Delhi

North East

CC/295/2016

DHRUV SHARMA - Complainant(s)

Versus

ICICI LOMBARD INSURANCE CO. - Opp.Party(s)

26 Sep 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

 

Complaint Case No.295/16

In the matter of:

 

	Dhruv Sharma, R/o A-1/3, Gali No. 06, East Krishna Nagar, New Delhi	Complainant
	Versus
1.           2.	ICICI Lombard General Insurance Co., DDA Market, First Floor, 101, J & K Market, Dilshad Garden, New Delhi 110095   ICICI Lombard General Insurance Co., ICICI Lombard House, 414, Veer Savarkar Marg, Near Sidhhi Vinayak Temple, Prabha Devi, Mumbai 400025	Opposite Parties

 

DATE OF INSTITUTION:         JUDGMENT RESERVED ON:                         DATE OF ORDER  :

26.10.2016 01.08.2023 26.09.2023

 

 

CORAM:

Surinder Kumar Sharma, President

Anil Kumar Bamba, Member

 

ORDER

 

Surinder Kumar Sharma, President

The Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986.

 

Case of the Complainant

1. The case of the Complainant as revealed from the record is that the Complainant through an agent had purchased an insurance policy from the Opposite Parties in the name of his wife namely Smt. Asha Sharma vide policy no. 4065/CCSM/83050189/00/000 and namely “CRITICAL CARE” for a sum insured of Rs. 6,00,000/-. The period of the said policy was from 19.09.2013 to 18.09.2018 i.e. for 5 years. The premium for the said policy was Rs. 18,419/-. It is his case that the said policy covered A) illness namely: cancer, end stage renal failure, multiple sclerosis, B) these following surgical procedures: Major organ Transplant, Heart Valve replacement or coronary Artery byepass graft, C) Occurrence of the following medical events:  Stroke, paralysis and myocardial infection, death of the insured on account of an accident and permanent total disablement of the insured on account of accident. Complainant stated that on 22.03.2015, wife of the Complainant got heart attack and she was got admitted in Crosslay Pushpanjali Hosptial and got discharged on 27.03.2015. Complainant stated that he told the Opposite Parties about the illness of his wife i.e. policy holder and Opposite Party promised that he would get the claim amount in few days. It is his case that after few days Complainant approached the Opposite Parties to know the status of the claim then Opposite Parties misguided the Complainant on one pretext or the other. It is his case that after couple of months when Opposite Party did not release the payment then Complainant had enquired on phone for the process to terminate the policy as no use of the policy. It is his case that on the very next day Complainant received a text message from the Opposite Party that your policy dated 20.09.2013 vide policy number 4065/CCSM/83050189/00/000 stands cancelled on the request of the Complainant. Complainant sent a legal notice dated 20.07.2016 to the Opposite Parties. Complainant has prayed to direct the Opposite Parties to provide the insurance claim i.e. Rs. 6,00,000/- along with interest. Complainant also prayed for Rs. 2,00,000/- on account of mental harassment and  Rs. 55,000/- on account of litigation expenses.  

Case of the Opposite Parties

2. The Opposite Parties contested the case and filed written statement. It is stated that the complaint is not maintainable as the Complainant has concealed the material facts from this Forum. It is admitted that the Complainant purchased a ‘Critical Care’-Secure Mind Policy vide policy no. 4065/CCSM/83050189/00/000 for his wife. The said policy was valid from 19.09.2013 to 18.09.2018. At that time the Complainant submitted the proposal form for obtaining the said policy and on the basis of information furnished by the Complainant the Opposite Parties issued the policy to the Complainant. It is stated that the Complainant never lodged any complaint in  respect of the present policy i.e. policy no. 4065/CCSM/83050189/00/000 at any point of time regarding the alleged heart attack dated 22.03.2015. It is stated that the Opposite Parties received a call from the Complainant with request to cancel the policy. On the request of the Complainant the said policy was cancelled on 08.06.2015 and the Opposite Parties refunded the premium amount of Rs. 16,393/- out of total premium of Rs. 18,419/- after deducting the service tax of Rs. 1967.16/-. The Complainant was also issued a cancellation letter in this regard. It is stated that the Complainant did not lodge any claim against the above said policy nor furnished the discharge summary of the hospital. It is stated that the Complainant did not approach the Opposite Parties for reimbursement of the treatment amount. It is prayed that the complaint is without any merit and the same deserve dismissal.
3. The perusal of the proceedings dated 11.05.2017 shows that the Complainant did not file rejoinder to the written statement of the Opposite Parties.

Evidence of the Complainant

4. The Complainant in support of his complaint filed his affidavit wherein he has supported the averments made in the complaint.

Evidence of the Opposite Parties

5. To support their case Opposite Parties has filed affidavit of Shri Vikash Goyal, Legal Manager, wherein, he has supported the case of the Opposite Parties as mentioned in the written statement.

 

Arguments & Conclusion

6. We have heard the Ld. Counsel for the Parties. We have also perused the file and written arguments filed by the Complainant and Opposite Parties. The case of the Complainant is that he has purchased Critical Care policy vide policy no. 4065/CCSM/83050189/00/000 from the Opposite Parties. The said policy was purchase by the Complainant in the name of his wife. The policy was valid from 19.09.2013 to 18.09.2018. The case of the Complainant is that on 22.03.2015,   Smt. Asha Sharma wife of the Complainant suffered heart attack and she was admitted in Crosslay Pushpanjali Hospital from 22.03.2015 to 27.03.2015. The case of the Complainant is that he told the Opposite Parties regarding the said illness of his wife but no claim amount was paid to the Complainant regarding the treatment of his wife in Crosslay Pushpanjali Hospital from 22.03.2015 to 27.03.2015. It is also the case of the Complainant that the Complainant was fed up with the response of the Opposite Parties regarding the payment of his claim amount, the Complainant asked the Opposite Parties regarding cancellation of the policy. The Complainant was surprised to know that on the next day the Complainant received a message that his policy had been cancelled on the request of the Complainant.  
7. On the other hand, the case of the Opposite Parties is that the Complainant never lodged any complaint regarding the treatment of his wife in Crosslay Pushpanjali Hospital for the period from 22.03.2015 to 27.03.2015. It is the case of the Opposite Parties that the Complainant did not submit any medial documents or discharge summary etc. regarding the treatment of his wife. The Complainant has not filed any document in this regard. It is also important to note that the Complainant has not controverted the stand taken by the Opposite Parties by not filing the rejoinder nor he led any evidence to rebut the said stand taken by the Opposite Parties.
8. The case of the Complainant is that he had only enquired from the Opposite Parties regarding the procedure for cancellation of the policy. The case of the Opposite Parties is that the Complainant has requested for cancellation of policy. In their written statement the Opposite Parties have stated that the Complainant made request to cancel the policy for the remaining period and thereafter the request was confirmed through VRS (Voice Recording System) and the policy was cancelled on 08.06.2015. The premium amount of Rs. 16,393/- was refunded to the Complainant. The Complainant has not controverted this assertion made by the Opposite Parties by not filing the rejoinder to the written statement of the Opposite Parties. Nor he has filed any evidence to controvert or to rebut this stand taken by the Opposite Parties.
9. The perusal of the file further shows that the Complainant has also applied for claim for the treatment of his wife from 22.03.2015 to 27.03.2015 at Crosslay Pushpanjali Hospital vide claim no. 220100306570 in policy                                        no. 41281/HPR/93362023/00/000. It is further revealed from the record that an amount of Rs. 96,804/- was sanctioned and paid to the Complainant. Thus, it is clear that the Complainant has already received an amount of Rs. 96,804/- regarding the treatment of his wife from 22.03.2015 to 27.03.2015 at Crosslay Pushpanjali Hospital. The Complainant has not disclosed this fact in his complaint.
10. In view of the above discussion, we do not find any merit in the complaint and the same is dismissed.  
11. Order announced on 26.09.2023.

Copy of this order be given to the parties free of cost

File be consigned to Record Room.

(Anil Kumar Bamba)		(Surinder Kumar Sharma)
(Member)		(President)