01.2021 from ICICI Lombard General Insurance Company Ltd. covering the risk of complainant and his family members i.e. wife, one daughter and two sons and policy was issued in continuation of the earlier policy issued by Star Health w.e.f. date of joining on 30.12.2017. As per the terms and conditions of the policy, the period of policy was from 30.12.2017 to 16.01.2021 and this fact has been duly mentioned in Policy No. 41281/P-IHN/191983163/00/000 issued by ops after receiving the premium of Rs.21,629/- from the complainant.
3. It is further averred that son of complainant namely Purvansh Goyal aged 3 years 5 months duly covered under the policy suddenly had few medical issues on 03.02.2020. The complainant contacted Dr. Jyoti Sehgal who advised for a test of MRI Brain of Purvansh Goyal. However, due to corona pandemic and lockdown all over the country the same could not be done and finally on 15.07.2020 MRI Brain was done from Alfa MRI Centre, Dabwali Road, Sirsa under the clinical guidance of Dr. A.R. Godara who after closely analyzing the MRI reported that “MRI Brain finding is abnormal shape of Cranium Craniosynostosis”. That thereafter complainant on 17.07.2020 went to Medanta Hospital, Gurgaon for clinical examination of his son from an expert medical profession i.e. Dr. V.P. Singh Neuro Surgeon who advised for CT scan with the observation that “Plain CT Head Scan to look at the Sutures with 3D reconstruction of head and face, to consult doctor R. Khazanchi Plastic Surgeon”. It is further averred that thereafter a detailed investigation was done on 17.07.2020 and team of Radiology department of Medanta Hospital then observed that “Bone window reveals early fusion of the left Coronal Squamosal Frontosphenodal and Sphenosqumosal Sutures with resultant Asymmetrical Flattening of the left side head. The imaging findings are suggestive of left frntal/ anterior Plagiocephaly.” That thereafter doctors decided for immediate surgery upon Purvansh Goyal costing around Rs. 4 to 5 lacs and complainant had no option but to give his consent for such surgery. It is further averred that before taking this decision for the surgery, the complainant immediately sent mail to the ops on 29.07.2020 with the request either to arrange the amount or in the alternate to permit the complainant to proceed for the surgery at the costs of insurance policy commencing from 17.01.2020 to 16.01.2021. That Purvansh remained brilliant and active in the entire academic and sports activities without feeling any problem till July, 2020. The surgery was performed on 16.09.2020 at Medanta Hospital and he remained as indoor patient under the observation of Dr. V.P. Singh and Dr. Khazanchi from 15.09.2020 to 21.09.2020 and also remained on post operation follow up treatment and till date he is taking medicines with precautions as per the advice of the doctors. That even after receiving intimation the ops did not respond to the request of complainant. Thereafter, the doctors informed to the ops through email on 15.09.2020 for providing cashless facilities on the basis of health insurance policy issued by them. The ops without properly analyzing the case of Purvansh and without going through the record and while acting in a casual manner rejected the cashless claim of complainant through email dated 15.09.2020 with the reason “Permanent exclusion NCH). The complainant since was already under tension and grief due to sudden life saving surgery of his son and he was thus totally shocked and stunned to know about the alleged rejection reason of the ops. The complainant was left with no option but to arrange his own funds for the surgery of Purvansh as per the advice of the doctors. That after getting discharge from the hospital, the complainant contacted the op no.4 and inquired about the reason of rejection of claim. The op no.4 in turn contacted the ops no.1 to 3 and then informed the complainant that due to lack of communication, the cashless claimw as inadvertently rejected and he further advised to submit the details of claim with original bills and other relevant documents so that entire claim could be settled and released in favour of complainant. It is further averred that upon receiving the assurances and promises made by ops, the complainant submitted claim form with all required documents as advised by op no.4 on 29.09.2020 for reimbursement of the entire expenses of Rs.5,06,170/- although complainant had also spent another amount of Rs. one lac on related expenses i.e. outside tests, medicines, transportation, and fee paid for advice from other doctor etc. The complainant as per the guidance and advice of op no.4 for early decision sent all these documents through email to the ops. That thereafter ops took advice from the concerned doctor namely Dr. V.P. Singh who had informed that there was no past history of such disease, though the name of problem relates to birth whereas patient Purvansh never complained for such type of problem so the same could not be treated as birth related problem. It is further averred that ops showing their negligence, deficiency in service and with the predetermined mind to reject the claim of complainant on 09.11.2020 simply denied the same with the observation “As per part-2 of schedule 3. 4 (xv) of policy wordings treatment relating to birth defects and external congenital illness or defects or anomalies are not payable, hence claim request is denied”. The impugned, illegal, nonest and cryptic decision taken by the ops clearly shows that they have adopted unfair trade practice in wrongly denying their liability under the policy despite having knowledge about the facts that problem of Purvansh was not a birth related problem, rather it came to the notice only after the report of MRI from Dr. A.R. Godara and as such ops have caused unnecessary harassment to the complainant. Hence, this complaint.
4. On notice, ops appeared and filed written statement taking certain preliminary objections regarding maintainability, locus standi, estoppal, jurisdiction, cause of action, complaint is time barred, mis joinder and non joinder of necessary parties, suppression of true and material facts and that policy of insurance is void because it was obtained by non disclosure of material facts or misrepresentation of fact which were false in material particulars. The liability of the ops is not limited to the extent of cheating. It is further submitted that claim of complainant has already been repudiated by the ops vide their repudiation letter dated 09.11.2020 under the wording that Permanent Exclusions (NCHI) i.e. as per part II of schedule clause 3.4 (XV) of policy wordings, treatment relating to birth defects and external congenital illnesses or defects or anomalies are not payable, hence claim request is denied, therefore, the insurance company is not liable to settle the claim of the complainant and to make any payment to him. On merits, the pleas taken in the preliminary objections are reiterated and prayer for dismissal of complaint made.
5. The complainant in evidence has tendered his affidavit Ex. CW1/A and copies of documents i.e. discharge summary dated 21.09.2020 Ex.C1, risk assumption letter Ex.C2 containing policy certificate etc., aadhar card Ex.C3, estimate form Ex.C4, invoice Ex.C5, bills Ex.C6 to Ex.C24 and application dated 29.07.2020 Ex.C25.
6. On the other hand, ops did not lead any evidence despite availing various opportunities including last opportunities and as such evidence of ops was closed by order.
7. We have heard learned counsel for the parties and have gone through the case file carefully.
8. Admittedly the complainant purchased insurance policy namely Nibhaye Vaade from the ops for the period 17.01.2020 to 16.01.2021 for himself, spouse Mrs. Nehal Goyal and children Ojasvi Goyal, Puruvansh Goyal and Arnav Goyal against the sum insured amount of Rs.5,00,000/- each which fact is also evident from policy certificate enclosed with letter issued by the ops as Ex.C2 and policy in question was issued by the ops on 27.01.2020 which is also evident from letter Ex.C2. The complainant paid premium amount of Rs.21,629/- to the ops. According to the complainant, they were already having insurance policy of Star Health since 2017 and on the asking and every types of assurances given by op no.4 about better features of the policy of ops, the complainant opted for purchase of above said health insurance policy of the ops. According to the complainant, it was also assured to him that policy is being issued to him in continuation of the earlier Medical Health Insurance Policy issued by Star Health w.e.f. date of joining on 30.12.2017. It is also proved on record that during the period of policy in question i.e. from 17.01.2020 to 16.01.2021, the minor son of complainant namely Puruvansh insured who had few medical issues on 03.02.2020 and undergone few tests i.e. MRI Branch etc. from Alfa MRI Centre, Dabwali Road, Sirsa was admitted in Medanta Hospital, Gurgaon on 15.09.2020. From the discharge summary dated 21.09.2020 of Master Purvansh Goyal aged four years Ex.C1, it is evident that he was operated in Medanta Hospital, Gurgaon for Craniosynostosis i.e. head surgery and it is also mentioned that he was presented with abnormality in the shape of his head noted by parents around eight months and he is having excessive bulging of right side of head with flattening of left half of forehead. According to the complainant he was given estimate of Rs.4,38,435/- of the surgery and due intimation before surgery was given to the ops and cashless request was made by complainant as well as doctors of Medanta Hospital through emails but the ops without properly analyzing the case of Purvansh and without going through the record and while acting in a casual manner rejected the cashless claim of complainant through email dated 15.09.2020 with the reason “Permanent exclusion (NCH)” and as such he had to spend an amount of Rs.5,06,170/- on the surgery and treatment of his son in the said hospital. In this regard complainant has also placed on file various bills as Ex.C5 to Ex.C24. However, the ops did not settle and pay the claim of the complainant which was genuine. The ops have admitted that they have repudiated the claim of complainant vide their repudiation letter dated 09.11.2020 under clause of Permanent Exclusions (NCHI) on the ground that treatment relating to birth defects and external congenital illnesses or defects or anomalies are not payable, hence claim request was denied. However, the said ground taken by the ops to repudiate the claim of complainant is not supported through any cogent and convincing evidence. The ops have not led any evidence in support of their repudiation letter dated 09.11.2020 and as such ops have wrongly and illegally repudiated the claim of the complainant. The son of the complainant Purvansh suffered from said disease only at the age of three years five months and it is not proved on record that said disease suffered by him is birth related or that he was suffering from said disease at the time of birth. So the disease of Purvansh cannot be termed as pre existing disease. The ops have failed to prove on record through any cogent and convincing evidence that son of complainant before surgery in Medanta Hospital, Gurgaon on 15.09.2021 was ever treated in any hospital for the said disease or he was taking treatment since birth and as such it is proved on record that son of complainant suffered from the said disease only in the month of July, 2020 for which he was admitted in Medanta Hospital, Gurgaon on 15.09.2020 were he was operated on 17.09.2020 and was discharged on 21.09.2020 and prior to it he was hale and hearty and the complainant and his family members only came to know for the first time about the disease of Purvansh only in the month of July, 2020. The ops have not led any evidence in support of their version. As such repudiation of the genuine claim of complainant is totally baseless, wrong and illegal and is liable to be set aside and complainant is entitled to the insured amount of Rs. five lacs as complainant has already spent more than insured amount on the treatment of his son who was also insured with the ops. It is also proved on record that complainant has spent amount of Rs.5,06,170/- on the surgery and treatment of his son and besides this amount he has also spent more amount on the treatment of his son and as son of complainant namely Purvansh was insured by the ops for sum insured amount of Rs. five lacs under the policy, therefore, complainant is entitled to sum insured amount of Rs. five lacs from ops. The ops have also caused unnecessary harassment, deficiency in service and adopted unfair trade practice towards the complainant who was already under mental trauma and as such complainant is also entitled to compensation for harassment etc.
9. In view of our above discussion, we allow the present complaint and direct the opposite parties no.1 to 3 to pay the claim amount of Rs.5,00,000/- i.e. sum insured amount to the complainant alongwith interest at the rate of @6% per annum from the date of filing of present complaint i.e. 18.12.2020 till actual realization within a period of 45 days from the date of receipt of copy of this order. We also direct the ops no.1 to 3 to further pay a sum of Rs.25,000/- as compensation for harassment to the complainant and also to pay an amount of Rs.10,000/- as litigation expenses to the complainant within above said stipulated period. A copy of this order be supplied to the parties as per rules. File be consigned to the record room.
Announced: Member President,
Dated: 13.03.2024. District Consumer Disputes
Redressal Commission, Sirsa.
