District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.272/2023.
Date of Institution:19.04.2023.
Date of Order: 25.10.2024.
Sudesh Kumar son of Shri Chaman Singh, resident of village Lohsighani Tehsil Sohna District Gurgaon at present R/o H.No. 704, War No. 23, Mohna Road, Opposite PBN Bank, Brahmanwara Ballabgarh District, Faridabad mobile NO. 9811113077.
…….Complainant……..
Versus
1. M/s. ICICI Lombard General Insurance Co. Ltd., Ist floor, SCO 17, Sector-16, near Moti Mahal Restaurant Faridabad – 121002 through its authorized person.
2. M/s. ICICI Lombard General Insurance Co. Limited, Grievance Redressal Cell CY NO. 115/1, Financial District Nanakram Guda Gachibowli, Hyderabad 500 032 through its authorized person.
…Opposite parties……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma………..Member
Indira Bhadana………….Member.
PRESENT: Shri V.K.Verma, counsel for the Complainant.
Shri Rakesh Dabaas, counsel for opposite parties.
ORDER:
The facts in brief of the complaint are that the complainant had taken the Family Floater policy bearing No. 4128i/HSRN/164487610/04/000 and the said policy time to time renew by the opposite parties and the complainant time to time making the premium amount to the opposite parties without any delay. During the insurance period, the wife of the complainant namely Sanju Rani was suffering from severe heachache, ghabrahat and giddiness and in this regard the wife of the complainant was admitted in Metro Heart Institute with Multispecialty Hospital situated at Sector-16, Faridabad Haryana on dated 23.2.2023 and was discharged on 26.02.2023 and the hospital raised the big amount of Rs.48,707/-. At the time of admission of the wife of the complainant in the hospital the hospital intimated to the opposite parties pertaining to admit the patient in the hospital and the opposite parties intentionally and knowingly not paid the hospital bill amount of Rs.48,707/- and the said amount was paid by the complainant from his own pocket although the said amount was to be paid by the opposite parties to the hospital as such the said policy of the complainant was the cashless policy. The complainant had sent all related documents regarding the treatment of the wife of the complainant as well as bill for getting the amount of Rs.48,707/- but the opposite parties lingering the matter on one pretext to the another. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) make the medi claim amount of Rs.48,707/- alongwith interest @ 18% p.a. to the complainant which had been paid by the complainant during the insurance period.
b) pay Rs.50,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 11,000 /-as litigation expenses.
2. Opposite parties Nos.1 & 2 put in appearance through counsel and filed written statement wherein Opposite parties Nos.1 & 2 refuted claim of the complainant and submitted that at the very threshold of the allegations contained in the complaint, from the relied upon documents by the complainant, it was established that the complainant was treated in QRG Hospital w.e.f 26.12.2021 to 29.12.2021 and where she was diagnosed as “Epigastric Pain Syndrome & Vascular headache” so the claim of the complainant stands non payable in view of exclusion clause (treatment for any type of gastric and duodenal ulcers was not payable within the first two (2) consecutive years of period of insurance start date) of the insurance policy so issued in this regard on 26.04.2020. On the day of discharge i.e. 29.12.2021, the insurance company had received the complete medical record including discharge summary & investigation reports in soft copy from the said treating hospital & then after reviewing the documents by the insurance company had arrived at a conclusion that the claim of the complainant stand non payable in view of exclusion clause (treatment for any type of gastric and duodenal ulcers was not payable within the first two (2) consecutive years of period of insurance start date) of the insurance policy so issued in this regard initially on 26.04.2020 so the cashless was rejected in view of said exclusion clause of the insurance policy vide “letter of intimation” with the remarks that denial of cashless authorization did not necessarily imply denial of the treatment and did not in any way prevent the insured from seeking necessary medical attention/hospitalization/claiming under reimbursement mode subject to the adherence of policy terms & conditions, which decision could not be termed unconscionable at all.Opposite parties Nos. 1 & 2 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite parties– M/s. ICICI Lombard General Insurance Co. Ltd. with the prayer to: a) make the medi claim amount of Rs.48,707/- alongwith interest @ 18% p.a. to the complainant which had been paid by the complainant during the insurance period. b) pay Rs.50,000/- as compensation for causing mental agony and harassment . c) pay Rs. 11,000 /-as litigation expenses.
To establish his case, the complainant has led in his evidence Ex.CW1 – affidavit of Sudesh, Ex.CW1/A – insurance policy valid from 28.2.2023 to 17.2.2024, Ex.CW1/B – tax certificate, Ex.CW1/C - customer payment,, Ex.CW-1/D – discharge summary, Ex.CW1/E - receipt, Ex.CW1/F – cash/credit memo, Ex.CW-1/G – final bill, Ex.CW1-H – Cash/credit memo, Ex.CW1/F –F – email dated 11.4.2024 regarding repudiation , Ex.CW1-J - Claim form, Ex.CW1/K - certificate dated 01.03.2023, EX.CW1/L- cardiology echocardiogram report,, EWx.CW-1/M –x-ray, Ex.CW1/N to CW1/R– tests, Ex.CW1/U – bill settlement receipt, Ex CW1/V – final bill, Ex.CW1/W to CW1/X– admission advance receipt, Ex.CW1/Y – test,, Ex.CW1/Z – discharge summary,, Ex.CW1/A1 - policy schedule, Ex.CW1.A-2 – photocopy of cheque of Rs.21,215/-, Ex.CW1/A3 – emergency assessment card.
On the other hand counsel for the opposite partiesNos.1 & 2 strongly agitated and opposed. As per the evidence of the opposite partiesNos.1 & 2 Ex.RW1/A – affidavit of Shri Rohan Mishra, Manager (legl), M/s. ICICI General Insurance company Ltd. 4th floor, Red Fort Capital Parsvnath Tower, Bhai Veer Singh Marg, Gole Market, New Delhi., Ex.R-1 – insurance policy,, Ex.R-2 – claim form, Ex.R-3 – discharge summary, Ex.R-4 – final bill,, Ex.R-5 – Individual reimbursement, Ex.R-6 – repudiation letter.
6. In this case, the complaint was filed by the complainant with the prayer to make the medi claim amount of Rs.48,707/- alongwith interest @ 18% p.a. to the complainant which had been paid by the complainant during the insurance period. As per discharge summary, the complainant was admitted in Metro Heart Institute with Multispecialty and several tests were done and managed her by the doctors of said hospital and discharged on 26.02.2023. During hospitalization of 3 days the complainant had paid sum of Rs.48,707/- to Metro Heart Institute with Multispecialty vide Ex.CW-1/G. Opposite party repudiated the claim of the complainant vide Rc.T-6 on the ground that “as per the policy wordings, Part II of the policy, 3.5 Permanent Exclusions: Unless covered by way of an appropriate Extension/Endorsement, we shall not be liable to make any payment under this policy in connection with or in respect of any expenses whatsoever incurred by you in connection with or in respect of i.code-Exc104: Investigation & Evaluation (a) Expenses related to any admission primarily for diagnostics and evaluation purposes only are excluded. (b) any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment are excluded, hence the claim stands rejected.
7. After going through the evidence led by the parties as well as the certificate issued by Dr. Sushma Sharma vide Ex.CW1/K stating that “This is to certify that Mrs. Sanju Rani, 46 years old female (UHID: 726669), was admitte don 23.02.2023. Patient had severe vascular headache with persistent vertigo recurrent vomiting with dehydration with one episoe of transient loss of consciousness (reflex neurocardiogenic syncope). Patient has very poor oral intake. Patient took OTC medicine but got no relief and she needed urgent IV medications with IV fluid therapy to maintain hemodynamic stablility, hence admission was required. She could not be treated with oral medication. Kindly reconsider.” in the interest of justice, the complaint is allowed.
8. Opposite parties are directed to process the claim of the complainant within 30 days from the date of receipt of the copy of order and pay the claimed amount to the complainant alongwith interest @ 6% p.a. from the date of filing of complaint till its realization. Opposite parties are also directed to pay Rs.3300/- as compensation for causing mental agony & harassment alongwith Rs.2200/- as litigation expenses to the complainant. Compliance of this order be made within 30 days from the date of receipt of copy of this order. Copy of this order be sent to the parties concerned free of costs. File be consigned to the record room.
Announced on:25.10.2024 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
