Chandigarh

DF-I

CC/347/2019

Krishna Gupta - Complainant(s)

Versus

ICICI Prudential Life Insurance Company Ltd., - Opp.Party(s)

Charu Sharma Adv. & Venu Gopal Adv.

27 Jan 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

 

                    

Consumer Complaint No.	:	CC/347/2019
Date of Institution	:	8.5.2019
Date of Decision	:	27.1.2023

Krishna Gupta W/o Sh. Om Prakash Gupta R/o House No. 5500, Sector 38 West, Chandigarh (UT)

… Complainant

V E R S U S

1. ICICI Prudential Life Insurance Company Ltd. Through its Managing Director, ICICI Prulife Towers, 1089, Appasaheb Marathe Marg Prabhadevi, Mumbai 400025.
2. Branch manager ICICI Prudential Life Insurance Company Ltd. Chandigarh 1^st floor of ICICI Bank, Sector 9, Chandigarh.

.  … Opposite Parties

 

CORAM :	PAWANJIT SINGH	PRESIDENT
	SURJEET KAUR SURESH KUMAR SARDANA	MEMBER MEMBER

                        

ARGUED BY	Sh. Atul Goyal, Advocate for the complainant.
	Sh. Pulkit Mahajan, Advocate proxy for Sh. Aseem Gupta, Advocate for OPs.

Per surjeet kaur, Member

1. Briefly stated, the complainant purchased Hospital Care policy  from Ops by paying premium of Rs.13,585/- on 27.1.2008.  The date of commencement of the policy was 20.3.2008. The complainant paid timely premium with fervent hope that she is insured for hospital expenses under the policy in question. On 27.8.2018  the complainant was hospitalized in context of pain and constipation for 5 days and was advised for colonoscopy and the complainant was discharged on 31.7.2018 with  hospital bill  of Rs.68,477/-. It is stated that the complainant applied for pre-hospitalization request on 27.7.2018 under the Hospital Care Policy  for cashless credit and the complainant was shocked that Rs.3000/- only was credited by the insurance company. It is alleged that the complainant has to pay almost all the expenses of the hospital.  The complainant asked the OPs of the misrepresentation made by them that upto 4.00 lakh per annum are covered under the hospital care policy then how Rs.3000/- was paid. It was intimated to the complainant that under the policy the complainant had opted for Plan A in which pre-post hospitalization benefits are covered.  It is alleged that the said fact was never explained to the complainant by the OPs. Alleging the aforesaid act of Opposite Parties deficiency in service and unfair trade practice on their part, this complaint has been filed
2. The Opposite Parties NO.1&2 while admitting the factual matrix of the case stated that a pre-authorization request was received by the OPs from Max Super  Speciality Hospital, Mohali on 30.7.2018 and the said request was duly  accepted by the OPs and the same was duly communicated to the complainant vide letter dated 31.7.2018. As the details received, complainant was admitted in the hospital for 3 days for medical management only, therefore, daily hospitalization cash benefit  was payable as per the plan  opted by complainant for 3 days.  It is averred that since the complainant opted for plan A, DHCB of Rs.1000/-  is payable for each day of hospitalization. Therefore Rs.3,000/- was paid to the complainant as per terms and conditions of the policy. It is averred that the policy in question is not a reimbursement policy but a fixed benefit plan where the complainant is not entitled to receive a full reimbursement of expenses incurred by her for all medical procedures undergone by her. It is averred that the complainant was duly communicated the terms and conditions of the policy and the complainant failed to avail free look period under the subject policy during which she could have got the policy cancelled in case of any dissatisfaction.  All other allegations made in the complaint has been denied being wrong. It is prayed that the complaint be dismissed.
3. Contesting parties led evidence by way of affidavits and documents.
4. We have heard the learned counsel for the contesting parties and gone through the record of the case.
5. It is evident from Annexure C-1 the policy document that the complaint purchased one policy  valid from 20.3.2008  to 28.3.2028  and for the said policy required premium was paid by her. The complainant is covered under the benefit of hospital care- Plan A. As per grouse of the complainant he was admitted in the Max hospital in the emergency.  She was advised for colonoscopy, therefore, she got hospitalized from 28.7.2018 to 31.7.2018 and the hospital raised bill of Rs.68,477.44  but as per the case of the complainant  she was credited Rs.3,000/- only by the OPs. Hence, it is alleged that the OPs are deficient in providing service.
6. The stand taken by the OPs is that the daily hospitalization benefit was payable as per plan opted by the complainant only for three days.  It has been contended that since the complainant opted for plan A, therefore, amount of Rs.1000/- is payable for each day of hospitalization. Hence, the amount of  Rs.3000/- was rightly disbursed to the complainant.
7. A perusal of repudiation letter Annexure C-7 dated 15.11.2018 at page No. 55 of paper book clearly shows the vague conclusion of the OPs that pre-post hospitalization benefit is not covered in hospital care policy, hence no benefit is payable for the claim but failed to give reference of any clause from the policy in question. More so as per the policy document at page 7 of the paper book there is mention of exclusion(s) NA, meaning thereby nothing included in the policy but under clause 5  exclusions of the policy document at page 11 it is stated as under:-

“(a)   Benefits shall be payable with respect to any period of hospital confinement/ICU stay unless the entire confinement/ICU stay and all the hospital services rendered and performed there had been recommended by a physician and are in accordance with the diagnosis and treatment of the condition for which hospitalization was required.

(b)No benefit shall be paid for the following services, products and conditions:

 Xxx xx xxxx

  Vii Hospitalization primarily for investigatory purpose, diagnosis, X-ray examination, general physical or routine medicine examination; preventive treatment/medicines, treatments/examinations specifically for weight reduction or gain regardless of whether the same is caused (directly or indirectly) by a medical condition; recuperation, custodial, sanitaria, rehabilitation centre, nature cure clinics or rest care and similar establishment or private nursing.

Xxxxxx”

 

8. A bare perusal of the Annexure-2  policy document placed on record by OPs clearly reveals that  the policy offers the following benefits:-

1. Daily hospital cash benefit (DHCB) upon hospitalization.
2. An additional ICU benefit upon hospitalization in an ICU ward (ICUB).
3. Surgical benefit (SB) upon actual undergoing a surgery and
4. Convalescence benefit (CB) is a post hospitalization benefit.

9. Pertinently perusal of Annexure C-5 (colly) the bill summary at sr. No.7 shows room rent as Rs.24,000/-but evidently the complainant is entitled only for Rs.3000/-,hence, in our opinion he cannot ask for remaining amount of Rs.21000/- out of the total bill paid of Rs.68,477.44. But we are of the considered opinion that the OPs have not honoured their own terms and conditions despite the complainant being duly covered under the scheme which proves deficiency in service on the part of OPs.
10. In the discharge summary Annexure C-2 it is clearly mentioned that patient was admitted in emergency and was resuscitated  meaning thereby the complainant was admitted in serious condition and during the course of her treatment various X-rays and medical examination was done, therefore, in our opinion the claim is payable.
11. We feel that the OPs did not appreciate the claim of the complainant carefully and rejected the same on vague reason outside the purview of policy document. As the medical record of the complainant clearly reveals that she was admitted in the hospital in emergency condition, so, expenses incurred for medical treatment are to be paid by the OPs company in accordance with the policy. Hence, the act of OPs for refusing the genuine claim of the complainant proves deficiency in service.
12. In view of the above discussion, the present consumer complaint succeeds and the same is accordingly allowed. OPs are directed as under:-

1. to pay Rs.47,477.44 (Rs.68,477.44-Rs.21000/-) to the complainant with interest @9% per annum from the date of repudiation of claim till realization.
2. to pay Rs.10,000/- to the complainant as compensation for causing mental agony and harassment to him;
3. to pay Rs.7000/- to the complainant as costs of litigation.

13.      This order be complied with by the OPs within thirty days from the date of receipt of its certified copy, failing which, they shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above
14.      Certified copies of this order be sent to the parties free of charge. The file be consigned

			Sd/-
			[Pawanjit Singh]
			President
			Sd/-
			[Surjeet Kaur] Member   Sd/-
			[Suresh Kumar Sardana]
mp			Member