Haryana

Ambala

CC/417/2011

SUKHWINDER SINGH - Complainant(s)

Versus

ICICI LOMBARD GIC, - Opp.Party(s)

G.S ALHUWALIA

23 Feb 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AMBALA.

 

                                                          Complaint case no.        : 417 of 2011

                                                          Date of Institution         : 30.12.2011

                                                          Date of decision   : 23.02.2017

 

            1.       Sukhwinder SinghWalia son of Sh. Amir Singh Walia.

2.       Smt. Jaspreet Kaur wife of Shri Sukhwinder Singh Walia son of Sh. Amir Singh Walia, R/o H.No.149,G-Manav Vihar, Walia Tyres, Hisar Road, Ambala City.

              ……. Complainants.

 

1.       ICICI Lombard GIC, ICICI Lombard Health Care, ICICI Bank Tower,Plot No.12, 12 Financial District Nanak Ram Guda, Gachibowli, Hyderabad-5000032 (Andhra Pradesh)  through its signatory.

 

2.       ICICI Lombard Health Care Branch Office at Ambala Cantt through its Manager.

 

           ….…. Opposite Parties

 

BEFORE:   SH. D.N. ARORA, PRESIDENT.

                   SH. PUSHPENDER KUMAR, MEMBER.                            

 

Present:       Sh. G.S. Ahluwalia, Adv. for complainant.

                   Sh. Rajesh Kumar, Adv. for Ops.

 

ORDER:

                   In nutshell, brief facts of the present complaint are that  complainant got a Health Care Policy from the Op vide policy no.40631/HAC/05522145/00/000 and paid a sum of Rs.15,000/- as premium and the policy was valid from 09.09.2010 to 08.09.2011. It has been submitted that wife of Jaspreet Kaur due to food poisoning  fell ill and she was got admitted in N.P. Singh Hospital, Ambala City but due to serious condition, she was shifted to Fortis Hospital, Mohali and a sum of Rs.54994/- towards the expenses of treatment. The complainant has submitted that  in terms of the policy, complainant is entitled for reimbursement of the expenses incurred on the treatment. So,  complainant submitted claim with the Op for the reimbursement.  But as per complainant, OP illegally and dishonestly   vide their letter dated 15.09.2011 repudiated the claim on the ground that ‘true  facts have not been declared or disclosed’, whereas the Ops are legally liable to pay the same. So, a legal notice dated 07.09.2011 served upon the Ops but of no avail.  As such, the complainant has prayed that the Ops have played unfair trade practice with them. Hence, the present complaint as per prayer clause.

2.                Upon notice, OPs appeared and filed written statement raising preliminary objections qua maintainability of complaint, suppression of material facts and the complaint  is bad for mis-joinder and non-joinder of necessary parties and submitted that at the time of taking the policy, complainant has not disclosed the real facts and concealed the material facts as well as her illness which she was having for the last three years prior to taking of the policy whereas there is a rider  in clause one of Part III Schedule that in case any incorrect statement  is found on the part of discloser later on, the policy shall be null and void and no benefit shall be payable. The Ops submitted that  the complainant has not disclosed her past medical history of RHD and mitral valvotomy in 2009 as per treatment record of Fortis Hospital, at the time of policy inception, so the complainant are not entitled for any benefit.  As such, the Ops have prayed that there is no deficiency in service as well as unfair trade practice on their part and sought for dismissal of complaint with cost.

3.                To prove his version, complainant Sukhwinder Singh tendered his affidavit as Annexure C-X alongwith documents as Annexure C-1 to C-11 and close his evidence. On the other hand, counsel for Op NO.2 tendered affidavit Annexure RX alongwith documents as Annexures  R-1 to R-5 and closed their evidence.

4.                We have heard learned counsels for the parties and carefully gone through the case file. The arguments of counsel for complainant is that complainant no.2 Jaspreet Kaur was covered under the Health policy in question and she fell ill due to food poisoning  and a sum of Rs.54994/- incurred on her treatment but the OP denied to reimburse the amount on the ground that  she was having pre-existing disease but the counsel for complainant has controverted this version of OP.

                   On the other hand, counsel for Ops stressed their arguments that complainant was having pre-existing disease at the time of taking the policy as emerges from the record of Fortis Hospital and reiterated the contents of their  written statement and the claim as per terms and conditions was not payable and the same was rightly rejected.

5.                Admittedly, the complainant had obtained mediclaim policy in his name alongwith her wife and paid Rs.15,000/- as premium. The policy period was w.e.f. 09.09.2010 to 08.09.2011.  Admittedly the complainant suffered illness and remained hospitalized w.e.f. 17.07.2011 to 18.07.2011 and spent a sum of Rs.54,494/- on her treatment.  The only dispute raised by OP is that  the complainant had concealed about the factum of his 3 years period illness and  therefore, he is not entitled for  claim. Bare perusal of the proposal form which is the first document on the basis of which insurance policy  is  being issued by insurance company reveals  that there is no such questionnaire /column in the whole proposal form with regard disclosure  of prior disease and in the absence of the same Op cannot say  that complainant had concealed anything  from OP.  Concealment is when “if the Op asks a specific question and the complainant intentionally did not answer the same or conceal. But the OP has never asked the complainant to disclose the prior disease history then no necessity has arisen to the complainant to disclose the same. As such, there is no concealment on the part of complainant. The case of OP does not fall within the ambit/definition of concealment.”  So, the complaint is allowed alongwith costs and Ops are directed to comply with the following directions within thirty days from the date of receipt of copy of the order:- 

(i)        To pay a sum of Rs.54,494/- to the complainant  no.2 Jaspreet Kaur alongwith interest @ 9% per annum  from the date of filing of the complaint till actual realization.

(ii)       Also to pay a sum of Rs.3000/- as costs of litigation.

                        Copies of the order be sent to the parties concerned, free of costs, as per rules. File after due compliance be consigned to the record room.

ANNOUNCED ON :23.02.2017                                                 Sd/-

                                                                                             (D.N. ARORA)

                                                                                                   PRESIDENT 

                                                                                                                                                                                                                                                                                                                            Sd/-

                                                                              (PUSHPENDER KUMAR)

                                                                                                       MEMBER