Mrs. Kamlesh Chauhan V/s ICICI Lombard Gen. Ins. Co. Ltd.
Case No. 462/13
25.09.17
Present: Husband of the complainant in person
Sh. Dheeru Nigam Adv. for the OP
Final arguments are heard. We have gone through the file very carefully. We proceed to decide the case.
The case of the complainant herself is that she had taken a Health Insurance Policy in question on 02.09.09 for sum assured of Rs.2 lacs from the OP which was got renewed on 02.09.11 for the same amount of Rs.2 lacs. The complainant underwent an operation for the replacement of right hip on 07.07.11 for which an amount of Rs.2,22,157/- was raised by the hospital and the complainant was compensated to the extent of the policy amount as per her insurance policy by the OP. However, the case of the complainant further is that after discharge from the hospital on 12.07.11 she again felt ill and was got admitted in the hospital on 23.08.11 and discharged on 07.09.11 for which the hospital raised a total bill of Rs.73,389/- which was submitted with the OP but was repudiated by the OP on the ground that since the sum assured had already been exhausted hence, the OP is not liable to pay any further amount to the complainant.
The OP has also taken the same pleas in the reply to the complainant but has stated that as per policy conditions the complainant is entitled for a sum of Rs.10,000/- as her hospitalization lasted consecutively for 10 days within the policy period (02.09.10 to 01.09.11).
Parties have led their respective evidence and also filed written arguments.
The contention on behalf of the Complainant is that since the policy in question was continuing on the date of 2nd admission and the OP has admitted its liability to pay Rs.10,000/- on account of 2nd admission of the complainant to the hospital, the OP was not entitled to repudiate the 2nd claim. Contention raised on behalf of the OP is to the contrary.
Admittedly, the Health Insurance Policy was taken by the complainant for the first time on 02.09.09 for a sum of Rs.2 lacs which was valid till 01.09.10 and thereafter the complainant must have got renewed the same policy w.e.f. 02.09.10 to 01.09.11. Therefore, both the claims of the complainant fell under the validity of the insurance policy valid for the period 02.09.10 to 01.09.11.
According to the Complainant, her 2nd claim has been rejected by the OP vide letter dated 07.09.11 (Annexure A-5). The policy period in the said document has been shown as 02.09.09 to 01.09.11. However, the date of 2nd admission of the complainant was 23.08.11. during the continuation of policy for the period 02.09.10 to 01.09.11 which was also the validity period of policy during which first claim had been sanctioned by the OP. Therefore, since the OP had already compensated the complainant to the extent of the policy amount as per the insurance policy she did into become entitled to claim the amount of expenditure incurred by her on her treatment during her 2nd admission in the hospital w.e.f. 22.08.11.
We are also are of the considered opinion that the complainant has failed to prove any deficiency in service on the part of the OP.
In view of the above discussion, we do not find any merit in the complaint and dismiss it with no order as to costs. Let a copy of this order be given dasti to the parties. File be consigned to record room.
Announced on 25.09.17.
