ICICI Lombard General Insurance V/S K.R. Nagendra Prasad - Consumer Court Case

Karnataka

Bangalore Urban

CC/08/2103

K.R. Nagendra Prasad - Complainant(s)

Versus

ICICI Lombard General Insurance - Opp.Party(s)

Chandra Chooda

17 Dec 2008

ORDER

BANGALORE URBAN DISTRICT CONSUMER DISPUTES REDRESSLAL FORUM, BANGALORE, KARNATAKA STATE.
Bangalore Urban District Consumer Disputes Redressal Forum, Cauvery Bhavan, 8th Floor, BWSSB Bldg., K. G. Rd., Bangalore-09.
consumer case(CC) No. CC/08/2103

K.R. Nagendra Prasad						...........Appellant(s)
Vs.
ICICI Lombard General Insurance TTK Healthcare Serv ice ltd						...........Respondent(s)

BEFORE:

Complainant(s)/Appellant(s):

OppositeParty/Respondent(s):

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ORDER

COMPLAINT FILED: 26.09.2008 BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT BANGALORE (URBAN) 17th DECEMBER 2008 PRESENT :- SRI. A.M. BENNUR PRESIDENT SMT. M. YASHODHAMMA MEMBER SRI. A. MUNIYAPPA MEMBER COMPLAINT NO. 2103/2008 COMPLAINANT Sri. K.R. Nagendra Prasad, S/o. K. Rajagopal, # 22, Central Street, 5th Block, K.P. West, Bangalore 560 020. Advocate (M.B. Chandra Chooda) V/s. OPPOSITE PARTIES 1. M/s. ICICI Lombard General Insurance Company Ltd., Zenith House, Keshavrao Khade Marg, Mahalaxmi, Mumbai 400 034. Advocate (B.C. Shivanne Gowda) 2. M/s. TTK Healthcare Service (P) Ltd., No. 7, J.B. Nagar Main Road, HAL III Stage, Bangalore 560 075. O R D E R This is a complaint filed U/s. 12 of the Consumer Protection Act of 1986 by the complainant seeking direction to the Opposite Party (herein after called as O.P) to reimburse the medical expenses of Rs.3,123/- and pay a compensation of Rs.50,000/- on an allegations of deficiency in service. The brief averments, as could be seen from the contents of the complaint, are as under: Complainant has taken the health insurance policy from the OP on 04.07.2007 and paid the required premium. The policy was inforce from 22nd June 2007 to 21st June 2008. On 20.03.2008 complainant experienced the neck pain, hence approached Dr. P.R. Desai Hospital for treatment. He was admitted and surgery was conducted to remove cist, thereafter he was discharged. For the said treatment complainant has spent Rs.3,123/-. After the discharge he made claim to OP to reimburse the medical expenses. Unfortunately OP repudiated the said claim which is unjust and improper. For no fault of his, he is made to suffer both mental agony and financial loss. When his repeated requests and demands, went in futile complainant felt the deficiency in service on the part of the OP. Under the circumstances he is advised to file this complaint and sought for the relief accordingly. 2. On appearance, OP filed the version denying all the allegations made by the complainant in toto. According to OP complainant has suppressed certain material facts which are well within his knowledge while submitting the proposal form with regard to his health condition and the disease. The treatment that is taken by the complainant is not covered under the policy. All the disease which are existed at the time of inception of the policy are excluded under policy for the first two years under exclusion clause 3.3. Hence OP is justified in repudiating the claim of the complainant. There is no deficiency in service on the part of the OP. Among these grounds, OP prayed for the dismissal of the complaint. 3. In order to substantiate the complaint averments, the complainant filed the affidavit evidence and produced some documents. OP has also filed the affidavit evidence and produced the documents. Then the arguments were heard. 4. In view of the above said facts, the points now that arise for our consideration in this complaint are as under: Point No. 1 :- Whether the complainant has proved the deficiency in service on the part of the OP? Point No. 2 :- If so, whether the complainant is entitled for the reliefs now claimed? Point No. 3 :- To what Order? 5. We have gone through the pleadings of the parties, both oral and documentary evidence and the arguments advanced. In view of the reasons given by us in the following paragraphs our findings on: Point No.1:- In Affirmative Point No.2:- Affirmative in part Point No.3:- As per final Order. R E A S O N S 6. At the outset it is not at dispute that the complainant has taken the health insurance policy from the OP which was inforce from 22.06.2007 to 21.06.2008. According to the complainant he had some pain in his neck, that is why he approached Dr. P.R. Desai Hospital on 20.03.2008. The Doctor who examined him suggested for the surgery of the removal of a cist. He underwent the said surgery and thereafter he was discharged. It is further contended by the complainant that he has spent Rs.3,123/- towards the said treatment. Thereafter made a claim to the OP to reimburse the said expenses. OP having kept the said claim for a long time ultimately repudiated it without any substantial grounds or reasons. Hence complainant felt that the said repudiation is unjust, improper and without due application of mind. 7. It is further contended by the complainant that though he patiently waited for the settlement of the claim, but all his hopes went in futile. Complainant has produced the discharge summary, it shows that swelling in right side of the neck since 3 months increasing in size with pain. That means to say that the said cist must have occurred in the month of January 2008 or December 2007. So when complainant took the medicalim policy on 22nd June 2007 he had no knowledge nor he is aware of the presence of cist in the neck. Under such circumstances the defence set out by the OP that there is a suppression of material fact by the complainant at the time of submission of his proposal with regard to the disease appears to be unfounded. It is further contended by the OP that the treatment is taken for the pre-existing disease, which has no basis. Further OP says that the insured person is not entitled for reimbursement of the expenses for first two years with regard to the said disease. This defence also appears to be an eyewash, just to save their skin out of sin. 8. People go for the medi claim policy with a fond hope under utmost good faith that OP will come to their assistance in an hour of need. OP accept the proposal and issues the policy collects the premium, when the question of reimbursement comes they take an untenable defence, which is unfortunate. It is not that huge amount which complainant has sought for reimbursement whatever the expenses he has incurred that is to the tune of Rs.3,123/- he demanded the same. That claim of the complainant cannot be considered as exorbitant or made with an ulterior motive to get himself illegally enriched. 9. The evidence of the complainant which finds full corroboration with the contents of the undisputed documents appears to be very much natural, cogent and consistent. There is nothing to discard his sworn testimony. As against the said unimpeachable evidence of the complainant, the defence set out by the OP appears to be defence for defence sake, just to avoid their liability. On reading of para.9 of the version it shows that though OP admits its liability it wants breathe hot and cold in contenting that the compensation if any payable to the complainant is limited as per the policy conditions. 10. We have perused the policy terms and conditions and the claim made by the complainant. We are satisfied that the complainant is able to establish the deficiency in service on the part of the OP. For no fault of his, he is made to suffer both mental agony and financial loss, it is all because of the hostile attitude of the OP. As already observed by us, the repudiation appears to be unjust and improper. Of course the complainant claimed Rs.50,000/- as compensation it has no basis. In our considered view the justice will be met by directing the OP to reimburse the actual medical expenses of Rs.3,123/-, pay a compensation of Rs.2,000/- and a litigation cost of Rs.1,000/-. With these reasons we answer point nos.1 and 2 accordingly and proceed to pass the following: O R D E R The complaint is allowed in part. OP is directed to settle the claim for Rs.3,123/-, pay a compensation of Rs.2,000/- and litigation cost of Rs.1,000/- to the complainant. This order is to be complied within 4 weeks from the date of its communication. (Dictated to the Stenographer and typed in the computer and transcribed by him, verified and corrected, and then pronounced in the Open Court by us on this the 17th day of December 2008.) MEMBER MEMBER PRESIDENT p.n.g.

COMPLAINT FILED: 26.09.2008 BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT BANGALORE (URBAN) 17th DECEMBER 2008 PRESENT :- SRI. A.M. BENNUR PRESIDENT SMT. M. YASHODHAMMA MEMBER SRI. A. MUNIYAPPA MEMBER COMPLAINT NO. 2103/2008 COMPLAINANT Sri. K.R. Nagendra Prasad, S/o. K. Rajagopal, # 22, Central Street, 5th Block, K.P. West, Bangalore 560 020. Advocate (M.B. Chandra Chooda) V/s. OPPOSITE PARTIES 1. M/s. ICICI Lombard General Insurance Company Ltd., Zenith House, Keshavrao Khade Marg, Mahalaxmi, Mumbai 400 034. Advocate (B.C. Shivanne Gowda) 2. M/s. TTK Healthcare Service (P) Ltd., No. 7, J.B. Nagar Main Road, HAL III Stage, Bangalore 560 075. O R D E R This is a complaint filed U/s. 12 of the Consumer Protection Act of 1986 by the complainant seeking direction to the Opposite Party (herein after called as O.P) to reimburse the medical expenses of Rs.3,123/- and pay a compensation of Rs.50,000/- on an allegations of deficiency in service. The brief averments, as could be seen from the contents of the complaint, are as under: Complainant has taken the health insurance policy from the OP on 04.07.2007 and paid the required premium. The policy was inforce from 22nd June 2007 to 21st June 2008. On 20.03.2008 complainant experienced the neck pain, hence approached Dr. P.R. Desai Hospital for treatment. He was admitted and surgery was conducted to remove cist, thereafter he was discharged. For the said treatment complainant has spent Rs.3,123/-. After the discharge he made claim to OP to reimburse the medical expenses. Unfortunately OP repudiated the said claim which is unjust and improper. For no fault of his, he is made to suffer both mental agony and financial loss. When his repeated requests and demands, went in futile complainant felt the deficiency in service on the part of the OP. Under the circumstances he is advised to file this complaint and sought for the relief accordingly. 2. On appearance, OP filed the version denying all the allegations made by the complainant in toto. According to OP complainant has suppressed certain material facts which are well within his knowledge while submitting the proposal form with regard to his health condition and the disease. The treatment that is taken by the complainant is not covered under the policy. All the disease which are existed at the time of inception of the policy are excluded under policy for the first two years under exclusion clause 3.3. Hence OP is justified in repudiating the claim of the complainant. There is no deficiency in service on the part of the OP. Among these grounds, OP prayed for the dismissal of the complaint. 3. In order to substantiate the complaint averments, the complainant filed the affidavit evidence and produced some documents. OP has also filed the affidavit evidence and produced the documents. Then the arguments were heard. 4. In view of the above said facts, the points now that arise for our consideration in this complaint are as under: Point No. 1 :- Whether the complainant has proved the deficiency in service on the part of the OP? Point No. 2 :- If so, whether the complainant is entitled for the reliefs now claimed? Point No. 3 :- To what Order? 5. We have gone through the pleadings of the parties, both oral and documentary evidence and the arguments advanced. In view of the reasons given by us in the following paragraphs our findings on: Point No.1:- In Affirmative Point No.2:- Affirmative in part Point No.3:- As per final Order. R E A S O N S 6. At the outset it is not at dispute that the complainant has taken the health insurance policy from the OP which was inforce from 22.06.2007 to 21.06.2008. According to the complainant he had some pain in his neck, that is why he approached Dr. P.R. Desai Hospital on 20.03.2008. The Doctor who examined him suggested for the surgery of the removal of a cist. He underwent the said surgery and thereafter he was discharged. It is further contended by the complainant that he has spent Rs.3,123/- towards the said treatment. Thereafter made a claim to the OP to reimburse the said expenses. OP having kept the said claim for a long time ultimately repudiated it without any substantial grounds or reasons. Hence complainant felt that the said repudiation is unjust, improper and without due application of mind. 7. It is further contended by the complainant that though he patiently waited for the settlement of the claim, but all his hopes went in futile. Complainant has produced the discharge summary, it shows that swelling in right side of the neck since 3 months increasing in size with pain. That means to say that the said cist must have occurred in the month of January 2008 or December 2007. So when complainant took the medicalim policy on 22nd June 2007 he had no knowledge nor he is aware of the presence of cist in the neck. Under such circumstances the defence set out by the OP that there is a suppression of material fact by the complainant at the time of submission of his proposal with regard to the disease appears to be unfounded. It is further contended by the OP that the treatment is taken for the pre-existing disease, which has no basis. Further OP says that the insured person is not entitled for reimbursement of the expenses for first two years with regard to the said disease. This defence also appears to be an eyewash, just to save their skin out of sin. 8. People go for the medi claim policy with a fond hope under utmost good faith that OP will come to their assistance in an hour of need. OP accept the proposal and issues the policy collects the premium, when the question of reimbursement comes they take an untenable defence, which is unfortunate. It is not that huge amount which complainant has sought for reimbursement whatever the expenses he has incurred that is to the tune of Rs.3,123/- he demanded the same. That claim of the complainant cannot be considered as exorbitant or made with an ulterior motive to get himself illegally enriched. 9. The evidence of the complainant which finds full corroboration with the contents of the undisputed documents appears to be very much natural, cogent and consistent. There is nothing to discard his sworn testimony. As against the said unimpeachable evidence of the complainant, the defence set out by the OP appears to be defence for defence sake, just to avoid their liability. On reading of para.9 of the version it shows that though OP admits its liability it wants breathe hot and cold in contenting that the compensation if any payable to the complainant is limited as per the policy conditions. 10. We have perused the policy terms and conditions and the claim made by the complainant. We are satisfied that the complainant is able to establish the deficiency in service on the part of the OP. For no fault of his, he is made to suffer both mental agony and financial loss, it is all because of the hostile attitude of the OP. As already observed by us, the repudiation appears to be unjust and improper. Of course the complainant claimed Rs.50,000/- as compensation it has no basis. In our considered view the justice will be met by directing the OP to reimburse the actual medical expenses of Rs.3,123/-, pay a compensation of Rs.2,000/- and a litigation cost of Rs.1,000/-. With these reasons we answer point nos.1 and 2 accordingly and proceed to pass the following: O R D E R The complaint is allowed in part. OP is directed to settle the claim for Rs.3,123/-, pay a compensation of Rs.2,000/- and litigation cost of Rs.1,000/- to the complainant. This order is to be complied within 4 weeks from the date of its communication. (Dictated to the Stenographer and typed in the computer and transcribed by him, verified and corrected, and then pronounced in the Open Court by us on this the 17th day of December 2008.) MEMBER MEMBER PRESIDENT p.n.g.