Date of Filing : 11.04.2011
Date of Order : 31.10.2011
BEFORE THE II ADDITIONAL DISTRICT CONSUMER
DISPUTES REDRESSAL FORUM,
SESHADRIPURAM, BANGALORE – 560 020
Dated 31st day of October 2011
PRESENT
Sri. S.S. NAGARALE, B.A., LL.B. (SPL) …. President
Sri. BALAKRISHNA V. MASALI, B.A., LL.B.(SPL) …. Member
COMPLAINT NO. 720 / 2011
Sunil Kapur,
S/o.J.C.Kapur,
Aged about 55 years,
Kapur Villa,
132-134, Nandidurg Road,
Benson town Post,
Banglaore 560 046. ……. Complainant
V/s.
1. Manager,
ICICI Lombard General Insurance Co.Ltd.,
2nd Floor, Prestige Corniche,
62/1, Richmond Road,
Bangalore 560 025.
2. Manager,
ICICI Lombard General Insurance Co.Ltd.,
1 Health Care,TGV Mansions, 5th Floor,
Plot No.6-2-1012,(above ICICI Bank),
Kairatabad,
Hyderabad 500 004.
3. Manager,
ICICI Lombard General Insurance Co. Ltd.,
Zenith House, Keshavarao Khadye Marg,
Mahalaxmi, Mumbai 400 034. … Opposite Parties
ORDER
(By the Member Sri. BALAKRISHNA V. MASALI )
This Complaint is filed by the Complainant u/s. 12 of the Consumer Protection Act, 1986.
2. The facts of the case are that, the complainant was the Policy holder and insured under the Policy No.4034/FFN/01538236/00/000, period from 01st November 2006 to 09th November 2007 and the same got renewed upto 10th September 2010 and also upto September 2011. the complainant has hospitalized in the month of July 2010 with the complaint of weakness and mild fever in paras Spring Meadows. F44, East of Kailash, New Delhi. The complainant on account of the aforesaid hospitalization and treatment spent about Rs.1,79,302/- the bills evidencing medical charges and expenses are herewith produced. In view of the above medical charges and expenses and in view of the complaint being covered under a medicalim policy, he made a claim for Rs.1,79,302/- under the policy taken out by him the claim letter dated 21st December 2010. The complainant has forwarded another claim letter dated 18.01.2011 in detail furnishing all the information and documents to the opposite parties. The complainant has received a rejection letter from the opposite parties stating that, since the complainant is having high blood sugar level without any authentical Doctor report the same is hereby produced. In view of the untenable replies from the opposite parties, the complainant cause a legal notice dated 18.03.2011 and the same received by the opposite parties on 21.03.2011. The opposite parties are attempting to try and make out a case that the ailment of the complainant was pre-existing medi-claim policy and is reputing to pay on the policy which is illegal and baseless. This constitutes deficiency of service and is a dishonest attempt to avoid bonafide claim of the complainant. Wherefore the complainant must respectfully pray that this Hon’ble forum may please to direct the opposite parties to pay actual medical claim amount of Rs.1,79,302/- with interest at 21% per annum and cost of the complaint. Hence the complaint.
3. Notice was issued to the opposite parties by RPAD. Opposite parties are put in appearance through adhere. The opposite parties filed defence version stating that, the respondent admits the policy was issued in favour of the complainant for the period from 10.09.2010 to 09.10.2011 and hence the liability of this respondent if any, is in accordance with the terms and conditions of the insurance policy. The complainant seeking compensation at Rs.1,79,302/- with interest at 21% p.a. and seeking compensation and cost is not maintainable either in law or on the facts. The same is liable to be dismissed. The respondents submits that, on the information received from the complainant, the respondents has requested the complainant to produce all documents along with claim form and accordingly the complainant has produced some documents alongwith claim form. It is further submitted that, on the basis of the documents produced by the complainant, it is noticed that the complainant was suffering from high blood sugar and he also a known case of Astrocytome and for that he was operated in the year 2004 and the treatment now taken by the complainant for the pre-existing disease and therefore the same is not covered under the policy and hence the said claim has been rejected by this respondent on 10.03.2011 and therefore the present complaint is liable to be dismissed. On verification of the discharge summary produced by the complainant, it is clearly mentioned that known case of diabetes and hypertension. Since ten years and for that he was on regular treatment and further it is mentioned that he was operated in 2004 for Astrocutome and since then he is on tab. Eptoin 100 mg. The respondents devise the averments made in the complaint other than those are admitted herein. The respondents further submitted that there is no deficiency in service on the part of the respondents. Wherefore the respondents respectfully prays that this Hon’ble Forum may kindly be dismissed the complaint with cost.
4. Affidavit evidence of the complainant and opposite parties filed. Parused the affidavit and documents.
5. Arguments are heard.
6. Points for consideration is
a) Whether the complainant has proved deficiency in service on the part of the opposite parties ?
b) Whether the complainant is entitled for relief ?
7. Perused the complaint, version and documents. It is an admitted fact that the complainant had taken the fresh insurance policy from the OPs from 10.11.2006 to 09.11.2007 and the same got renewed upto 10th September 2010 and also upto September 2011, vide policy No.4018/KPP-113269/00/00, the complainant was hospitalized in the month of July 2010 with the complaint of weakness and mild fever in Paras Spring Meadows, F-44, East of Kailash, New Delhi. On account of the aforesaid hospitalization and treatment spent about Rs.1,79,302/- the bills evidencing medical charges and expenses are produced with the complaint. In view of the said medical charges and expenses and in view of the complainant being covered under a medi-claim policy, he made a claim for Rs.1,79,302/- under the policy taken out by him. The complainant had applied for reimbursement of the said medical bill amount with opposite parties and also forwarded another claim letter dated 18.01.2011 in detail furnishing all the information and documents to the opposite parties. But the complainant has received a rejection letter from the opposite parties stating that, since the complainant is having high blood sugar level and pre-existing illness, the claim arising on account of in connection with any pre-existing illness, shall be excluded from the scope at the cover under the policy. Hence rejected. The complainant has continued to renew the policy regularly for over claim free 5 years, therefore the exclusion clause does not arise. In the defence version the opposite parties not taken the defence that the complainant has not taken the policy regularly for ever claim free 5 years. The complainant medical check-up report dated 10.07.2008 from Medinova Diagnostic Service Ltd., Bangalore, which shows his diabetics level was normal the same report produced by the complainant. Inspite of repeated request made by the complainant, the opposite parties have failed to settle the claim amount. It is clearly shows that the opposite parties committed deficiency in service to the complainant for non settling his claim. The Consumer Protection Act is one of the Benevolent Socio Legislation, intended to protect the consumers from the exploitation. Therefore, in our opinion the ends of justice will be met by awarding Rs.1,79,302/- to the complainant. Accordingly, we hold that the complainant is entitled to claim Rs.1,79,302/- from the opposite parties. In the result we pass the following:
ORDER
Complaint is allowed. The opposite parties are directed to pay Rs.1,79,302/- to the complainant towards the mediclaim incurred by the complainant.
The complainant is also entitled for Rs.2,000/- as a cost of the proceedings from the opposite parties. The opposite parties shall comply the order within 60 days from the date of order.
The amount be sent directly to the complainant by way of DD or cheque with information to this Forum.
Send copy of this Order to both the parties free of cost immediately.
Pronounced in the Open Forum on this 31st day of October 2011.
Order accordingly
MEMBER
I concur the above findings
PRESIDENT
