Delhi

North East

RBT/CC/264/2022

SUBHASH CHANDER - Complainant(s)

Versus

ICICI LOMBOARD HEALTH CARE - Opp.Party(s)

28 Nov 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: NORTH-EAST

GOVT. OF NCT OF DELHI

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

RBT/Complaint Case No. 264/22

 

 

 

In the matter of:

		Sh. Subhash Chander S/o Lt. Sh. Hukum Chand R/o D-36/2, Main 30 Feet Road, Jain Nagar Extn, Karala, New Delhi-110081		Complainant
		Versus
	1.         2.	ICICI Lombard Health Care, Aggarwal City Mall 315, 3rd Floor, Pitampura, New Delhi-110034   ICICI Lombard Health Care, ICICI Bank Tower, Plot No. 12, Financial District Nanakram Guda, Gachibowli, Hyderabad-500032		Opposite Parties
			DATE OF INSTITUTION:         JUDGMENT RESERVED ON:                           DATE OF ORDER:		04.12.18 29.08.23 28.11.23

 

CORAM:

Surinder Kumar Sharma, President

Anil Kumar Bamba, Member

Adarsh Nain, Member

ORDER

Ms. Adarsh Nain, Member

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 purchased policy from ICICI Lombard Health Care (Opposite Party No. 1). It has been stated by the Complainant that initially he was a policy holder of Royal Sunderam and the same was merged in ICICI Lombard general insurance company ltd. After merger, the official of Opposite Party No.2 issued policy and renewed his policy on 17.04.17 vide policy no. 4113i/XOL/79182605/02/000 valid till 16.04.19 for Complainant and his wife for sum insured amount Rs. 8,00,000/-and the Complainant paid Rs. 10,215/- as premium. On 10.09.18 Complainant’s wife was hospitalized due to cyst in her stomach and the hospital authorities sent for approval of expenditure to TPA 3 times. The Complainant alleged that at the time of discharge, hospital demanded for payment of Rs. 4,90,730/- stating that the claim is rejected. The Complainant got discharged his wife from hospital on 13.09.18 after paying the above noted amount. The Complainant allegedly approached consumer court helpline and lodged complaint on 18.09.18 vide complaint no. 918737.The Complainant stated that Opposite Party rejected the claimon the ground of pre-existing disease “depression” and as per doctor the depression has no ink with cyst. The Complainant again approached consumer court helpline on 23.10.18 vide complaint no. 973832 and submitted all documents. Meantime, the Complainant kept on pursuing the matter with the Opposite Parties. On 05.01.19 Opposite Party had transferred amount Rs. 1,36,870/- to the account of Complainant through NEFT. The Complainant approached several time to Opposite Party for his medi-claim amount but Opposite Party keep avoiding the matter on one pretext or another.  The Complainant has prayed to released       Rs. 3,07,519.12 with interest from the date of payment and Rs. 4,00,000/- for mental harassment. He further prayed for Rs. 11,000/- towards litigation cost.

Case of the Opposite Party i.e. ICICI Lombard General Insurance Company

2. Upon service, ICICI Lombard General Insurance Company entered appearance as single Opposite Party on behalf of Opposite Parties through their counsel and filed written statement. The Opposite Party while admitting the health insurance policy since 2013, takes preliminary objection  that said policy is subject to terms and conditions and at the time of taking the policy, Complainant was provided with complete set of kit containing policy certificate, policy wording/schedule etc. On merits, it has been contended that it is clearly mentioned in the schedule that the deductible SI is Rs. 3,00,000/- and settlement was done as per the settlement letter. As per settlement letter, the sum of Rs. 3,00,000/- was deducted from the requested claim amount of Rs. 4,43,384/-. It is prayed that the present complaint be dismissed since the Opposite Party has not been deficient in services.

Rejoinder to the written statement of Opposite Party

3. The Complainant filed rejoinder to the written statement of Opposite Party wherein the Complainant has denied the pleas raised by the Opposite Party and has reiterated the assertion made in the complaint.

 

 

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 Party

5. In order to prove its case Opposite Party has filed affidavit of Ms. Sanskriti Mishra, Legal Manager of Opposite Party, wherein the averments made in the written statement of Opposite Party have been supported.

Arguments & Conclusion

6. We have heard the Complainant in person and we have also perused the file. It is the case of the Complainant that the Complainant purchased health insurance policy from ICICI Lombard Health Care (Opposite Party No.1) for sum insured amount Rs. 8,00,000/-. It is alleged that as the Complainant’s wife was hospitalized due to cyst in her stomach and received treatment but his claim for cashless was not approved by the Opposite Party and at the time of discharge, he had to pay the hospital Rs.4,90,730/-. The Complainant allegedly approached consumer court helpline and lodged complaint on 18.09.18 vide complaint no. 918737. The Complainant stated that Opposite Party rejected the claim on the ground of pre-existing disease “depression” while as per doctor the depression has no link with cyst. The Complainant again approached consumer court helpline on 23.10.18 vide complaint no. 973832 and submitted all documents.
7. It is to be noted that the Complainant filed the complaint on 04.12.2018 and  meantime, as the record reveals, the Complainant kept on pursuing the matter with the Opposite Parties. On 05.01.19 Opposite Party had transferred amount Rs. 1,36,870/- to the account of Complainant through NEFT and the Complainant filed an amended complaint with all the relevant documents.
8. On the other hand, the Opposite Party contends that said policy is subject to terms and conditions and at the time of taking the policy, Complainant was provided with complete set of kit containing policy certificate, policy wording/schedule etc. It has been contended that it is clearly mentioned in the schedule that the deductible SI is Rs. 3,00,000/- and settlement was done as per the settlement letter. As per settlement letter, the sum of Rs. 3,00,000/- was deducted from the requested claim amount of Rs. 4,43,384/-. Hence, Opposite Party has not been deficient in services.
9. It is an admitted fact that the Complainant was continuously insured with the Opposite Party since 2013 and the subject claim arose during the subsistence of a valid policy. The genuineness of the Complainant’s claim is also not disputed.
10. The grievance of the Complainant is that the Opposite Party has only paid       Rs. 1,36,870/- while the claim amount was for Rs.4,90,730/-.  The contention of the Opposite Party is that they have paid the amount as per the terms and conditions of the subject policy and as under the policy the deductible sum insured was Rs. 3,00,000/-, the claim was paid after deducting the said amount. It is evident from the policy document that the deductible sum insured as mentioned in the policy is Rs. 3,00,000/-. It is also contended by the Opposite Party that at the time of taking the policy, Complainant was provided with complete set of kit containing policy certificate, policy wording/schedule, however, the Complainant, in his rejoinder, denied to have received any such set. Since, onus shifted to the Opposite Party to prove the supply the complete set and Opposite Party has failed to discharge the same, the said contention stands rejected.
11. The Complainant also alleges that initially his claim was rejected on the ground of pre-existing disease depression while there was no link between the cyst for which the insured was treated and the depression. Thereafter, the Complainant approached the consumer helpline for his grievance and the Opposite Party had acknowledged the complaint. The Complainant has supported his contention by producing copy denial letter of cashless access dated 13.09.2018 issued by Opposite Party which clearly mentions that the claim of the Complainant was rejected due to non-disclosure of depression. The Complainant also filed copy of complaints lodged on 18.09.2018 and 23.10.2018 and each time Opposite Party closed the complaint by updating the remark that the claim was not payable due to non-disclosure of pre-existing disease-depression.
12. It is clear from the record that the sum deductible was mentioned in the policy document and the Opposite Party has settled the claim after deducting the same. It is also true at the same time that Opposite Party has not been able to show that the Complainant was explained/informed the applicability of the deductible and its implications at the time of taking the policy. On the contrary, the whole sequence of events highlights the careless and casual conduct of the Opposite Party Company. It is a proven fact of the matter that the cashless claim of the wife of insured was rejected on the ground of pre-existing disease and the Complainant had to bear the treatment expenses despite having a cover. Even when the Complainant raised the grievances several times, every time he was informed the same ground. Then, on 05.01.19, Opposite Party had transferred amount of Rs. 1,36,870/- to the account of Complainant through NEFT without clarifying to the Complainant as to why earlier the claim was rejected and the Complainant was made to suffer for no fault of his. The conduct of Opposite Party has been totally unfair more particularly when the Opposite Party itself admits that the Complainant was insured with the Opposite Party since 2013. The Opposite Party has failed miserably to show or justify the reason behind taking different stands while processing the claim of the Complainant’s wife, causing mental agony and harassment to the Complainant.
13. In view of above discussion, we are of the considered view thatthe Opposite Party has been liable for unaccounted delay in processing the claim and taking altogether different stands while processing the claim of the Complainant. hence, we hold Opposite Party guilty of deficiency in services towards Complainant.
14. Thus, the present complaint is allowed partly and the Opposite Party i.e. ICICI Lombard General Insurance Companyis directed to pay to the Complainant Rs. 2,00,000/- as compensation on account of mental harassment and suffering caused and Rs.11,000/- as litigation cost along with 9 % interest p.a. from the date of this order till its recovery.
15. Order announced on 28.11.23.

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

File be consigned to Record Room.

(Anil Kumar Bamba)           Member

(Adarsh Nain) Member

(Surinder Kumar Sharma) President