Before the District Consumer Disputes Redressal Commission, Rohtak.
Complaint No. : 186
Instituted on : 03.04.2023
Decided on : 23.08.2023
Surender Singh Rathee S/o Sh. Hoshiyar Singh Rathee age 65 years R/o H.No.856/33, Kath Mandi, Rohtak District Rohtak at present R/o House No. 1756, Sector-9A, Bhadurgarh, Tehsil Bahadurgarh, District Jhajjar.
……….………..Complainant.
Vs.
- ICICI Prudential Life Insurance Co. Ltd. through its Manager, Branch Rohtak, Raj Complex Rohtak, Tehsil & District Rohtak.
- ICICI Prudential Life Insurance Co. Ltd. Claim Cells, Ground Floor, Unit No. 1 A52 A, Raheja Tipco Plaza, Ranisati Marg Malad(East) Mumbai 400097, through its General Manager, Email I.D.-lifeline@iciciprulife.com
..…….……….Opposite parties.
COMPLAINT U/S 35 OF CONSUMER PROTECTION ACT,2019.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
DR. TRIPTI PANNU, MEMBER.
DR.VIJENDER SINGH, MEMBER.
Present: Sh. Jitender Singh, Advocate for complainant.
Sh. Rajesh Sharma, Advocate for opposite party No. 1 and 2.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Brief facts of the case as per complainant are that he got ICICI Pru Health Saver policy bearing no.16692974 from the opposite parties from June 2012 onwards and insured till the age of 75 years. The complainant had paid the premium Rs.25,000/- annually and was insured for Rs.5,00,000/- extendable due to time span. It is further submitted that complainant was suffering from Carcinoma Prostate(Cancer) and is still under treatment under Dr. Ankur Bahl at Fortis Memorial Research Institute Gurugram. Complainant is a day care patient since 28.03.2022, so the complainant was not admitted for 24 hours or more. All previous claims were accepted by the opposite parties before the said claim dated 25.10.2022, which was rejected by the opposite parties. The details of previous claims which were accepted are as under:-
i) Claim dated 15.05.2022 for Rs.1,41,177/-.
ii) Claim dated 25.05.2022 for Rs.18,671/-.
iii) Claim dated 18.07.2022 for Rs.31,373/-.
iv) Also claim for radiation therapy was approved as cashless on 5h August, 2022.
It is further submitted that complainant filed claim dated 25.10.2022 to the opposite parties. The original bills and discharge summary were submitted to the opposite parties alongwith claim letter. The claim was of Rs.70,296/-. The complainant claimed the said amount from the opposite parties, then they assured the complainant that the claim will be paid as early as possible. The complainant completed all the formalities but the opposite parties repudiated the claim vide letter dated 29.10.2022 on the ground that “The sickness doesn’t come under the day care treatment as the hospitalization is less than 24 hours. Since inception of the policy of the complainant there are huge development and improvement and drastic changes in the treatment of the ailment like complainant. The aforesaid development reduced the consumption of time and expenses of not only of the patient but also of the doctors and hospital and due to the latest scientific developments the treatment has become fast and speedy that is why the period of complainant has been reduced through in normal circumstances it took long time by all means and the complainant cannot be forced to suffer for the developments rather is entitled for the benefits. The complainant approached the opposite parties for his claim but they did not pay any heed towards genuine requests of the complainant. He also filed the complaint by email to opponent grievance committee redressal on dated 21.12.2022 and 02.02.2023 but no response was received. As such, the act and conduct of the opposite parties is illegal and amounts to deficiency in service. Hence this complaint and it is prayed that opposite parties may kindly be directed to pay the claim to the tune of Rs.1,12,503/- alongwith 12% interest on the amount of compensation. It is further prayed that opposite parties be also directed to pay Rs.50,000/- + Rs.11,000/- as litigation charges to the complainant as explained in relief clause.
- After registration of complaint, notices were issued to the opposite parties. Opposite parties No. 1 and 2 appeared and submitted their joint reply that on 28.10.2022, the company was in receipt of a claim from the complainant for admission on 25.10.2022. From the documents submitted by the complainant it was seen that the complainant/Life Assured was admitted on 25.10.2022 and discharged on the same date from Fortis Memorial Hospital on 25.10.2022. Further from the discharge summary and invoices provided by the complainant, it was seen that he was admitted in Fortis Memorial Hospital for treatment in the form of third dose of Injection-Zoladex 10.8 which the life assured/complainant received for high risk carcinoma Prostate Acinar Adenocarcinoma Gleason Score. The complainant has claimed an amount of Rs.50,296/- in the claim form. Upon evaluation of the claim, it was noted that the complainant was not hospitalized for a minimum of 24 hours for any treatment. Thus complainant was not eligible for the hospitalization benefit as per Clause 2A. The complainant was also not eligible for day care procedure as well, as the procedure underwent by the complainant did not fall under the list of the day care procedures covered under the subject policy. Clause 2A.b. A claim is payable for a day care procedure only if the same is for a treatment or procedure which involved hospitalization less than 24 hours, on written advise from the treating doctor and specifically covered under Annexure 1. It is further submitted that complainant was not eligible for pre-hospitalization or post hospitalization covered under the subject policy. The present claim was only for a treatment of high risk carcinoma Prostate Acinar Adenocarcinoma Gleason Score in the form of the Zoladex Injection the same was not covered hence the claim has been correctly rejected by the opposite party. The same was duly communicated to the complainant vide letter dated 29.10.2022. All the other contents of the complaint were stated to be wrong and denied and opposite party prayed for dismissal of complaint.
3. Learned counsel for the complainant in his evidence has tendered affidavit Ex. C21, documents Ex. C1 to Ex. C20 and closed the evidence vide separate statement dated 05.06.2023. Ld. Counsel for the opposite parties in his evidence has tendered affidavit Ex.RW-1/A, documents Ex.R-1 to Ex.R-6 and closed the evidence vide separate statement dated 21.07.2023.
4. We have heard learned counsel for the complainant and have gone through material aspects of the case very carefully.
5. In the present case the claim of the complainant has been repudiated by the insurance company vide letter Ex.R4 as per terms and conditions of the policy as per condition no.3, which is as under:
“3. Benefits: Benefits are payable subject to the Policy being in force on the date of Event.
A. Hospitalisation Insurance Benefit: Hospitalisation insurance Benefit shall be available only till the Primary Insured attains the age of 75 years nearest birthday. This beninfit reimburses the Medical Expenses incurred for the Insured Person(s) in case of following:
a. Hospitalisation "Hospitalisation" means admission and subsequent stay in a Hospital for a continuous period of minimum 24 hours for the purpose of necessary medical treatment of a Disease or Injury upon the written advice of a Medical Practitioner,
b. Day Care Procedure "Day Care Procedure" means the course of medical treatment or surgical procedure carried out in a Hospital which is fully equipped with advanced technology and specialized infrastructure for the listed procedure. The procedure must require Hospitalisation for less than 24 hours and must be on written advice of Medical Practitioner. The requirement of minimum beds of the Hospital definition will be waived provided other conditions are met.
The list of Day Care Procedures covered under the Policy is given in Annexure I
c. Pre-Hospitalisation and Post-Hospitalisation
i)"Pre-Hospitalisation Expenses” means Medical Expenses incurred during the period of 30 days prior to the date of Hospitalisation or Day Care Procedure, on the written advice of Medical Practitioner. Any nedical Expenses not directly related to the Event shall not be included as a part of Pro-Hospitalisation Expenses and shall not form part of any claim under the Policy.
ii)"Post-Hospitalisation Expenses" means Medical Expenses incurred during the period of 60 days from the date of discharge from the Hospital, on the written advice of Medical Practitioner. Any Medical Expenses not directly related to the event shall not be included as a part of Post-Hospitalisation expenses and shall not form a part of any claim under the Policy. These expenses shall be reimbursed only in the event of acceptance of the related Hospitalisation or Day Care Procedures claim by the company”.
6. We have minutely perused the documents placed on record by both the parties. The perusal of the documents placed on record by the respondent itself shows that claim of the complainant has been accepted by the insurance company 9 times prior to rejection of the claim and they have paid the claim regarding the same illness. As per Ex.C4 i.e. discharge summary issued by Fortis Memorial Research Institute, Gurgaon, the complainant was admitted on dated 25.10.2022 and discharged on the same day. As per the brief history the complainant is a diagnoses case of carcinoma Prostate -Acinar Adenocarcinoma Gleason Score-4+3. Now admitted for 3rd dose Inj.Zoladex 10.8. Meaning thereby two injections were already been injected by the hospital regarding the same ailment and those claims have been accepted by the insurance company. Now a days due to advancement of technology, treatment has become fast and speedy. Earlier to cure the ailment, 2 or 3 days were taken by the hospital or treating doctor but now a days it take less time due to improvement of technology or new research . So the complainant was discharged by the hospital on the same day after giving the injection. As per affidavit of the opposite party itself, the respondent have paid 9 claims which have been mentioned in para no.8 of their affidavit. We have also placed reliance upon the law cited by ld. counsel for the complainant 2008(4)CPJ 27 2009(1)CLT53 2008(53)RCR(Civil)304 of Hon’ble Uttarakhand State Commission, Dehradun titled as United India Insurance Company Limited Vs. Indu Joshi, as per which Hon’ble State Commission has held that: “Reimbursement claim repudiated-Contention that insured did not remain hospitalized for treatment for minimum period of 24 hours on each occasion-Not acceptable-Insured required to be hospitalized on 6 occasion starting from 18.04.2001 to 19.02.2022-Insured admitted for CAPD(Dialysis), time limit of minimum period of 24 hours would not apply as stipulated in clause 2.3 of Insurance Policy-Admission and discharge on 6 occasions indicates that insured used to be hospitalized also for minimum period of 24 hours-Insurer liable to pay claim under the policy alongwith interest”. The alleged law is fully applicable on the facts and circumstances of the case and opposite parties are liable to pay the claim to the complainant. Through this complaint the complainant has demanded Rs.112503/- i.e. Rs.70296/- rejected by the opposite party and complainant has demanded some more amount of bills, which has been spent by him on his treatment within two months after the discharge on 25.10.2022 i..e.Rs.42207/-. As per no claim letter Ex.R4, complainant is entitled for the Pre-hospitalisation medical expenses incurred during the period of 30 days prior to the date of hospitalization or day care procedure and Post-hospitalisation medical expenses incurred during the period of 60 days from the date of discharge from the hospital. As such as per terms and conditions of the policy complainant is entitled for the whole amount of Rs.112503/-, which has not been paid to the complainant. As such there is deficiency in service on the part of opposite parties and opposite parties are liable to pay the claim amount to the complainant.
7. In view of the facts and circumstances of the case we hereby allow the complaint and direct the opposite parties to pay the amount of Rs.112503/-(Rupees one lac twelve thousand five hundred and tree only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e. 03.04.2023 till its realization and shall also pay Rs.5000/-(Rupees five thousand only) as compensation on account of deficiency in service and Rs.5000/-(Rupees five thousand only) as litigation expenses to the complainant within one month from the date of decision.
8. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
23.08.2023.
................................................
Nagender Singh Kadian, President
..........................................
Tripti Pannu, Member.
…………………………..
Vijender Singh, Member
