a) pay the treatment charges of Rs.1,85,576/- to the complainant alongwith interest to the complainant, jointly & severally.
b) pay Rs. 2,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 15,000 /-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 it was established form the claim documents as well investigation report so got conducted by the opposite parties that the claim of the complainant was a fraudulent claim as defined under Part III of the policy General Terms & condition No. 12 so incorporated in the insurance policy. The complainant neither had any cause of action nor locus standi in lodging of the present complaint before this Hon’ble Commission, reason being, the complainant had submitted claim form dated 22.04.2021 alongwith relied upon documents with regards to indoor treatment w.e.f 05.04.2021 to 17.04.2021 from Asha Hospital, Mathura (UP). After scrutiny of the claim papers, an independent investigator viz. True Value Investigation Services was deputed to verify the treatment record as well as ascertain the status of the hospital in question. After verification, the said investigator had prepared and submitted his report by incorporating the all facts and circumstances therein as well as annexing the Xerox of indoor treatment record, questionnaire of the patient & Google time provided by her. Since, it had been established form the claim documents as well investigation report so got conducted by the opposite parties that the claim of the complainant as to treatment of his wife was a “fraudulent claim’ as defined under Part III of the policy General Terms& Condition No.13 so incorporated in the insurance policy. Thus, the insurance company had treated the subject claim as “No claim” by closing the file in terms of letter of intimation dated 27.07.2021, 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– ICICI Lombard Gen. Insurance co. & Others with the prayer to: a) pay the treatment charges of Rs.1,85,576/- to the complainant alongwith interest to the complainant, jointly & severally. b) pay Rs. 2,00,000/- as compensation for causing mental agony and harassment . c) pay Rs. 15,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, PW1/A – affidavit of Partic Kumar,, Ex.P-1 – Risk Assumption Letter, Ex.P2 – Policy certificate, Ex.P3 – Policy certificate,, Ex.P-4 – register details, Ex.P-5 – receipt, Ex.P-6 to 17 – bills,, Ex.P-18 – courier receipt, Ex.P-19 – discharge summary, Ex.P-20 – email dated May 20,2021 regarding repudiation of the claim of the complainant. , Ex.P-21 – legal notice,, Ex.P-22 & 23– postal receipts.
On the other hand counsel for the opposite parties strongly agitated and opposed. As per the evidence of the opposite parties, Ex.RW1/A – affidavit of Rohan Mishra, Manager (Legal), M/s. ICICI Lombard General Insurance Co. Ltd., 4th floor, Red Fort Capital Parsvnath Tower, Bhai Veer Singh Marg, Gole Market, New Delhi – 110 001, Ex.R-1(colly) – (a) Policy schedule (Policy certificate), Rc.R-2 – claim form, Ex.R-3 – discharge summary, Rc.V-4 (colly) - Individual reimbursement, Ex.R-5 – repudiation letter dated 27.07.2021.
6. In this case, the complainant, his wife namely Smt. Sonia and daughter namely Naina taken Mediclaim policy bearing No. 4128i/iHA/1438154867/03/000 valid from 02.02.2021 to 05.02.2022 for the insured benefit/value of Rs.3,00,000/-. On 05.04.2021 the complainant’s wife Smt. Sonia became sick so the complainant taken his wife and got admitted her in Asha Hospital near Bajrang Dharamkanta Maholi Road, Mathura Uttar Pradesh in ICU due to impact of fever, weakness, vertigo and vomitting. She remained under treatment as indoor patient in the said hospital w.e.f.05.04.2021 to 17.04.2021. Due to this disease several tests like urine test, blood test etc. were conducted in Asha Hospital Mathura. The said hospital also raised the bill for Rs.1,85,576/- which was paid by the complainant to the said hospital at the time of discharge opf Smt. Sonia wife of the complainant. Opposite parties repudiated the claim of the complainant vide email dated 20.05.2021 vide Ex.P-20 on the ground that “ insured sated that she was admitted in Asha Hospital under Dr. Praveen Kumar Solanki in ICU from 5 April 21 to 17 April 21 with complaints of fever, weakness indigestion, vertigo and vomiting since 7-10 days. Pre admission she consulted to Dr. Tiwari. Then she visited to her maternal house Mathura where she was admitted in Asha Hospital. She underwent blood test, urine test. Her total bill was of Rs.1,85,576/- which was paid by spouse in cash. At the time of hospitalization she had her phone with her. She provided her Google time. We visited to Asha Hospital, but insured’s IPD register entry and ICP not found in hospital (AVR attached), available staff affirmed they would provide it later diagnosed with Septicaemia with fever). As per Google time details she was in Haryana at the period of hospitalization, while hospital is in Mathura, UP she constantly visited to crown Plaza during hospitalization period. Hence, this case is recommended for repudiation under fraud.”
7. After going through the evidence led by the parties, the Commission is of the opinion that the complaint is allowed, subject to deduction of 25% in lumpsump of the bill. The opposite parties Nos.1 & 2 are also directed to pay Rs.2200/- as compensation on account of mental tension, agony and 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 order. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 17.02.2023 (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.
