BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.179 of 2016
Date of Instt. 21.04.2016
Date of Decision: 01.11.2017
Sh. Balraj Kumar, aged 64 years S/o Sh. Inderjit Singh R/o House No.133, GTB Avenue, Jalandhar.
..........Complainant
Versus
1. ICICI Lombard General Insurance Company Limited, ICICI Lombard Health Care, ICICI Bank Tower, Plot No.12, Financial District, Nanakram Guda, Gachibowli, Hyderabad-500032
2. ICICI Lombard General Insurance Company Limited, 2nd Floor, Plot No.EH-198, Nirmal Complex, Near Gujarat Palace, Near Bhagat Namdev Chowk, G.T. Road, Jalandhar-144001 through its Branch Manager.
….… Opposite parties
Complaint Under the Consumer Protection Act.
Before: Sh. Karnail Singh (President)
Sh. Parminder Sharma (Member)
Present: Sh. IS Bhatia, Adv Counsel for the complainant.
Sh. RK Sharma, Adv Counsel for the OP No.1 and 2.
Order
Karnail Singh (President)
1. This complaint filed by the complainant, wherein stated that he is a senior citizen having meagre financial resources. The complainant purchased Health/Hospitalization benefit Insurance Policy No.4128i/HPR/92755171/00/000 valid from 21.08.2014 to 20.08.2015 from the OPs. The complainant was issued Card No.100453188 against the said policy. The complainant suffered from a disease in left foot thumb and approached doctor Shubhang Aggarwal of Satyam Hospital, Jalandhar on 18.10.2014, who advised for scanning. After receiving the scanning reports, the complainant was admitted in Satyam Hospital on 21.10.2014 for medical treatment. However, the complainant was not satisfied with the treatment being given at Satyam Hospital, Jalandhar. Therefore, he got himself discharged from the said hospital on 22.10.2014, after clearing their dues.
2. That on 22.10.2014, the complainant approached Dr. Suresh Nanda of Nipun Nanda Nursing Home, Jalandhar on 22.10.2014 and was admitted there for medical treatment. The complainant again was not satisfied with the medical treatment being given by the said hospital and got himself discharged from the said hospital on 23.10.2014, after paying the dues of the said hospital.
3. That on 24.10.2014, the complainant contacted Dr. Ravul Jindal of Fortis Hospital, Mohali and he was advised admission. Accordingly, the complainant got admitted in the said hospital on 24.10.2014. The left foot thumb of the complainant was surgically operated and the complainant was discharged from Fortis Hospital, Mohali on 27.10.2014. The OPs have settled the claim for the expenses claimed by Fortis Hospital on cashless basis. The claim for the expenses paid to Satyam Hospital, Jalandhar and Nipun Nanda Hospital, Jalandhar have also been reimbursed.
4. That at the time of being discharged from Fortis Hospital, Mohali, Dr. Ravul Jindal has prescribed post operation treatment and had prescribed medicines, injections and dressings to be arranged by the complainant locally at Jalandhar. The complainant followed the prescribed instructions and purchased the injections, medicines as prescribed and also arranged for the dressings and had submitted a separate claim for post hospitalization expenses vide claim No.220100289160-2. The complainant also submitted three cash memos in original alongwith the claim. The said medicine was purchased from M/s Sodhi Medical Centre, Shop No.4, GTB Avenue, Jalandhar, on 31.10.2014 for amounting to Rs.24,597/- and then on 04.11.2014 for amounting to Rs.24,597/- and then on 05.11.2014 for amounting to Rs.27,985/- and the said firm M/s Sodhi Medical Centre issued cash memo bearing No.1200, 1233 and 1351 respectively and the total claim amount is Rs.77,179.75/-. Thereafter, the complainant received SMS on his mobile phone that the claim shall be settled within 14 days, but later on, he was informed that his claim is rejected on the following remarks:-
“Rejected, according to Part-III of the schedule clause No.14 if any claim in any respect fraudulent or if any false statement or declaration is made or used in support thereof. Or if any fraudulent means or devices are used by the insured or anyone acting on his behalf to obtain any benefit under this policy is not payable”.
5. The OPs have illegally and wrongly rejected the lawful and genuine claim, lodged by the complainant and accordingly, a legal notice was served to the OPs, but all in vain and as such, there is a deficiency in service on the part of the OP and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay a sum of Rs.77,179.75/- including interest thereon @ 18% per annum with effect from 05.11.2014 till realization and OPs be further directed to pay compensation for causing undue harassment, mental tension, inconvenience, to the tune of Rs.5,00,000/- and also cost of litigation be awarded to the complainant.
6. Notice of the complaint was given to the OPs and accordingly, both the OPs filed reply and contested the complaint of the complainant by taking preliminary objections that the complaint is not maintainable against the OPs, as such, the same is liable to be dismissed and further averred that the complainant can not take advantage of his own wrongs. The complainant has submitted the Post Hospitalization reimbursement claim fraudulently by submitting the bills of expenses with dates thereon, which do not match with the dates on the carbon copies of the bills submitted i.e. with the record of the Medical Store M/s Sodhi Medical Centre, Shop No.4, G.T.B. Avenue, Jalandhar and accordingly, as per Part- III General Policy Terms and Conditions with its Clause 12, the claim of the complainant was rightly repudiated. It is further averred that there is no deficiency in service on the part of the OP because the repudiation of the claim is as per term and condition of the insurance policy. On merits, the purchase of policy as well as submitting of claim and repudiation of the said claim is admitted and further OP also admitted that the claim of the complainant with regard to treatment of the complainant from Satyam Hospital, Jalandhar, Nipuan Nanda Hospital, Jalandhar and Fortis Hospital, Mohali stands settled and paid to the complainant and further submitted that when the claim of the complainant was processed, it was found that dates on the submitted bills are manipulated and are not matching with the carbon copy available with the medical store and evidently, the bills were submitted fraudulently to get the claim and other allegations as made in the complaint are categorically denied and lastly prayed that the complaint of the complainant is without merits and the same may be dismissed.
7. In order to prove the case of the complainant, counsel for the complainant tendered into evidence affidavit of the complainant Ex.CA alongwith some documents Ex.C1 to Ex.C10 and closed the evidence.
8. Similarly, counsel for the OP No.1 and 2 tendered into evidence affidavit of Sh. Karan Nagla, Manager (Legal) Ex.OP/A alongwith documents i.e. Copy of Insurance Policy Ex.O1, Terms and conditions of the Policy Ex.O2 , Carbon copy of the bills of Sodhi Medical Centre Ex.O3 to Ex.O5 and Repudiation letter Ex.O6 and then closed the evidence.
9. We have heard the learned counsel for the respective parties and also gone through the case file very minutely.
10. In this case, the factum in regard to getting treatment from different hospital by the complainant and its reimbursement by the OP has been made is not in dispute. The dispute is only in regard to three medical bills, submitted by the complainant by purchasing medicines on the prescription of Dr. Ravul Jindal of Fortis Hospital, Mohali and these medical bills are proved on the file by the complainant as Ex.C5, Ex.C6 and Ex.C7, but the claim of the complainant has been repudiated by the OPs, simply on the ground that the bills submitted by the complainant are manipulated because the dates put on the bills, submitted by the complainant do not match with the dates on the carbon copy of the bills, submitted i.e. with the record of the medical store M/s Sodhi Medical Centre, Jalandhar and these photostat copy of the bills produced on the file by the OP are Ex.O3 to Ex.O5 and reference of these medical bills is given in the repudiation letter Ex.O6.
11. We have gone through the dates put on the bills, submitted by the complainant as well as the dates put on the bill produced on the file by the OPs and find that the dates on the bills Ex.O3 to Ex.O5 having an over writing but there is no over writing upon the bills, produced by the complainant i.e. Ex.C5 to Ex.C7. The original bill was issued to the party, who purchased the goods and carbon copy remained with the shopkeeper and copy of the bills obtained by the OP from the shopkeeper i.e. Sodhi Medical Centre and if there is any over writing in regard to date, then it is the duty of the OP to summon the said original carbon copy of the medical bill from the said Sodhi Medical Centre, but for the best known reason, the OP has not summoned the original record rather produced on the file photostat copy of the bills and it is not established, who made the over writing over the said bills, produced by the OP. We can see with naked eyes that the dates are over writing, if there is any over writing on the carbon copy of the bills, then the purchaser is not responsible for that, the liability for over writing on the carbon copy of the bill is upon the shopkeeper and the best person is the shopkeeper, who can explain why the over writing was done and moreover, it is not established on the file that the said over writing has been done by the shopkeeper or by some official of the OP just to restrain the complainant from eating the foods of insurance policy. So, with these observations, we are of the opinion that the complainant has not made any manipulation in the bills nor given any false statement or declaration nor any fraudulent act has been committed. Therefore, the case of the complainant is not covered under the said provision i.e. Part No.3 General Policy terms and conditions Clause 12, if so then, the claim of the complainant has been wrongly and illegally repudiated by the OP, vide repudiation letter Ex.O6.
12. In the light of above detailed discussion, the complaint of the complainant succeeds and accordingly, the same is partly accepted and OPs are directed to pay a sum of Rs.77,179.75/- plus interest @ 9% per annum from the date of purchase of the medicines i.e. 05.11.2014, till realization and further OPs are directed to pay compensation for causing undue harassment and mental tension, to the tune of Rs.15,000/- to the complainant and further directed to pay litigation expenses of Rs.5000/-. The entire compliance be made within one month from the date of receipt of the copy of order. The complaint could not be decided within stipulated time frame due to rush of work.
13. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Parminder Sharma Karnail Singh
01.11.2017 Member President
