Tamil Nadu

North Chennai

CC/28/2017

Mr.S.Amir Jowher - Complainant(s)

Versus

The General manager ICICI Lombard Health Care - Opp.Party(s)

Party in Person

23 Jan 2020

ORDER

 

                                                            Complaint presented on:  05.01.2017

                                                               Order pronounced on:  23.01.2020

 

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHENNAI (NORTH)

2^nd Floor, Frazer Bridge Road, V.O.C.Nagar, Park Town, Chennai-3

 

PRESENT:  TMT.K.LAKSHMIKANTHAM, B.Sc., B.L., DTL.,DCL, DL & AL -  PRESIDENT

 

TMT.P.V.JEYANTHI B.A., MEMBER - I

 

THURSDAY  THE 23^rd   DAY OF JANUARY  2020

 

C.C.NO.28/2017

 

Mr.S.Amir Jowher, M/64 years,

S/o. M.S.Deen,

No.1, First Main Road,

Karpagam Garden, Adyar,

Chennai – 600 020.

 

                                                                                     …..Complainant

 ..Vs..

1.The General Manager,

ICICI Lombard Health Care,

ICICI Bank Tower,

Plot No.12, Financial District,

Nanakaram Guda,

Gachibnuli, Hyderabad 500 032,

Telangana.

 

2. The Manager,

ICICI Lombard General Insurance Co. Ltd.,

84/85, Arihant Plaza, First Floor,

Wall Tax Road, Chennai – 600 003.

 

.....Opposite Parties

Counsel for Complainant                         : Mr.M.Vijayakumar

 

Counsel for  opposite parties                      : M/s.Elveera Ravindran & K.Vinod

 

ORDER

 

BY PRESIDENT TMT.K.LAKSHMIKANTHAM, B.Sc., B.L., DTL.,DCL, DL & AL

          This complaint is filed by the complainant u/s 12 of the Consumer Protection Act.1986.

1.THE COMPLAINT IN BRIEF:

          The complainant had  Mediclaim Insurance Policy from the 1^st opposite party through the 2^nd opposite party vide policy No.41281/HPR/87904186/01/000 ICICI compete Health Insurance for the period 05.03.2015 to 04.03.2016. The sum assured under policy is Rs.5 lakhs and the opposite party had collected the premium. The complainant on 08.01.2016 was diagnosed with the coronary Arteny disease TVD S/P – CABG and his Cardiac evaluation was done.   He was advised to undergo Enhanced External Counter Pulsation  treatment for 40 sittings and Act Arterial Clearance Therapy for one  sitting and Ozone therapy for five sittings. The complainant completed the treatment and paid a sum of Rs.1.65 lakhs towards treatment. The complainant in order to claim money back from the opposite party under the above said medi claim insurance taken from them had   submitted all the  necessary documents. The opposite party rejected his claim stating that the treatment is Experimental, Unproven and non standard which is utterly false. Insurance Ombusman also by its order dated 28.08.2016 rejected his claim. The treatment  Oxymed  hospital by EECP is a proven treatment and it is hereby admitted by leading hospital all over India. Hence this complaint.

 

 

2. WRITTEN VERSION OF THE   OPPOSITE PARTIES IN BRIEF:

          The opposite parties put the complainant  to strict proof of the complaint that on 08.01.2016 he was diagnosed with Coronary Artery Disease TVD S/P- CABG and his evaluation was done.  He was advised to undergo EECP (Enhanced External Counter Pulsation) treatment for 40 sittings and Act Arterial Clerance Therapy for one sitting and Ozone therapy for 5 sittings. The  complainant has suppressed material facts and at the time of the proposal and inception of the policy, he suppressed material facts that he was a known case of Coronary Artery Disease – TVD (Triple Vessel Disease) S/P – CABG, Diabetes Melllitus and the same is substantiated by the Discharge Sumary issued by OXYMED Hospitals Private Limited dated 08.02.2016, and such mandatory information was suppressed at the time of inception of the policy. The opposite parties had rightly repudiated his claim as per the terms and conditions of the policy of insurance. The complainant had argued that the treatment undergone by him has been proved by famous hospitals of Chennai, like Sri Ramachandra Medical College etc., However whether this treatment is standard or non standard, the fact remains that the complainant had not disclosed about his bye pass surgery undergone by him in July 2003 while taking the policy in February 2012. Hence there was a clear suppression of material facts and  the repudiation has been done as per law.

3. POINTS FOR CONSIDERATION:

          1. Whether there is deficiency in service on the part of the opposite parties?

          2. Whether the complainant is entitled to any relief? If so to what extent?

4. POINT NO :1 

          The complainant   had taken Medi-claim Insurance policy from the 1^st opposite party  through the 2^nd opposite party  vide policy No.41281/HPR/87904186/01/000 ICICI  Complete Health Insurance for the period from 05.03.2015 to 04.03.2016. The sum assured under the policy is Rs.5 lakhs. Premium is Rs.32,042/-  as  per  Ex.A1. On 08.01.2016 during the subsistence of the policy the complainant  was diagnosed with  the Coronary Artery Disease TVDS/P-CABG and as per   Cardiac evaluation the complainant  was advised to undergo Enhanced External Counter Pulsation treatment  for 40 sittings Act Arterial Clearance Therapy  for one sitting and Ozone therapy for 5 sittings at Oxymed Hospital at Chennai.

 05. The case of the complainant  is  as stated above.  He   had completed the  treatment and paid to the hospital  a sum of  Rs.1.65 lakhs as per Ex.A6 and had submitted  all the necessary documents to opposite parties  for the claim. Additional information was requested by opposite parties from the complainant in Ex.A1 dated  24.2.2016.  After perusing the documents submitted by complainant opposite parties  have rejected the claim under Ex.A2 based on the reason of the treatment is experimental, unproven one and non-standard   and  undergone day care treatment, and also for non-disclosure of the pre-existing disease. The complainant  approached Ombudsman  and further steps  taken by him ended in vain . Hence the Complaint.

             06. The opposite parties  would contend as stated by the complainant  the claim was rejected based on the reasons stated in the rejection letter in Ex.A2 and it is not a fit case to release the claim as per their norms. Ex.A3 is the Discharge Summary dated 08.02.2016 from Oxymed Hospital, Chennai. Rejection of the claim by ombudsman  is Ex.A4 letter dated 28.08.2016. The complainant  then issued legal notice to the opposite parties  under Ex.A5 dated 27.10.2016. Hospital receipt is produced in Ex.A6. On the side of the opposite parties  Ex.B1 is the Policy Insurance  and  Ex.B2 is the terms and conditions. Correspondence between the parties are Ex.B3 and B4.

07. Learned counsel for the complainant  submitted an unreported Judgment by Hon’ble Madras High Court in “M.D. Venugoapal Vs the Director General of Police”  dated  28^th August 2014 and argued focusing on the point of  approval dealt  by Hon’ble  High Court. As per G.O.No.174 the treatment of Enhanced External Counter Pulsation Therapy (EECP) was approved. Hence the treatment undergone by the complainant  is an approved one proving it to be as non-experimental and it is also a proven one. Therefore the opposite parties  rejection on those points are not accepted by this forum and found to be incorrect. The complainant  affirms his disclosure of pre-existing disease in the form submitted at the time of proposal but  the opposite parties  have denied the same and rejected the claim  relying  on the non-disclosure of pre-existing disease.  The opposite parties have duty bound to file either the original or copy of the application form submitted by the complainant at the inception of insurance policy which is in their possession in order to disprove the statement of the complainant but they failed to produce the same.   Therefore the objection raised by opposite parties on this point is not accepted by this forum as correct.

             08. The opposite parties  have also raised the point  that the complainant  had taken treatment as only outpatient and  a person under the said insurance policy is only eligible for the claim when he has taken as  an in-patient. It is pertinent to note para 2 (B) in Ex.B2 (series) under the head of ‘what we will pay’ “If during the policy period, You  require Hospitalization as an inpatient for less than 24  hours in a Hospital (but not in the outpatient department of a Hospital) on the written advice of a Medical Practitioner, then we will  pay you for the Medical Expenses incurred for undergoing such Day Care Procedure/Treatment of surgery.”  It is also to be noted that as per the requirement, the complainant was advised by the doctor who had treated the complainant   to undergo the treatment for many sittings and it is also noticed in the discharge summary in Ex.A3. Hence the rejection by the opposite parties on the above said point is also not correct.

         09.  As discussed above we come to the conclusion  that the claim of the complainant  is a genuine one and it was rejected without noticing the essential aspects by opposite parties  and denial by opposite parties  regarding the claim amounts to deficiency in service  and the complainant  is entitled for the amount as claimed.  Accordingly point No.1 is answered.

10. POINT NO.2:

 The complainant’s  sufferings  in view of non-payment of the claim is accepted by this forum as explained in the complaint  and  this forum is of the view that it would be appropriate to order  a sum of Rs.30,000/ for mental agony and  deficiency in service by opposite parties . Therefore opposite parties are directed to pay to the complainant a sum of Rs. 1,65,000/- , the claim amount  and also a sum of Rs. 30,000/-  for mental agony and deficiency in service besides a sum of Rs.5,000/- for cost.

In the result, the complaint is partly allowed. The opposite parties are directed to pay a sum of Rs.1,65,000/- (Rupees one lakh sixty five thousand only) towards the claim amount to the complainant and also a sum of Rs.30,000 /-(Rupees thirty thousand only) towards compensation for mental agony  besides a sum of Rs.5,000/- (Rupees five thousand only) for costs.

The above amount shall be paid to the complainant within 6 weeks from the date of receipt of the copy of this order failing which the above said amount shall carry 9% interest till the date of the payment.

          Dictated to the Steno-Typist transcribed and typed by her corrected and pronounced by us on this 23^rd day of January 2020.

 

MEMBER – I                                                                PRESIDENT

LIST OF DOCUMENTS FILED BY THE COMPLAINANT:

Ex.A1 dated 24.02.2016                   Letter from ICICI Lombard

Ex.A2 dated 22.03.2016                   Rejection letter from ICICI Lombard

Ex.A3 dated  08.02.2016                  Oxymed Hospital Discharge Summary

Ex.A4 dated 20.09.2016                   Rejection of Claim by Insurance Ombudsman

Ex.A5 dated 27.10.2016                   Copy of Legal Notice

Ex.A6 dated 08.01.2015                   Oxymed Hospital Receipt No.4341 Rs.1.65Lakhs

LIST OF DOCUMENTS FILED BY THE   OPPOSITE PARTIES:

 

Ex.B1 dated 09.03.2015                   Policy of Insurance

 

Ex.B2 dated NIL                      Terms and Conditions

 

Ex.B3 dated 21.03.2016                   Letter sent by the opposite parties to the

                                                   complainant

 

Ex.B4 dated 12.04.2016                   Letter sent by the opposite parties to the

                                                   complainant

 

 

 

MEMBER – I                                                               PRESIDENT