Delhi

North East

CC/13/2022

Ms. Komal Malhotra - Complainant(s)

Versus

M/s ICICI Lombard General Insurance co. - Opp.Party(s)

31 Oct 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: NORTH-EAST

GOVT. OF NCT OF DELHI

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

Complaint Case No. 13/22

 

 

 

 

In the matter of:

 

		Smt. Komal Malhotra W/o Sh. Manish Kumar R/o H.No. 374 C, 2nd Floor, Pocket J & K, Dilshad Garden, Delhi-110095		Complainant
		Versus
		M/s ICICI Lombard General Insurance Co. Ltd.  At:- 1st Floor, Unit no. 101, Dilshad Garden Metro Station, Delhi-110095 Through its authorized signatory/Branch Head.   M/s ICICI Lombard General Insurance Co. Ltd. Having its Regd. Office, At:- 401 and 402, 4th Floor, interface 11, New linking Road, Malad (West), Mumbai, Maharashtra-400064 Through its authorized signatory /chairmen /MD   Also at:- M/s ICICI Lombard General Insurance Co. Ltd. At:- ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai, Maharashtra 400025 Through its authorized signatory /chairmen /MD		Opposite Party
			DATE OF INSTITUTION:         JUDGMENT RESERVED ON:                           DATE OF ORDER:		02.02.22 06.07.23 31.10.23

 

CORAM:

Surinder Kumar Sharma, President

Adarsh Nain, Member

 

 

 

ORDER

Ms. Adarsh Nain, Member

 

The Complainant has filed the present complaint under Section 35 of the Consumer protection Act, 2019 against the Opposite Party i.e. M/s ICICI Lombard General Insurance Co. Ltd.

Case of the Complainant

1. The case of the Complainant as revealed from the record is that the husband of  the Complainant had taken a family health insurance policy from the Opposite Party for the period of 02.07.19 to 01.07.21 and also paid the premium for the same. The Complainant stated that during Covid 19 corona pandemic, on 02.05.21 the husband of Complainant and Complainant herself got infected and got admitted in Rathi Hospital and discharged on 11.05.21. The expenses incurred on the treatment of the husband of Complainant were Rs. 2,98,949/- while Complainant herself incurred Rs. 2,46,055/-on her treatment. After recovery, on 17.05.21, the husband of Complainant and Complainant filed their respective claims for the aforesaid amount before the Opposite Party. On 13.08.21 after long inquiry, claim amount of Rs. 2,02,000/- of husband of Complainant had been approved by the Opposite Party instead of Rs. 2,98,949/- and the claim of Complainant has been declined/rejected with the reason “fraudulent claims”.  As per the medical record of Complainant, issued by the aforesaid hospital, the Complainant was got admitted in the same hospital on 02.05.21 and remained over there till 11.05.21 and she got treatment of high fever, breathing difficulty and high chest infection in the hospital and HRCT of Complainant was conducted in the aforesaid hospital and score of the same was 04, which was very high suspicion of Covid 19 in her both lungs, as per report. In this regard, Complainant was also given plasma therapy on 03.05.21.  The Complainant stated that Complainant approached Opposite Party several times and informed about the correct facts and circumstances but all in vain. The Complainant stated that claim amount of Rs. 2,46,055/- is legally recoverable from Opposite Party and Complainant is entitled to receive the same from Opposite Party. The Complainant stated that she had also sent legal notice to Opposite Party dated 17.11.21 through speed post dated 22.11.21 but Opposite Party did not comply the same. Hence, this shows deficiency in service on behalf of Opposite Party. The Complainant has prayed for Rs. 2,46,055/- with interest 18 % p.a. from filing of the claim till its realization.  She further prayed for Rs. 50,000/- for mental as well as physical harassment and Rs. 15,000/- towards litigation expenses.   

Case of the Opposite Party

2. The Opposite Party contested the case and filed written statement. Opposite Party, while taking preliminary objections, submits that there has been no deficiency on their part. It is contended that there was misrepresentation of material facts and on verification and investigation conducted by Opposite Party, the claim was found to be fraudulent as the bills were found inflated. It is also alleged that there was no requirement of hospitalisation as the SPO2 of the Complainant was 92 and further RT PCR was done twice i.e. before and during hospitalisation and both the reports were negative. It is also alleged by the Opposite Party that the complaint is not maintainable as the hospital from where the treatment was taken has not been made a party while same was a necessary party to the present complaint since the inflated bills were created by the treating hospital taking advantage of pandemic situation. It is submitted that the competent authority of the Opposite Party after carrying out investigations, found the claim to be fraudulent and recommended for repudiation.

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 objection raised by the Opposite Party and has reiterated the assertion made in the complaint.

Evidence of the Complainant

4. The Complainant, in support of her complaint, filed her evidence by way of affidavit wherein she has supported the averments made in the complaint.

 

 

Evidence of the Opposite Party

5. In order to prove its case Opposite Party filed affidavit of Ms. Atalanta Chakrabarti, Manager Legal of Opposite Party wherein she has supported the case of the Opposite Party as mentioned in the written statement.

Arguments & Conclusion

6. We have heard the Ld. Counsel for Complainant. We have also perused the file and the written arguments filed by the Opposite Party.
7. The case of the Complainant is that she had taken a family health insurance policy from the Opposite Party and during Covid 19 corona pandemic, the husband of Complainant and Complainant herself got infected and remained admitted in Rathi Hospital from 02.05.21 to 11.05.21 for treatment. It is submitted that the expenses incurred on the treatment of the husband of Complainant were Rs. 2,98,949/- while Complainant herself incurred                  Rs. 2,46,055/-on her treatment. It is alleged that only claim amount of                Rs. 2,02,000/- of husband of Complainant had been approved by the Opposite Party instead of Rs. 2,98,949/- and the claim of Complainant has been declined/rejected with the reason “fraudulent claims. The Complainant stated that claim amount of Rs. 2,46,055/- is legally recoverable from Opposite Party and Complainant is entitled to receive the same from Opposite Party.
8. On the other hand, it has been contended by Opposite Party that there was misrepresentation of material facts and on verification and investigation conducted by Opposite Party, the claim was found to be fraudulent as the bills were found inflated. It is also alleged that there was no requirement of hospitalisation as the SPO2 of the Complainant was 92 and further RT PCR was done twice i.e. before and during hospitalisation and both the reports were negative. It is also alleged by the Opposite Party that the complaint is not maintainable as the hospital from where the treatment was taken has not been made a party while same was a necessary party to the present complaint since the inflated bills were created by the treating hospital taking advantage of pandemic situation. It is submitted that the competent authority of the Opposite Party after carrying out investigations, found the claim to be fraudulent and recommended for repudiation.
9. The perusal of the medical record of the Complainant shows that the remained admitted in the Rathi hospital from 02.05.21 till 11.05.21 and received treatment of high fever, breathing difficulty and high chest infection in the hospital. It is also observed that HRCT Chest conducted on 03.05.2021 records the findings that “ multi focal ground glass opacities seen in both lungs in sub pleural and posterior predominance ” and “…very high suspicion of covid 19”. In light of above, the contention of the Opposite Party that there was no requirement of hospitalisation as the RT PCR was done twice i.e. before and during hospitalisation and both the reports were negative, is rejected for being unrealistic.
10. The other contention of the Opposite Party is that the treating hospital has generated inflated bills but the Opposite Party has failed to support their contention with any evidence. The Opposite Party has also contended that treating hospital was a necessary party and was not made party to the present complaint. The contention of Opposite Party cannot be admitted since the Opposite Party has not moved any application before this commission in this regards and failed to take any concrete step in that direction.
11. The Opposite Party has also contended that the competent authority of the Opposite Party after carrying out investigations found the claim to be fraudulent and recommended for repudiation. The contention of the Opposite Party cannot be believed as true since the Opposite Party has neither filed any affidavit of the concerned investigator to prove the investigation report nor have supported their contention with any other evidence.
12. In view of above discussion, we are of the considered view that the Opposite Party has been deficient in services by rejecting the valid claim of the Complainant, causing mental agony and torture to the Complainant.
13. Accordingly, we allow the complaint and direct the Opposite Party i.e. M/s ICICI Lombard General Insurance Co. Ltd. to pay to the Complainant the claim amount of Rs. 2,46,055/- with interest @9% per annum from the date of institution of the complaint. The Opposite Party is also directed to pay Rs. 20,000/- towards compensation and Rs.10,000/- towards litigation cost along with interest @ 9 % per annum from the date of this order till its recovery.
14. Order announced on 31.10.23.

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

File be consigned to Record Room.

 

(Adarsh Nain)               Member

(Surinder Kumar Sharma) President