IN THE COURT OF THE LD. DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT S I L I G U R I.

CONSUMER CASE NO. : 66/S/2014.                            DATED : 24.10.2016.   

BEFORE  PRESIDENT              : SRI BISWANATH DE,

                                                              President, D.C.D.R.F., Siliguri.

                      MEMBERS              : SMT. PRATITI BHATTACHARYYA &

                                                              SRI PABITRA MAZUMDAR.

COMPLAINANT             : SRI RAKESH SAHARAN,

  S/O Late Kulwant Rai Saharan,

  C/o Saharan Engineering Works, Saharan House,

  2^nd Mile, Sevoke Road, P.O. – Siliguri,

  P.S.- Bhaktinagar, Dist.- Jalpaiguri,

  PIN – 734 001, West Bengal.     

O.P Nos.        1.                        :THE BRANCH MANAGER,

  ICICI Lombard General Insurance Co. Ltd.,

  “Ganeshayan”, Plot No.737, Sevoke Road,

  Near Panitanki More, P.O. & P.S.- Siliguri,

                                                  Dist.- Darjeeling – 734 001, West Bengal.

                        2.                        :THE HEAD CUSTOMER CARE SERVICE,

  ICICI Lombard General Insurance Co. Ltd.,

  ICICI Lombard Health Care, ICICI Bank Tower,

  Plot No.12, Financial, Dist.- Nanankram ‘Gude’,    

  Gachibowli, Hyderabad – 500 032, Andhra Pradesh.

3.                    : THE CHAIRMAN,

  ICICI Lombard General Insurance Co. Ltd.,

  ICICI Lombard House, 414, Veer Savarkar Marg,

  Near Siddhi Vinayak Temple, Prabhadevi,

                                                  Mumbai – 400 025, Maharashtra.

FOR THE COMPLAINANT         : Sri Ashoke Kr. Singhi, Advocate.

J U D G E M E N T

Sri Biswanath De, Ld. President.

The complainant’s case in brief is that he obtained Health Insurance Policy namely Family Product Premier (FPP) from the OP No.1, and he paid the required premium.  The complainant renewed the policy from time to time, and it covered the complainant and his wife, and their son.  The sum assured was Rs.3,00,000/- , and it was later enhanced to Rs.8,00,000/- on payment of extra premium.  The complainant’s wife was treated at Apollo Hospital Enterprises Limited at Chennai for treatment.  The complainant requested the Apollo Hospital to provide him cashless access under the policy, since the Insurance Company

Contd......P/2

-:2:-

was required to bear the expenses as per terms of the policy.  The Apollo Hospital informed the OP about the complainant’s request of cashless access, but the OP denied to provide the same.  The complainant’s wife was discharged from the hospital after the complainant made the full payment of the expenses from his own funds.  The complainant accordingly filed this case praying that the OPs be directed to pay him all the expenses incurred towards the treatment of his wife, and he prays for compensation and some other reliefs as well.         

       The OP Nos.1, 2 & 3 have filed written version denying inter-alia all the material allegations as raised by the complainant.  The OPs admit that complainant took the said policy as stated by the complainant.  The OPs admit the Insurance Policy, but states that the complainant took the policy by suppression of material facts and by making untrue and incorrect statement.  The OPs have repudiated the claim of the complainant after a thorough investigation.  The complainant suffered from HTN from last ten years, but the complainant had suppressed that at the inception of the policy.  The insured had suppressed his previous illness which goes against the terms & conditions of the policy.  Accordingly, OPs pray for dismissal of the complaint.   

To prove the case, the complainant has filed the following documents:-

1.       Original letter dated 07.02.2013.

2.       Original cheque no.143360 on ICICI Bank dated 26.02.2013.

3.       Original letter dated 05.01.2013.

4.       Letter dated 22.01.2013.

5.       Original cheque no.140846 on ICICI Bank dated 23.01.2013.

6.       Attested Xerox copy of the policy documents 4 documents.

7.       Attested Xerox copy of the Denial letter dated 22.11.2012.

8.       Original copy of the FIR dated 26/27.09.2016

9.       Original ICICI Health Care Card valid up to 12.05.2013 06 nos.

OP Nos.1, 2 & 3 have filed the Xerox copies of following six documents :-

1.       Certified copy of the application for proposal for General Insurance by Rakesh Saharan (3 sheets).  Annexure-A.

2.       Certified copy of the admission request note dates 21.11.2012 by Apollo Hospital, Chennai.  Annexure-B.

3.       Certified copy of the additional information request to Apollo Hospital, Chennai.  Annexure-C.

4.       Certified copy of the receipt with seal of additional information request by Apollo Hospital Enterprise Ltd., Chennai dated 22.11.2012.  Annexure –D.

5.       Certified copy of the PAN Number.  Annexure-E.

Contd......P/3

-:3:-

6.       Certified copies of the all AHC Medical summery of 22.11.2012 by Apollo Hospital, Chennai.  Annexure- F series containing 7 sheets.

7.       Certified copy of the denial of cashless excess dated 22.11.2012 address to Apollo Hospital by OP ICICI Lombard G.I.C. Ltd.  Annexure-H.

8.       Certified copies of the schedule of the policy condition containing 4 sheets.  Annexure-H.

          Complainant has filed evidence in-chief.

OP Nos.1 & 2 have filed evidence-in-chief.

          Complainant has filed Written Notes on argument.

OP Nos.1 & 2 have filed Written Notes of Argument.

Points for determination

1.       Is there any deficiency in service on the part of the OPs ?

2.       Is the complainant entitled to get any relief as prayed for ?

Decision with reason

          Both issues are taken up together for the brevity and convenience of discussion.

In evidence on oath, the complainant has stated his case as per contentions of the complaint.  The complainant’s wife was admitted in the Apollo Hospital for abdominal hysterectomy.  The complainant wanted benefit of cashless access under the Health Insurance Policy, but the Apollo Hospital denied to provide the cashless access benefit to the wife of the complainant as per information of OP No.2 who denied to extend benefit as the patient was suffering from hypertension for 10 years which was not disclosed at the time of the policy inception as per clause of the policy.  The OP also stated the case that as patient was suffering from HTN, so, the benefit of the policy has not been extended to the complainant.  So, the complainant’s claim stands that he did not get benefit of the policy, whereas OP stands is that as the complainant has been suffering from HTN for ten years even before starting the policy, so the complainant will not get the benefit of the policy. 

The complainant has filed argument and referred some principle of law laid down in IV (2014) 580 (NC), I (2014) CPJ 75 (Uttarakhand).  The complainant has also relied on the principle of Valsa Jose Case of IV (2012) CPJ 839 (NC) and I(2006) CPJ 494 OICL Vs. Madhusadan Sharma.  The summation of principles stands that “We have taken a view in large number of cases that diseases like

Contd......P/4

-:4:-

hypertensions, diabetes etc.  Are so common and are always controllable and unless and until patient has undergone long treatment including hospitalisation and remain in hospital for days and undergoes operation etc, in the near proximity of taking the policy cannot be accused of concealment of material fact.  We have also taken a view that insurance companies are also expected and supposed to subject the insured to medical examination in order to rule out those diseases which are common and half of population is suffering from such diseases”. 

It is also argued the Hon’ble West Bengal State Commission in II (2008) CPJ Bijoy Kumar Agarwalla Vs. NIACL held that the contention that the patient known hypertensive for last 20 years as per doctors’ prescription not acceptable in absence of evidence in support.  The alleged ailment pre-existing before taking/renewal of policy or knowledge about ailment not proved. 

In the case in hand, there is nothing in record about the Doctor’s Panel who considered the complainant’s claim as lodged and on what basis.

Thus, in the present case mere mention that the complainant is Hypertensive for 10 years in the Discharge summary of the Apollo Hospital on which basis the OP repudiated the claim is not the conclusive evidence of suppression of material facts and/or Pre-existence of any disease to cancel the policy as done by the OP insurance company in the present case.

Moreover, in this case the complainant’s wife was admitted for total abdominal hysterectomy operation which is a Gynaecological problem and this problems is not in no way connected with Hypertension which has been considered by the OPs as a cause of repudiation of the claim of the complainant on ground of suppression of material fact.

Accordingly, after deliberation over the evidence on record, and statement of both sides and terms and conditions embodied in the certificate, and principle of law adopted by Hon’ble National Commission and State Commission, we are of opinion that the ground of repudiation of claim of the complainant is not reasoned and is not acceptable.  Therefore, the complainant is entitled to get relief as prayed for. 

In the result, the case succeeds.         

Hence, it is

                     O R D E R E D

that the Consumer Case No.66/S/2014 is allowed on contest in part against the OP Nos.1, 2 & 3 with cost.

Contd......P/5

-:5:-

The complainant is entitled to get Rs.1,16,925/- for treatment of the wife of the complainant at Apollo Hospital from the OP Nos.1, 2 & 3.

The complainant is further entitled to get Rs.2,00,000/- towards compensation for mental pain, agony and harassment from the OP Nos.1, 2 & 3. 

The complainant is further entitled to get Rs.30,000/- on account of litigation cost from the OP Nos.1, 2 & 3.

The complainant is further entitled to get interest @ 9% per annum on the awarded sum of Rs.3,16,925/- from the date of filing of this case till full realization.    

The OP Nos.1, 2 & 3, who are jointly and severally liable, are directed to pay Rs.1,16,925/- by issuing an account payee cheque in the name of the complainant for treatment of the wife of the complainant at Apollo Hospital, within 45 days from the date of this order.

The OP Nos.1, 2 & 3, who are jointly and severally liable, are further directed to pay Rs.2,00,000/- by issuing an account payee cheque in the name of the complainant towards compensation for mental pain, agony and harassment, within 45 days from the date of this order.

The OP Nos.1, 2 & 3, who are jointly and severally liable, are  further directed to pay Rs.30,000/- by issuing an account payee cheque in the name of the complainant for litigation cost, within 45 days from the date of this order.

The OP Nos.1, 2 & 3, who are jointly and severally liable, are further directed to pay interest @ 9% per annum on the awarded sum of Rs.3,16,925/- from the date of filing of this case till full realization.

Failing which the amount will carry further interest @ 9% per annum on the awarded sum of Rs.3,16,925/- from the date of this order till full realization.

In case of default, the complainant is at liberty to execute this order through this Forum as per law.          

Let copies of this judgment be supplied to the parties free of cost.

  -Member-                           -Member-                       -President-