Punjab

Sangrur

CC/443/2015

Pawan Kumar Garg - Complainant(s)

Versus

ICICI Lombard GIC - Opp.Party(s)

Shri Darshan Kumar Gupta

19 Feb 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

 

                                                               

                                                Complaint No.  443

                                                Instituted on:    08.06.2015

                                                Decided on:       19.02.2016

 

Pawan Kumar Garg son of Shri Roshan Lal, resident of Street No.2, Defence Avenue, Haripura Road, Sangrur.

                                                        …Complainant

                                Versus

1.     ICICI Lombard General Insurance Company Limited, SCO 26, Kaula Park, 1^st Floor, Harman Hotel, Sangrur through its Manager.

2.     ICICI Lombard General Insurance Company Limited, ICICI Lombard House, 414, Veer Savarkar Marg, Near Sidhi Vinayak Temple, Prabhadevi, Mumbai-400 025 through its Managing Director.

                                                        ..Opposite parties

 

 

For the complainant  :       Shri Darshan Gupta, Adv.

For OPs                    :       Shri G.S.Shergill, Adv.

 

Quorum:   Sukhpal Singh Gill, President

                K.C.Sharma, Member

                Sarita Garg, Member

 

 

 

Order by : Sukhpal Singh Gill, President.

 

1.             Shri Pawan Kumar Garg, complainant (referred to as complainant in short) has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the complainant obtained the services of Ops by getting the health care cashless health card i.e. medical policy baring number 4034/FPP/03410534/00/000 and card number IHPN-03562593/01 in the year 2008-09 and the same is being renewed regularly.  It is further averred that the mediclaim policy was renewed which was valid upto 22.3.2015 vide policy number 4128i/HPR/88566725/00/000 for Rs.3,00,000/- for which the complainant paid a premium of Rs.10,454/-. It is further averred that before issuance of the policy, the OPs also got examined the complainant and ECG report was also taken at that time and only after going through the same the policy in question was issued.  It is further averred that the complainant was having good health and taking active part in the business.  It is further averred that on 1.6.2014, the complainant felt severe pain in the abdomen and consulted the doctor at Civil Hospital, Sangrur, who advised to consult from a calculus specialist, as such, the complainant went to Nitin Nursing Home, Patiala and after complete check up, the doctor found that a calculus is located in the right renewal pelvic and prescribed medicine. It is further stated that though after taking medicine the condition of the patient improved, but again on 13.8.2014 the pain in the abdomen started as such the complainant went to the RG Stone and Super Speciality Hospital, Ludhiana and the doctors advised him admission for operation, where he remained admitted from 14.8.2014 to 15.8.2014, where he spent an amount of Rs.66,770/- on the treatment.  Thereafter the complainant requested the Ops for reimbursement of the amount of Rs.66,770/- and submitted medical bills of RG Stone and Super Speciality Hospital, but the Ops vide letter dated 21.3.2015 repudiated the claim on flimsy grounds.  It is further mentioned in the complaint that no terms and conditions were ever issued to the complainant. Thus, alleging deficiency in service on the part of the Ops, the complainant has prayed that the Ops be directed to pay to the complainant an amount of Rs.66,770/- along with interest @ 18% per annum from the date of lodging the claim till realisation  and further claimed compensation for mental torture, agony and harassment and  litigation expenses.

 

2.             In reply filed by OPs, preliminary objections are taken up on the grounds that the complainant has not come to the court with clean hands and has suppressed the true and correct facts from this Forum.  It is further stated that non disclosure of the fact of pre existing disease was material to the issuance of the policy and ought to have been disclosed by the insured. By not doing so the proposer has misled the Ops to grant his insurance cover as stated in the policy schedule. It is further stated that the contract of insurance is a contract of uberrimae fidei and the insurer is under obligation to make true and full disclosure of statement within his knowledge, that the complainant applied for insurance policy through telephonically conversation and as such with the consent of the insured that the OP had issued the policy to the insured, but the insured did not disclose any facts regarding his pre existing illness, that the complainant has concealed and has suppressed the material and relevant facts of the case. The complaint has been filed with malafide and dishonest intention and has only concealed the material facts, but has also twisted and distorted the same to suite their own convenience and to misled the Forum.  Maintainability of the complaint is also disputed.  On merits, it is stated that the policy to the complainant was issued to the complainant on the basis of various quarries made in the voice recording system regarding the good health. It is stated that the claim has rightly been repudiated as per the terms and conditions of the policy. However, any deficiency in service on the part of the OPs has been denied.

 

3.             The learned counsel for the complainant has produced Ex.C-1 copy of insurance policy, Ex.C-2 to Ex.C-4 copies of cash less health card, Ex.C-5 copy of prescription slip of Nitin Hospital, Ex.C-6 copy of prescription slip of RG Stone Hospital, Ex.C-7 copy of discharge summary, Ex.C-8 copy of Lab report, Ex.C-9 to Ex.C-16 copies of bills, Ex.C-17 copy of repudiation letter and closed evidence. On the other hand, the learned counsel for the OP has produced Ex.OP-1 affidavit, Ex.OP-2 copy of repudiation letter, Ex.OP-3 copy of request letter dated 22.1.2015, Ex.OP-4 copy of discharge summary, Ex.OP-5 copy of investigation report Ex.OP-6 copy of discharge summary, Ex.OP-7 copy of cardiology report dated 5.8.2013, Ex.OP-8 copy of OPD card, Ex.OP-9 copy of proposal form, Ex.OP-10 copy of policy, Ex.OP-11 copy of terms and conditions and closed evidence.

4.             We have very carefully perused the complaint, version of the opposite parties, evidence produced on the file and written submissions and also heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits acceptance, for these reasons.

 

5.             It is not in dispute between the parties that the complainant is obtaining the medi claim policy since the year 2008 and it is further not in dispute that the complainant renewed his policy bearing number 41281/HPR/88566725/00/000 for Rs.3,00,000/- by paying the requisite premium of Rs.10,454/- to the OPs which was valid upto 22.3.2015.

 

6.             In the present case, the grievance of the complainant is that he lodged the claim with the OPs for Rs.66,770/- as he remained admitted for conducting the operation in the RG Stone and Super Speciality Hospital, Ludhiana from 14.8.2014 to 15.8.2014, but the Ops repudiated the claim vide letter dated 21.3.2015 on the ground that the complainant was having pre existing disease.

 

7.             After carefully hearing the arguments of the learned counsel for the parties and hearing the arguments of the learned counsel for the parties, we feel that the claim lodged by the complainant is genuine one and the repudiation of the same is wrong and illegal.  Since it is the own case of the OPs that the complainant was taking the policy since the year 2008 and on 1.6.2014 he felt severe pain in the abdomen and accordingly consulted the doctor of Civil Hospital, Sangrur, who advised further to consult from a calculus specialist, as such he approached Nitin Nursing Home, Patiala and prescribed medicines.  Thereafter on 13.8.2014, he again felt severe pain in the abdomen and as such he went to RG Stone and Super Speciality Hospital, Ludhiana, where the doctors operated and the complainant remained admitted there from 14.8.2014 to 15.8.2014 and  he spent there an amount of Rs.66,770/- on his treatment.   Ex.C-6 is the copy of prescription card issued by Nitin Nursing Home and Ex.C-7 is the copy of discharge summary issued by RG Stone and Super Speciality Hospital, which shows that the complainant remained admitted from 14.8.2014 to 15.8.2014 and was treated for right renal calculus with CAD (post PTCA), as the complainant has been complaining of pain in right flank radiate to back for 5-6 months on and off, meaning thereby the complainant was not having any history or pre-existing disease for which the complainant was treated at RG Stone and Super Speciality Hospital, Ludhiana.  The OPs have not produced on record any documentary evidence to show that the complainant was suffering from any pre existing disease. We have also perused the copy of discharge summary of Metro Hospital and Heart Institute, Ex.OP-6, which is alleged by the OPs that the same belongs to the complainant, but we feel that this document is not at all helpful to the case of the complainant as it belongs to the year 2003, meaning thereby if it was in the knowledge of the OPs then why they issued the mediclaim insurance policy in the year 2008 and thereafter also in regular.  As such, we are of the considered opinion that the OPs have failed to discharge their part of duty by producing cogent and reliable evidence to show that the complainant had taken the policy by representing false facts.  Reliance can also be placed in the judgment of the Hon'ble Apex Court of India pronounced in Life Insurance Corporation of India versus Smt. G.M. Channabasemma 1991 AIR (SC) 392, wherein it has been held that in the contract of insurance, the assured is under the solemn obligation to make full disclosure of material facts, but at the same time to prove the allegation of insured being guilty of making false representation and suppressing material facts lies on the Corporation.  Further the Apex Court in P.Vankat Naidu versus Life Insurance Corporation of India and another IV (20110 CPJ 6 (SC)  has held that the onus to prove that the deceased withheld the material information about his hospitalization and treatment is on the insurance company. As such, we find it to be a case of deficiency in service on the part of the OPs. 

 

8.             Now, coming to the point of quantum of compensation payable to the complainant.  The complainant has claimed an amount of Rs.66,700/- from the Ops on account of mediclaim, but we are unable to grant such an amount, as the complainant has not produced any evidence to show that he spent an amount of Rs.66,700/-.  We have perused the copies of the bills issued by the RG Super Speciality Hospital from Ex.C-9 to Ex.C-16, which are only to the tune of Rs.26720/-, as such, we feel that the complainant is entitled to claim any amount of Rs.26,720/- from the OPs. 

 

9.             So, in view of our above discussion, we find it to be a case of deficiency in service and accordingly, we allow the complaint and direct OPs number 1 and 2 to pay to the complainant an amount of Rs.26,720/-   along with 9% interest from the date of filing of the complaint i.e. 08.06.2015 till realisation in full. We further direct OPs number 1 and 2 to pay to the complainant a sum of Rs.5,000/- on account of mental tension, agony and harassment and a sum of Rs.5,000/- as litigation expenses. This order of ours shall be complied with by the OPs  within a period of thirty days of  receipt of a copy of this order. A copy of the order be issued to the parties free of cost. File be consigned to records.  

                Pronounced.

                February 19, 2016.

                                                        (Sukhpal Singh Gill)

                                                           President

 

 

                                                              (K.C.Sharma)

                                                                Member

 

 

                                       

                                                                (Sarita Garg)

                                                                    Member