Punjab

Fatehgarh Sahib

RBT/CC/706/2018

J.N.Bakshi - Complainant(s)

Versus

ICICI LOMBARD HEALTH CARE - Opp.Party(s)

Pankaj Sharma

28 Mar 2023

ORDER

 

  DISTRICT CONSUMER DISPUTES REDRESSAL

                                     COMMISSION

                                 FATEHGARH SAHIB

 

RBT No.	:	CC/706/2018
Complaint No.	:	RBT/CC/706 of 2018
Date of Institution	:	05/07/2018
Date of Decision	:	28/03/2023

 

J.N. Bakshi, aged about 63 years, R/o Flat no.125-B, S.B.P. Homes, Ext-2, Chajju Majra Road, Sector-126, Greater Mohali, Tehsil Kharar, Distt., Mohali

                                                                                                                     …………....Complainant

                                                Versus

 

1.  ICICI Lombard Health Care,  I L Health Care, Retail Claims, ICICI Bank Tower, Plot No.12, Financial District Nanakramguda , Gachibowli, Hyderabad, Andhra Pradesh . PIN 500032, through its Managing Director

 

2. ICICI  Bank Ltd., SCS no.38-39, Phase-7 SAS Nagar Mohali, through its Manager

 

3. ICICI Lombard General Insurance Company Ltd, Plot no.149, Fourth Floor, Industrial Area, Phase-1 Chandigarh, through its Manager
4. ICICI Lombard General Insurance Company Ltd, ICICI Lombard House,414, Veer Sanvarkar Marg, Near Sidhivinayak Temple, Prabhadvi, Mumbai-400025, through its Manager.

                                                                              ..………....... Opposite Parties

 

Complaint under Section 12 of Consumer Protection Act 1986(Old)

Quorum

Sh. S.K. Aggarwal, President

Ms. Shivani Bhargava, Member

Sh. Manjit Singh Bhinder, Member

Present: Sh. Pankaj Sharma, counsel  along with  complainant.

             OP no.1 Ex-Parte.

             Sh. Puneet Tuli, counsel for OP NO.2.

    Sh.Vinay Sood, counsel for OPs no.3 and 4.

 

The  complaint has been filed against the OPs (opposite parties) under Section 12 of Consumer Protection Act-1986(old) alleging deficiency in service with the prayer for giving direction to the OPs to give the insurance claim of Rs.1,12,500/- along with 24%  PA interest from the date of filing the claim till its realisation and to pay  Rs.3,00,000/- as compensation  for mental and physical harassment  and Rs.25,000/-  as  litigation expenses.

1.   The complainant had taken a personal loan from the ICICI Bank Ltd bearing account no. LPKRH00031158364.  OPs 1,3 ,4 issue ICICI Lombard Group Personal Accident Insurance Policy to the Personal Loan Customers of ICICI Bank Ltd. to secure the loan amount. OPs issued the  above said insurance  Policy to the complainant vide Policy no.4005/M/IBNKPL/97823226/00/00 from 24/12/2014 to 23/12/2017. The complainant had been insured for Rs.1,50,000/- . The Bank  deducted Rs.1125/- as  premium from his ICICI bank account. On 10.7.2016, the complainant met with an accident on Patiala-Mohali road. The complainant was admitted to Fortis Hospital, Mohali and discharged from Hospital on 16.7.2016. Complainant has lost his hearing Power  from both ears (95% from right ear & 57% on left ear). A general diary report was also registered in Mohali Police station vide GD no.028 dated 13.7.2016. He lodged his insurance claim to the OPs under the above said Policy.  In the month of May, 2017 OP’s surveyor has  got the complete information from the complainant and  the complainant showed the Disability certificate from PGI Chandigarh. In the said certificate, the doctors have certified that the complainant has lost his hearing Power from both Ears i.e B/L Sensorineural hearing loss  with 57% disability.  The OPs repudiated the claim. Hence this complaint.
2.        Notice of the complaint was given to the OP no.1 through registered Post OP no.1 did not appear despite service of summons as such OP no.1 was proceeded against Ex-Parte for non appearance vide order dated 29.10.2019. OPs no.2 appeared through its Counsel  and filed  written version. OPs no.3 and 4 appeared through their counsel and filed written version jointly.
3.        The complaint has been contested by the OP no.2 and filed written version. The complainant was  having a loan account in  ICICI Bank i.e OP no.2 no.LPKRH00031158364. The Insurance was done to secure the said loan by Ops no.1,3 and 4.  The OP no.2 is engaged in the business of financing vehicles, personal and home loans , credit facilities etc.  The ICICI Bank  and ICICI Lombard Health Care are two different entities . There is no relief claimed against OP no.2.  Hence prayer  for  dismissal of complaint has been made.
4. The complaint has been contested by the OPs no.3 and 4 and  filed joint written version  and  raising  preliminary objection that the present  complaint is wholly misconceived, baseless, groundless, false and frivolous which  is unsustainable in the eyes of law. The OPs no.3 and 4 has contested on merits that the disability suffered by the complainant  is not denied but the claim stands repudiated by the Company. The same was duly informed to the complainant vide letter dated 13.7.2017. The claim does not fall with in ambit  of insurance policy  because as per the policy’ terms  and conditions loss of hearing will fall under permanent partial disablement and the same is not covered under this Policy. Policy covers only Death and Permanent total Disability.  Hence prayer of dismissal of complaint has been made.
5. The complainant in support of his complaint tendered in evidence his  affidavit along with copies of  documents  i.e Ex.C1  claim  Form , EX.C2  Policy documents.  Ex.C3 statement of account in ICICI Bank, Mohali, Ex.C4 General Dairy details regarding accident dated 13.7.2016, Ex.C5 Certificate from  PGI regarding percentage of hearing loss,  Ex.C6 to Ex.C13 Mails/Emails of regarding the correspondence  of information of insurance claim .  Ex.C14 copy of PGI OPD Card, Ex.C15 hearing evaluation of the complainant. Along with reply OPs no.3 and 4 filed affidavit of Nishant Gera Legal Manager and copies of documents i.e Ex.OP1 Letter dated 13.7.2017,  Ex.OP2 letter dated 10.8.2017, Ex.OP3 insurance Policy.  Ex.OP4 terms and conditions.
6. Heard. Entire record perused.
7.  Admittedly, complainant had a loan account no.LPKRH00031158364 in ICICI Bank, Phase 7, Mohali i.e OP no.2. OPs no.1,3 and 4 issued ICICI Lombard Group Personal accident Insurance Policy no.4005/M/IBNKPL/97823226 w.e.f 24.12.2014 to 23.12.2017, vide Ex.C2 to secure the loan. Complainant  had been insured for Rs.1,50,000/- and premium of Rs.1125/-  was deducted from the loan account vide Ex.C3. Complainant met with an accident  on 10.07.2016. This fact is proved from the documents  vide Ex.C4. Complainant suffered B/L sensorineural 57%   hearing loss as  per disability certificate  by PGI, Chandigarh vide Ex.C5. Complainant lodged his claim to the OPs under  the Policy vide Ex.C1 but OPs rejected his claim vide Ex.C13.
8. Ld. Counsel for the complainant  submitted that complainant’s case comes under the permanent partial disablement. It covers under Section-2.1(iii) i.e Permanent partial disablement which covers loss of hearing of both the ears. As per disability certificate by PGI, complainant has lost his 57% hearing power.  
9.  This argument of the complainant was rebutted by the Ld. Counsel for the OPs no.3 and 4 and he has placed reliance  upon the judgement  by the  National Consumer Disputes Redressal Commission , Delhi, Revision Petition no.267 of 10.6.2016 Namdeo Ramachandra Khedu  Patel & Others Vs The Chief  Executive officer,  Bajaj Allianz general Insurance Co.. Ltd. & Other. Where in it has been held that Medical certificate can not be the basis for reimbursement .
10.  From the perusal of the record , we find that OPs rejected complainant’ claim  on the ground that it comes  under permanent partial disability vide Ex.OP1. We find that complainant suffered 57% B/L  i.e Bilateral sensorineural  hearing loss as per PGI’ disability certificate vide Ex.C5.  He can not hear without hearing aid. The permanent partial disablement  refers to a person ‘ inability to perform all the duties & bodily functions that he could perform before the accident though  he is able to perform  some of them and is still able to  engage in some gainful activity . One can not perform  smoothly daily  function of life  where as total permanent  disability  refers to a person’ inability  to perform  any  avocation or employment  related activities as  a result of accident.

The OPs issued ICICI Lombard Group Personal Accident Policy with product code 4005 tocomplainantvide Ex.C2. In Policy,product code 4005 is mentioned before the Policy no. i.e 4005/M/IBNKPL/97823226/00/000. On thePolicy Product code cover, it does find mentions that the InsurancePolicy compensates the insured in case of accidentaldeath,loss of limbs and eyes, permanent total disablement and permanent partial disablement. Insurance Policies must be interpreted in a way that gives effect to the reasonable expectation of the parties. Insurance Companies are refusing claims on technicalgrounds.Rejection of claim purely ontechnical ground will result in Policy holder’ loosingconfidence inInsuranceCompanies and giving rise to excessive litigation. Insurance companiesshouldoverlook thetechnicalities. In order tosustain a claimunder accident benefit cover it mustbeestablished that the assured has sustained a bodilyinjury which resulted solely & directly from the accident.There must in other words exits aproximate causalrelationshipbetween theaccident& the bodily injury. The outcome of the present complaint involves the interpretation of the accident benefit cover becausecomplainantsufferedhearing lossas a result of accident. OPs no.1,3 and 4 are liable for deficiency in service. OP no.2 is proforma OP.

11.     As  a corollary of our above discussion, the present complaint is partly allowed.  OPs no.1,3 and 4 are jointly and  severally liable  to pay the claim. The OPs no.1,3 and 4 directed as follows :-

[a] To pay the claim of Rs.1,12,500/- to the complainant within 30 days, along with interest @ 6%, failing which interest @ 9% P.A. shall be payable.

 [b]  To payRs.25,000/-compensation for harassmentandlitigation charges to the complainant.

The compliance of this order be made by the OPs no.1,3 and 4 within a period 30 days from the date of receipt of certified copy of this order. Failing which the complainant shall be entitled to recover the above said amount through legal process. The complaint could not be decided within the statutory period due to pandemic of Covid-19. Copy of this order be sent to the complainant and the OPs as per rules. File be sent back to District Consumer Commission, Mohali, for consignment.

Pronounced: 28 March 2023

                                                           

                                                                      (S.K. Aggarwal)

                                                                              President

                                                                    

    

                                                                             (Shivani Bhargava)

                                                                              Member

 

                                                                             ( Manjit Singh Bhinder )

                                                                                         Member