Tamil Nadu

South Chennai

CC/326/2018

S John Robert - Complainant(s)

Versus

ICICI Lombard General Insurance & Another - Opp.Party(s)

M/s K Ganesan

22 Jan 2020

ORDER

                                                                             Date of filing      : 21.08.2018

                                                                               Date of Disposal : 22.01.2020

                                                                                  

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHENNAI (SOUTH)

@ 2^ND Floor, T.N.P.S.C. Road, V.O.C. Nagar, Park Town, Chennai – 3.

 

PRESENT: THIRU. M. MONY, B.Sc., L.L.B, M.L.                    : PRESIDENT

TR. R. BASKARKUMARAVEL, B.Sc., L.L.M., BPT., PGDCLP.  : MEMBER

 

C.C. No.326/2018

DATED THIS WEDNESDAY THE 22^ND DAY OF JANUARY 2020

                                 

S. John Robert,

S/o. Mr. Selvanayagam,

Flat No.4 ab Kings Trinity Apartments,

Dr. Ambedkar Street,

Near Vaigai Nagar,

Ext. Tambaram West,

Chennai – 600 045.                                                        .. Complainant.

 

                                                                                                ..Versus..

 

 

1. The Chief – Underwriting & Claims,

ICICI Lombard General Insurance Co. Ltd.,

ICICI Bank Tower,

Plot No.12, Financial District,

Nanakramguda,

Gachibowli,

Hyderabad – 500 032.

 

2. The Branch Manager,

ICICI Lombard General Insurance Company Limited,

Chotabhai Centre, 2^nd & 3^rd Floors,

No.140, Uthamar Gandhi Road,

Chennai – 600 006.                                                ..  Opposite parties.

 

Counsel for the complainant                 : M/s. K. Ganesan & another

Counsel for the opposite parties 1 & 2 : Mrs. Elveera Ravindran &

                                                                 another

 

ORDER

THIRU. M. MONY, PRESIDENT

       This complaint has been filed by the complainant against the opposite parties 1 & 2 under section 12 of the Consumer Protection Act, 1986 prays to restore the policy contract bearing No.4113I/XOL/74405522/02/000 on the books of the opposite party with full benefits accruing thereon, to pay the amount of Rs.7,26,723/- paid towards medical expenses and to pay a sum of Rs.5,00,000/- towards compensation for mental agony, pain, sufferings, deficiency in service with cost of Rs.25,000/- to the complainant.

1.    The averments of the complaint in brief are as follows:-

The complainant submits that he has taken ICICI Lombard Complete Health Insurance policies bearing No.4128IHSR/102834591/01/000 and extended cover on No.4113I/XOL/74405522/02/000 issued on 24.05.2007 and 10.10.2012 respectively.  The said Health Insurance policies totalling to a sum insured of Rs.11,20,000/- were issued by the opposite parties to cover the medical expenses incurred on account of hospitalization for any medical exigencies to the complainant.  The policies were issued by the opposite parties with a promise that the medical expenses incurred by the complainant would be paid and the premium was charged on yearly basis for such service rendered by the opposite parties.   The policy bearing No.4128I/HSR/102834591/01/000 for an insurance of Rs.3,00,000/- with effect from 24.05.2007.  The complainant states that the policy was kept in force and premiums were paid by the complainant regularly in accordance with the terms and conditions of the policy.   The opposite parties keeping this track record in view during the month of October 2012 offered to enhance the Insurance cover by Rs.8,00,000/- through top-up card as a gesture to recognize the complainant’s goodwill in keeping the policy in force.   Thereby, the policy coverage is only extension of the sum assured under the original policy and not a new contract.   The complainant submits that he was keeping a robust health and neither complained of any sickness nor hospitalized for any major illness till the year 2015.  He was diagnosed with renal dysfunction only during the month of November 2015 when his laboratory blood report showed slightly elevated levels of Creatinine.  

2.     The complainant further submits that Type II Diabetes and Systemic Hypertension was diagnosed for the first time during the year 2014 or 2015.  The complainant submits that he was admitted in Annai Arul Hospital, Chennai on 25.02.2016 and was discharged on 29.02.2016 for treating the Right Thigh Abscess and infected great Toe. During the preliminary investigations, it revealed that Asotemia, proteinuria suggestive of Acute Kidney injury on chronic kidney disease and dyslipidemia.  The Ultra Sonography examination revealed bilateral medical renal disease.   That was the first time that the complainant came to know of his disease and not prior to it.   The complainant submits that on 25.04.2016, the complainant was admitted in Christian Medical College Hospital, Vellore and undergone the treatment related to Diabetic Nephropathy and was discharged on 29.04.2016.   The complainant submits that on 27.12.2017 once again, the complainant was admitted in Annai Arul Hospital, Tambaram West for the treatment of Catheter related infection – Bacteremia and was discharged on 29.12.2017. Thereafter, the complainant had undergone treatment as outpatient for some time and the Doctors advised him to undergo Kidney transplantation as his condition necessitated.  Accordingly, a living donor came forward to donate a kidney and due transplantation was done on 24.05.2018 at Annai Arul Hospital, Chennai and the complainant was  hospitalized from 24.5.2018 to 08.6.2018 for further treatment and medical care.  

3.     The complainant has expended a huge sum of Rs.10,46,723/-.   The complainant submits that while he was admitted for such major surgery of kidney transplantation opted for cashless treatment and requested for the settlement of hospital expenditure by the opposite parties under the extended policies issued by the opposite parties in the name of the complainant. But the opposite parties have settled the claim of Rs.3,20,000/- directly to the hospital vide AL Number 110100349199 pertaining to the policy bearing No.4128I/HSR/102834592/01/000.   The payment for the balance amount of Rs.7,26,723/- as per the terms and conditions of the policy Contract under AL Number 110100350443 and claim No.220100453365 pertaining to the Policy No.4113I/XOL/74405522/02/000 was denied.   The complainant submits that while the policy is subsisting, the opposite parties are indifferent in providing service and repudiated the claim against the settled principle of law caused great damage, mental agony, loss etc.   The complainant submits that the opposite parties sent email dated:05.06.2018 seeking the complete set of indoor case papers from the hospital. 

4.     The complainant submits that the opposite parties rejected the claim with the remarks which reads as follows:-

“As per the documents furnished patient is k/c/o HYPERTENSION, DIABETES prior inception the same was not disclosed at the time of policy inception, as per clause PART III OF THE SCHEDULE 1: Incontestability and Duty of Disclosure:The Policy shall be null and void and no benefit shall be payable in the event of untrue or incorrect statements, misrepresentation,  Misdescription or on non-disclosure, hence DENIED”.

5.     The complainant submits that the allegation that he was a known case of hypertension and Diabetes is only a fiction invented by the opposite parties.  The failure on the part of the opposite parties to honour the contractual obligation is a clear deficiency in service.   The conduct of the opposite parties in collecting the annual premium for a service to be provided and failing to perform when an occasion so demands amounts to unfair trade practice.  The opposite parties 1 & 2 rejected the claim No.220100453356 preferred by the complainant on 20.07.2018 vide their email ref.74405522 with remarks that the claim is rejected under non-disclosure of hypertension and diabetes prior to policy as per the part III of schedule, clause 1 of policy T & C.  Further the opposite parties did not take into consideration the letter dated:03.07.2018 sent by the complainant which answered all the allegations made by the opposite parties and proceeded to terminate the policy No.4113I/XOL/74405522/02/000 with effect from 16.07.2018 which had been in force for over 5 years for which necessary premium were paid regularly in time without any default. The opposite party who had the bounden duty of honouring the contractual obligation of paying for the medical expenditure incurred by the complainant.   But the opposite parties failed to do so amounts to deficiency in service and unfair trade practice which caused great mental agony.  Hence, the complaint is filed.

6.      The brief averments in the written version filed by opposite parties 1 & 2 is as follows:

The opposite parties 1 & 2 specifically deny each and every allegations made in the complaint and put the complainant to strict proof of the same.     The opposite parties 1 & 2 state that the claim is barred by limitation.  The opposite parties 1 & 2 state that the Health Insurance policy was renewed from time to time, on 24.05.2007 covering the complainant and thereafter on the renewal of the policy the complainant and his wife sought to be covered under the policy and the present policy being valid form 24.05.2017 to 23.05.2019 for a sum assured of Rs.2,00,000/- and an additional sum of Rs.1,20,000/-.   The opposite parties 1 & 2 state that the Reset Benefit for the policy holders is as follows:-

For plans with SI/deductible Rs.3 lacs and above, we will reset upto 100% of the sum insured once in a policy year in case the sum insured including accrued additional sum insured (if any) is insufficient as a result of previous claims in that policy year, provided that:-

• The reset amount can only be used for all future claims within the same policy year, not related to the illness/ disease/injury for which, a claim has been paid in that policy year for the same person
• Reset will not trigger for the first claim.
• For individual policies, reset sum insured will be available on individual basis whereas for floater policies, it will be available on floater basis.
• Any unutilized reset sum insured will not be carried forward to subsequent policy year.

Hence, it is denied that the opposite parties offered to enhance the insurance cover by Rs.8 lakhs as alleged by the complainant.

7.     The opposite parties 1 & 2 put the complainant to strict proof of his allegations made in para Nos.7 & 8 regarding his ailment namely; renal dysfunction during the month of November 2015 and Type II diabetes and Systemic Hypertension during 2014 and 2015 and the period of hospitalisation form 25.02.2016 to 29.02.2016 and that he was diagnosed with azotemia, proteinuria suggestive of acute kidney injury and dyslipidemia and that he came to know of the said ailments only now.   The opposite parties 1 & 2 state that the complainant filed this case of misrepresentation and suppression of material facts.    The opposite parties 1 & 2 state that he was a known case of hypertension and diabetes and through their email dated:06.06.2018, the opposite parties had clearly stated that as per the documents furnished the patient is a k/c/o hypertension and diabetes prior to policy inception, the same was not disclosed at the time of policy inception as per clause Part III of the Schedule I: Incontestability and duty of disclosure.  Hence, the claim was repudiated.  The opposite parties that the complainant conveniently suppressed the material fact of hypertension and diabetics and undergone kidney transplantation after availing ICICI Lombard Complete Health Insurance policy and additional Top-up card etc claiming huge amount of Rs.10,46,723/- and hence was rightly repudiated as per the principles laid down by IRDA.  The opposite parties 1 & 2 state that the contract of insurance is a contract of Uberrimae fidei and both the contracting parties are bound by the terms and conditions of the policy of insurance.   Therefore, there is no deficiency in service on the part of the part of the opposite parties and hence, the complaint is liable to be dismissed.

8.     To prove the averments in the complaint, the complainant has filed proof affidavit as his evidence and documents Ex.A1 to Ex.A20 are marked.  Proof affidavit of the opposite parties 1 & 2 is filed and no document is marked on the side of the opposite parties 1 & 2.

 

 

 

9.      The points for consideration is:-

1. Whether the complainant is entitled to restore the policy bearing No.4113I/XOL/74405522/02/000 with full accruing benefits thereon as prayed for?
2. Whether the complainant is entitled to reimburse a sum of Rs.7,26,723/- paid towards medical expenses and was rejected by the opposite parties as prayed for?

1. 3.Whether the complainant is entitled to a compensation of Rs.5,00,000/- for mental agony, pain, sufferings, deficiency in service with cost of Rs.25,000/- as prayed for?

10.    On point:-

Both parties filed their respective written arguments.   The complainant filed documents Ex.A1 to Ex.A20.   The opposite parties even after repeated adjournments has not come forward to file any documents.   Heard the complainant’s Counsel.  Perused the records namely; the complaint, written version, proof affidavits and documents.    Admittedly, the complainant has taken ICICI Lombard Complete Health Insurance policies bearing No.4128IHSR/102834591/01/000 and extended cover on No.4113I/XOL/74405522/02/000 issued on 24.05.2007 and 10.10.2012 respectively as per Ex.A1 & Ex.A20.  The learned Counsel for the complainant contended that the premium due to the policies were paid by the complainant regularly in accordance with the terms and conditions of the policy; is also admitted.   The opposite parties taken into consideration and keeping the prompt payment of premium on track  offered to enhance the Insurance cover by Rs.8,00,000/- through top-up card as a gesture to recognize the complainant’s goodwill in keeping the policy in force.   Thereby, the policy coverage is only extension of the sum assured under the original policy also not denied by the opposite parties.  

11.    Further the contention of the complainant is that he was keeping a robust health in the year 2014.  He was diagnosed that he was having diabetics in the year 2014 as per Ex.A2.   Further the contention of the complainant is that he was admitted in Annai Arul Hospital, Chennai on 25.02.2016 and was discharged on 29.02.2016 for treating the Right Thigh Abscess and infected great Toe.   During the preliminary investigations, it revealed that Asotemia, proteinuria suggestive of Acute Kidney injury on chronic kidney disease and dyslipidemia.  The Ultra Sonography examination revealed bilateral medical renal disease.  For the first time, Ex.A5, Discharge Summary shows as follows:-

“Type II diabetes mellitus & Systemic hypertension since 1½ years” which was considered and the claim was settled by the opposite parties’ Insurance Company.   Further the contention of the complainant is that on 25.04.2016, the complainant was admitted in Christian Medical College Hospital, Vellore and was discharged on 29.04.2016 and thereafter the complainant was admitted before the same hospital on 29.11.2017 to 13.12.2017 and undergone the treatment related to Diabetic Nephropathy as per Ex.A6 & Ex.A8.  Wherein, it is mentioned that “Diabetic and Hypertensive since last 6 years”.  But there is no basic rudimentary evidence given in the discharge summary except the History of the Patient which shall be collected either from the complainant who is the patient or from the bystanders / relatives of the complainant.    On a careful perusal of Ex.A6, there is nothing stated about the collection of history of the patient.   

12.    Further the contention of the complainant is that on 27.12.2017 once again, the complainant was admitted in Annai Arul Hospital, Tambaram West for the treatment of Catheter related infection – Bacteremia and was discharged on 29.12.2017 as per Ex.A7.   Thereafter, the complainant had undergone treatment as outpatient for some time and the Doctors advised to undergo Kidney transplantation as his condition necessitated.  Accordingly, a living donor came forward to donate a kidney and due transplantation was done on 24.05.2018.  The complainant was kept in the hospital for the post-operative observation from 24.05.2018 to 08.06.2018 as per Ex.A9 after transplantation of kidney.   The complainant has expended a huge sum of Rs.10,46,723/- as per Ex.A10.   The complainant while admitted for such major surgery of kidney transplantation opted for cashless treatment and requested for the settlement of hospital expenditure by the opposite parties under the 2 policies issued by the opposite parties in the name of the complainant. But the opposite parties have settled the claim of Rs.3,20,000/- directly to the hospital vide AL Number 110100349199 pertaining to the policy bearing No.4128I/HSR/102834592/01/000 as per Ex.A11.   The opposite parties wantonly and deliberately has not come forward to settle the balance amount of Rs.7,26,723/- as per the terms of the policy Contract under AL Number 110100350443 and claim No.220100453365 pertaining to the Policy No.4113I/XOL/74405522/02/000 was denied as per Ex.A20, copy of repudiation mail by the opposite parties and Ex.A13 is the correspondence related to that effect proves the unfair trade practice and deficiency in service.  

13.    Further the contention of the complainant is that while the policy is subsisting, the opposite parties are indifferent in providing service and repudiated the claim against the settled principle of law caused great damage, mental agony, loss etc.   It is also known to the opposite party that the complainant undergone Kidney transplantation, incurred huge expenses related to his hospitalization with a fond hope of settling the claim of medical expenses by the opposite parties’ Insurance company; availed ICICI Lombard Complete Health Insurance policy long back and renewed from time to time and considering the goodwill of payment of premium, granting extended cover policy, top up card for huge amount etc.  Further the contention of the complainant is that as per Ex.A20, the opposite partied rejected the claim with the remarks which reads as follows:-

Sr. No.	Reason	Remarks
	Standard Exclusion	Claim is rejected under non-disclosure of Hypertension, and diabetes prior to policy, as per part III of schedule, clause 1 of the policy T & C, Incontestability and Duty of Disclosure: the Policy shall be null and void and no benefit shall be payable in the event of untrue or incorrect statements, misrepresentation, mis-description or on non-disclosure inn any material particular in the proposal form, personal statement, declaration and connected documents, or any material information having been withheld, or dev! Ices being used by You or any one acting or Your behalf to obtain any benefit under this Policy.

 

But the opposite parties settled the claim for a sum of Rs.3,32,000/- as per Ex.A11 proves deficiency in service. The complainant made several communications as per Ex.A14 to Ex.A16 for which, the opposite parties has not sent any proper reply.  

14.    The learned Counsel cited the decisions reported in:

1. NATIONAL CONSUMER DISPUTES RESDRESSAL COMMISSION, NEW DELHI

REVISION PETITION NO.686/2007

Between

Tarlok Chand Khanna

-Versus-

United India Insurance Co. Ltd.

Held that

          “The facts of the case, according to the Petitioner who was the original complainant before the District Forum, and that he had obtained a medi-claim insurance policy from the Respondent / Insurance company from 01.01.2002 to 31.12.2002 for a sum of Rs.1,50,000/- for himself and his wife, Smt. Karuna Khanna.   During the subsistence of this policy, Smt. Karuna Khanna suddenly developed pain in her knees.    She had never suffered from any medical problems relating to her knees earlier.  However, she went to the doctor who advised her to undergo surgery for knee replacement of both knees which she underwent on 15.09.2002 at a total cost of Rs.1,78,945/-.   Unfortunately, she died due to sudden cardiac arrest in the hospital on 29.09.2002.   The respondent / insurance company repudiated the claim was not covered as per Clause 4.8 of the policy as well as the Exclusion Clause 4.1 since it was a pre-existing disease.

Result: Respondent/ Insurance company is directed to pay the Petitioner Rs.1,78,945/- along with interest at the rate of 6% p.a. from the date of the claim and Rs.1,000/- as litigation cost within six weeks from the date of this order”.

2. NATIONAL CONSUMER DISPUTES RESDRESSAL COMMISSION, NEW DELHI

II (2005) CPJ 78 NC

Between

LIC of India

-Versus-

Joginder Kaur & ors.

Held that

          “Feeling aggrieved by the order of the State Commission, the present revision petition has been filed by the LIC.   The petitioner sought to justify the repudiation on the ground that on investigation, it was found that the deceased was a chronic alcoholic for the last 15 years and was afflicted with diabetes mellitus for 13 years and had also a past history of jaundice in 1973 which  were revealed from the statement of the doctor who attended the accused before his death.  He however did not disclose these facts in the proposal form and instead had given false statements which were in violation of the terms and conditions of the policy.  That proposal was submitted on 30.08.1997 i.e. less than a year before the date of death.  It was clear case where suppression of material particulars in the form of concealment with fraudulent intent was writ large.

3.      NATIONAL CONSUMER DISPUTES RESDRESSAL COMMISSION,

NEW DELHI

Revision Petition No.1304/2014

Between

M/s. ICICI Prudential Life

-Versus-

Mrs. Veena Sharma & anr.

Held that

          “In the present case only question is to be determined whether the insured has knowledge suppressed the material facts at the time of submitting the proposal form.   Onus to prove contention of suppression was on the insurance company.  In order to prove his case the opposite parties filed the affidavit of Senior Manager Ex.RW1/A in her affidavit she only deposed that statement made in all the paragraphs of the reply are true and correct.  Nothing else has been deposed with regard to ailment of deceased.  Opposite party only relied on medical treatment record Ex.R3.  Counsel for the opposite party argued that in Ex.R3 in patient history it is written A known patient of Diabetes Mellitus Type-2 was admitted.  Patient Deepak was admitted on 13.04.2010 and he was discharged on 24.04.2010 according to Ex.R3.  Except this document opposite party did not produce any other record of treatment of insured”.

4. STATE CONSUMER DISPUTES REDRESSAL COMMISSION, CHENNAI

Appeal No.700/2002

Between

New India Assurance Co. Ltd.

-Versus-

Shiv Kumar Rupramka

Held that

          “Through this appeal filed under section 15 of the Consumer Protection Act, 1986, the impugned order has been assailed mainly on the ground that the respondent intentionally concealed the factum of suffering from the disease and existence of disease and existence of disease of manifest from the fact that respondent was admitted in the hospital for aforesaid disease within 1 month of taking the insurance policy and secondly, even if it is assumed that the disease was not pre-existing the appellant is not liable to reimburse the medical expenses incurred on equipment C-PAP, which is used for curing the disease of excessive snoring or sleeplessness, as the policy was only to reimbursement of medical and surgical expenses”.

15.    Further the contention of the complainant is that the opposite party without any notice, terminated the policy as per Ex.A17 and without settling the claim on the ground of non-disclosure of hypertension and Diabetics against the settled principles of law.   The opposite parties also has not denied or whispered anything about the drastic action of termination of the policy.   Hence, the opposite parties are liable to restore the policy with all benefits.  The complainant is claiming a sum of  Rs.7,26,723/- towards medical expenses with a compensation of Rs.5,00,000/- with cost of Rs.25,000/-.

16.    The contention of the opposite parties 1 & 2 is that at the outset, the claim is barred by limitation.  But on a careful perusal of the records, the complainant had undergone kidney transplantation only on 24.05.2018.  Equally, the opposite parties terminated the policy on 16.07.2018 as per Ex.A19.   This case is filed only on 31.07.2018 proves that the claim is within time.   Further the contention of the opposite parties 1 & 2 is that the impugned policy of insurance was issued to the complainant out of his own volition of the complainant who opted for a health insurance policy and the proposal made by the complainant after thorough knowledge and the policy was issued on 24.05.2007 and was renewed from time to time and is subsisting till 23.05.2019 for an assured sum of Rs.2,00,000/- and an additional sum of Rs.1,20,000/-.   But the opposite parties has not filed any policy or proposal form etc.  On a careful perusal of Ex.A1, it is very clear that the annual sum insured is of Rs.2,00,000/- and an additional sum insured is of Rs.1,20,000/-, as per the Top up card the sum insured is Rs.8,00,000/- and an additional sum insured is of Rs.1,60,000/- and the total sum insured is of Rs.9,60,000/-.   Equally, the second claim related to organ transplantation is Rs.8,00,000/-.   The opposite party also admitted the Top-up Policy and ICICI Lombard Complete Health Insurance policies bearing No.4128IHSR/102834591/01/000 and extended cover on No.4113I/XOL/74405522/02/000 issued on 24.05.2007 and 10.10.2012 respectively.  Equally, the opposite parties has not denied the Top-up card to the tune of Rs.8,00,000/-. 

17.    Further the contention of the opposite parties is that the Reset Benefit for the policy holders is as follows:-

For plans with SI/deductible Rs.3 lacs and above, we will reset upto 100% of the sum insured once in a policy year in case the sum insured including accrued additional sum insured (if any) is insufficient as a result of previous claims in that policy year, provided that:-

• The reset amount can only be used for all future claims within the same policy year, not related to the illness/ disease/injury for which, a claim has been paid in that policy year for the same person
• Reset will not trigger for the first claim.
• For individual policies, reset sum insured will be available on individual basis whereas for floater policies, it will be available on floater basis.
• Any unutilized reset sum insured will not be carried forward to subsequent policy year.

Hence, it is denied that the opposite parties offered to enhance the insurance cover by Rs.8 lakhs as alleged by the complainant.

18.    But on a careful perusal of Ex.A1 page No.15, it is very clear that the condition No.36 which reads as follows:-

36. How Reset Benefit works?

Examples of Reset Benefit:-

Sum Insured	Sum Insured
2nd Claim	Reason	Heart Attack	Organ Transplant
	Second claim payable amount	2,50,000	8,00,000
	Will the Reset trigger?	No-Since the available Sum Insured is enough to pay the claim, reset won’t trigger	Yes-Reset to 800,00  - Since the available Sum Insured is not enough to pay the claim
	Balance Sum Insured	1,50,000	Nil

 

19.    Further, it is very clear from condition No.36 that if sufficient amount is available, no question of reset trigger arises.  In this case, admittedly, the complainant availed the policy of Rs.2,00,000/- + Rs.1,20,000/- + Top up card of Rs.8,00,000/- totally of Rs.11,20,000/- in which, towards the first claim  a sum of Rs.3,20,000/- has been settled by the opposite parties against the claim of Rs.10,46,723/-. Thereby, a balance amount of Rs.7,26,723/- against the available insured sum of Rs.8,00,000/- is spent.  Hence, the contentions related to reset benefits have no importance which is against the true facts and an imaginary one with regard to the case on hand.    Further the contention of the opposite parties is that as per Ex.A2, Treatment Sheet issued by Kasthuri Hospital, Tambaram, Ex.A4, Laboratory Test Report and Ex.A5, Discharge Summary given by Annai Arul Hospital & Ex.A6, Discharge Summary issued by Christian Medical College, Vellore etc shows that the complainant had Type II Diabetics and Systemic Hypertension from 2014 to 2015 which fact was totally suppressed by the complainant and the claiming such huge amount towards policy; is not acceptable.   But while filing of the policy in the year 2007, there is no diabetics, hypertension etc.   Equally, the law is well settled that such alleged Diabetic, Hypertension shall not be taken into consideration in the case of medical claim. 

20.    Further the contention of the opposite parties is that the complainant conveniently suppressed the material fact of hypertension and diabetics and undergone kidney transplantation after availing ICICI Lombard Complete Health Insurance policy and additional Top-up card etc claiming huge amount of Rs.10,46,723/- as per Ex.A10 which was rightly repudiated as per the principles laid down by IRDA.   But the opposite parties admitted the origin of policy of the year 2007 and extended policy, top up policy etc but the opposite parties miserably failed to produce any relevant IRDA rules and all the policies.  On the other hand, the law is well settled that hypertension, diabetes, mellitus and other like disorders shall not be taken into consideration in the medical claim cases.  The opposite parties has not denied the subsistence of policy and the treatment undergone and the medical expenditure incurred thereon by the complainant.  Further the contention of the opposite parties is that the claim is an imaginary one.  The compensation claimed is exorbitant.  But there is no proof.   The opposite parties has not raised any substantial ground and reason for the termination of policy.   Considering the facts and circumstances of the case, this Forum is of the considered view that the opposite parties 1 & 2 shall restore the policy contract bearing No.4113I/XOL/74405522/02/000 with all benefits from the date of cancellation i.e. 16.07.2018, to pay a sum of Rs.7,26,723/- towards medical expenses and to pay a compensation of Rs.50,000/- for mental agony with cost of Rs.10,000/-.

In the result, this complaint is allowed in part.  The opposite parties 1 & 2 are jointly and severally liable restore the policy contract bearing No.4113I/XOL/74405522/02/000 will all benefits from the date of cancellation i.e. 16.07.2018, to pay a sum of Rs.7,26,723/- (Rupees Seven lakhs twenty six thousand and seven twenty three only) and to pay a sum of Rs.50,000/- (Rupees Fifty thousand only) towards compensation with cost of Rs.10,000/- (Rupees Ten thousand only) to the complainant.

The above amounts shall be payable within six weeks from the date of receipt of the copy of this order, failing which, the said amounts shall carry interest at the rate of 9% p.a. to till the date of payment.

Dictated  by the President to the Steno-typist, taken down, transcribed and computerized by her, corrected by the President and pronounced by us in the open Forum on this the 22^nd day of January 2020. 

 

MEMBER                                                                                PRESIDENT

 

COMPLAINANT SIDE DOCUMENTS:-

Ex.A1		Copy of the policy Certificate booklet bearing No.4128I/HSR/102834591/00/000
Ex.A2		Copy of treatment sheet issued by Kasthuri Hospital, Tambaram
Ex.A3		Copy of treatment by Dr. S. Jayaraman for Sleep Apnea
Ex.A4		Copy of patient’s laboratory test report by Sharon Clinical Laboratory N.L. Polyclinic
Ex.A5	25.02.2016 to 29.04.2016	Copy of Discharge summary given by Annai Arul Hospital for hospitalization
Ex.A6	25.04.2016 to 29.04.2016	Copy of discharge summary given by Christian Medical College, Vellore for the treatment undergone during 25.04.2016 to 29.04.2016
Ex.A7		Copy of discharge summary issued by Annai Arul Hospital
Ex.A8	29.11.2017 to 13.12.2017	Copy of discharge summary issued by Christian Medical College, Vellore for the treatment undergone during 29.11.2017 to 13.12.2017
Ex.A9		Copy of case sheet by Annai Arul Hospital
Ex.A10		Copy of Credit bill raised by Annai Arul Hospital
Ex.A11		Copy of authorization letter to the hospital by the opposite parties with respect to the claim on 4128I/HSR/102834591/00/000
Ex.A12	05.06.2018	Copy of additional information sought by the opposite parties
Ex.A13		Copy of email informing denial of cashless access
Ex.A14		Copy of mail correspondence between the complainant and opposite parties
Ex.A15	17.06.2018	Copy of letter dated:17.06.2017 written by the complainant
Ex.A16	28.06.2018	Copy of explanation letter sent by the complainant
Ex.A17	29.06.2018	Copy of termination notice of Health Policy
Ex.A18	03.07.2018	Copy of reply letter sent by the complainant
Ex.A19	16.07.2018	Copy of email sent by the opposite parties confirming the termination of the policy with effect from 16.07.2018
Ex.A20		Copy of email sent by the opposite parties confirming the rejection of the claim No.220100453356 under policy No. 4113I/XOL/74405522/02/000

 

OPPOSITE PARTIES’ 1 & 2 SIDE DOCUMENTS:-  NIL

 

 

MEMBER                                                                                                                                                                      PRESIDENT