BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 161 of 2022
Date of Institution : 11.03.2022
Date of Decision : 13.08.2024
Chandan Jain aged about 34 years son of Shri Mahinderpal Jain, resident of H. No. 5345/3, Darzian Chowk, Ambala City, Haryana now resident of Water Works Road, Mandi Kalanwali, District Sirsa.
……Complainant.
Versus.
1. ICICI Lombard General Insurance Company Ltd., Matropolis Hisar Mall, 5th Floor, Unit No. 5F-7, 5F-8, Opposite Vidyut Sadan Delhi Road, Hisar through its authorized person.
2. ICICI Lombard General Insurance Co. Ltd. ABW Towers, Unit No. 511-512, 5th Floor, M.G. Road, Iffco Chowk, Gurugram- 122001 through its Director.
…….Opposite Parties.
Complaint under Section 35 of the Consumer Protection Act, 2019.
Before: SH. PADAM SINGH THAKUR……. PRESIDENT
MRS.SUKHDEEP KAUR……………MEMBER.
Present: Sh. R.K. Garg, Advocate for the complainant.
Sh. R.K. Mehta, Advocate for opposite parties.
ORDER
The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred as Ops).
2. In brief, the case of complainant is that on 17.12.2020 complainant had purchased a health insurance policy bearing No. 4128i/ HAS/ 212152878/00/000 from op no.1 vide which complainant, his wife Malti Jain and his minor daughter namely Navriti Jain were insured. The policy was effective for the period 17.12.2020 to 16.12.2021 and premium of Rs.17,411/- was paid to op no.1 and the sum assured amount was Rs.10,00,000/-. That at the time of issuance of the policy, they were physically examined and no pre existing illness or injury was found and after due satisfaction, the policy was sold to them. It is further averred that unfortunately in the month of March, 2021 leakage was diagnosed in heart chamber of minor daughter of complainant and she was got admitted by complainant in SPS Hospital, Ludhiana on 05.03.2021 where she remained under treatment till 20.03.2021. That during treatment, a number of medical tests of his daughter were got conducted, medicines were advised and other treatments were given to her and a total sum of Rs.4,00,000/- was spent by complainant on her treatment. It is further averred that information regarding disease was supplied by complainant to op no.1 and he lodged his claim with op no.1 and also submitted all the required documents including treatment record on the asking of op no.1 and complainant a number of times contacted the op no.1 regarding approval of his claim but on all the occasions, the op no.1 postponed the request of complainant with one pretext or the other and ultimately on 19.09.2021 the op no.1 has repudiated the claim of complainant without any cogent and reliable reason which is totally illegal and unlawful and excuse taken by op no.1 that it was a pre existing disease has no legal sanctity in the eyes of law. The complainant also got served a legal notice to the ops on 24.11.2021 but despite that ops did not indemnify the claim of complainant and have flatly refused to admit the genuine claim of complainant and as such act and conduct on the part of ops clearly amounts to deficiency in service, unfair trade practice and gross negligence on account of which complainant has suffered unnecessary harassment and mental agony. Hence, this complaint seeking direction to the ops to pay sum assured amount of Rs.10,00,000/- and to pay a sum of Rs. two lacs as compensation for harassment, further to pay a sum of Rs. one lac as penalty on account of deficiency in service and also to pay litigation expenses.
3. On notice, ops appeared and filed written statement taking certain preliminary objections regarding maintainability, cause of action, jurisdiction and that there is no deficiency in service in any manner on the part of company or its officials as complainant never lodged any claim seeking claim for alleged treatment of his daughter, rather complainant acted in a deficient manner by not lodging the claim within a calendar year from the date of alleged treatment, hence complaint is not maintainable and is liable to be dismissed. It is further submitted that without admitting the alleged treatment to be taken by daughter of complainant, as no intimation has ever been given to answering ops, resultantly there is no investigation by the Investigator/ Surveyor deputed by the Competent Authority, hence complainant is not entitled to claim due to violation of term and conditions of insurance policy on his part, as he was under contractual mandate to inform the company immediately about the alleged treatment. As per record no intimation has ever been given to answering ops and now this complaint has been filed after expiry of the period of intimation directly before this Commission without lodging the claim in accordance with the policy term and conditions, hence complaint is liable to be dismissed. It is further submitted that complaint is false and frivolous and that complaint is also liable to be dismissed on the ground of jurisdiction as answering ops are not having any branch in Sirsa and complainant is also not residing at Sirsa. As per insurance policy complainant is resident of Ambala, District Ambala. It is further submitted that complainant has suppressed true and material facts from the Commission, therefore, he is not entitled for any relief. The insured cannot claim anything more than what is covered by the insurance policy. In a contract of insurance, rights and obligations are strictly governed by the policy of insurance and no exception or relaxation can be made on the ground of equity. It is further submitted that complaint is bad for mis joinder and non joinder of necessary parties and that policy of insurance is void because it was obtained by non disclosure of material facts which were false in material particulars and complainant is estopped by his own act and conduct to file the present complaint. On merits, the pleas taken in the preliminary objections are reiterated, contents of complaint are denied to be wrong and prayer for dismissal of complaint made.
4. The complainant in evidence has tendered his affidavit Ex, CW1/A and documents Ex.C1 to Ex.C21.
5. On the other hand, ops have tendered affidavit of Sh. Sonu Rathi, Legal Manager as Ex. RW1/A.
6. We have heard learned counsel for the parties and have gone through the case file.
7. From the policy documents Ex.C20 containing pages 1 to 51, it is evident that health insurance policy was issued by ops to the complainant for the period 17.12.2020 to 16.12.2021 vide which complainant, his wife Smt. Malti Jai and minor daughter Navriti Jain were insued for the sum insured amount of Rs.10,00,000/-. It is also evident that at the time of issuance of policy in question the complainant was residing in Ambala and now due to illness of his daughter, they are residing in Kalanwali, District Sirsa with his brother in law Jatin Jain as is evident from rent deed Ex.C21. Since complainant with his family is residing in Kalanwali, District Sirsa due to illness of his daughter and her treatment and as per amended provisions of Consumer Protection Act, the complainant can file a consumer complaint where he is residing, therefore, this Commission has territorial jurisdiction to entertain, try and decide the present complaint and as such the objection raised by ops in this regard is immaterial and turned down. It is also proved on record that during the period of policy i.e. on 05.03.2021, the minor daughter of complainant namely Navriti Jain aged about four years four months was taken to SPS Hospital, Ludhiana and then she was admitted in the said hospital on 18.03.2021 where she was diagnosed with disease Ductus Arteriosus and device closure ductus arteriosus was done on 19.03.2021 and she was discharged on 20.03.2021 as is evident from discharge summary Ex. C17. The ops have not led any cogent and convincing evidence to prove their plea. There is nothing on file to prove the fact that complainant has not lodged his claim with ops and violated any terms and conditions of the policy. It is not believable that a person who has a health insurance policy and has spent amount on treatment of his daughter will not file any claim with the insurance company, therefore, the plea of ops is not tenable in the eyes of law. Although complainant has stated that a sum of Rs.4,00,000/- was spent by him on the treatment of his daughter and has claimed sum insured amount of Rs.10,00,000/- but from bills/ receipts placed on file by complainant as Ex. Ex.C3 to Ex.C11, it is evident that complainant has spent an amount of Rs.1,30,380/- on the treatment of his daughter and as such he is entitled to reimbursement of the amount of Rs.1,30,380/- from ops and non payment of the said genuine claim of complainant well in time clearly amounts to deficiency in service. Besides this complainant is also entitled to compensation for harassment and also litigation expenses from ops because ops have not paid genuine claim of complainant despite the fact that a small child of the complainant suffered from above said disease due to which her parents were already under mental shock and ops should have been prompt in paying claim amount to the complainant but they have failed to do so.
8. In view of our above discussion, we partly allow this complaint and direct the opposite parties to make payment of Rs.1,30,380/- to the complainant alongwith interest at the rate of @6% per annum from the date of filing of present complaint i.e. 11.03.2022 till actual realization within a period of 45 days from the date of receipt of copy of this order, failing which complainant will be entitled to receive the said amount at the rate of @9% per annum for the default period. We also direct the ops to further pay a sum of Rs.25,000/- as compensation for unnecessary harassment and Rs.10,000/- as litigation expenses to the complainant within above said period. A copy of this order be supplied to the parties as per rules. File be consigned to the record room.
Announced: Member President,
Dated: 13.08.2024. District Consumer Disputes
Redressal Commission, Sirsa.
