District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.67/2022.
Date of Institution: 03.02.2022.
Date of Order: 11.01.2023.
Braham Pal S/o Shri Lakhi Ram r/o House No. 292, Siya Patti Mohalla, Near Lamba Chowk, Mujesar, Faridabad C/o Jakhar Tempo Service Krishna Colony, Sector – 25, Faridabad Age 46 years, M. 9810719914.
…….Complainant……..
Versus
1. The ICICI Lombard General Insurance Company Ltd., Registered Office: ICICI Lombard House, 414 Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai.
2. The ICICI Lombard General Insurance Company Ltd., Branch Office: 5B/4BP, 2nd floor, Neelam Bata Road, NIT, Faridabad.
…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: Sh. D.C.Dhankar, counsel for the complainant.
Sh. Rakesh Dabaas counsel for opposite parties Nos.1 & 2.
ORDER:
The facts in brief of the complaint are that the complainant took medical claim insurance policy bearing No. 41281/IH/138241793/02/000 for the period from 29.10.2019 to 28.10.2021 in his name as well as in the name of his family members. And prior to making and issuing the above medical policy, opposite party got enquired done the entire formalities and also opposite party got medically checked complainant and his other family members through his designated medical center. After finding that there was no old and pre-existing disease and after having full satisfaction by their side, opposite party issued the policy in favour of the complainant as the complainant was having mediclaim policy since the year 2009 continue. The complainant suffered from ailments and in the month of Oct. 2020 he was got admitted in NIIMS Hospital INATIONAL Institute of Medical Sciences), Sector-23A, Faridabad and he remained admitted in the above hospital since 13.10.2020 to 15.10.2020 and various investigations were conducted and complainant was given various medicines as per requirements. The above NIIMS hospital sent the details of complainant in respect of his admission, disease and treatment given to him alongwith all the investigation reports and other related documents to opposite party on 13.10.2020 wherein the expected cost of Rs.35,000/- was given. In response thereto, opposite party sought some additional information vide email dated 13.10.2020 at 8.56p.m. Thereafter, the hospital sent the above said additional information to opposite party Thereafter, opposite party again sought some additional information on 14.10.2020 at 4.58 p.m. Thereafter, the hospital again sent all the requisite information and documents to opposite parties. Opposite party without considering the claim of the complainant and without appreciating the medical records, treatment given to
the complainant and other relevant things as well, opposite party had repudiated the claim of the complainant on the flimsy grounds that insured was suffering with disease of hypertension prior to policy commencement, which was absolutely against the terms and conditions of the policy and same was against the principal of natural justice and without considering the fact that the mediclaim policy of the complainant was continue since the year 2009. Right from the first day of admission i.e.13.10.2021, the intention of opposite party was malafide and thus opposite party tried to defer the claim of the complainant by way of seeking additional information and document s and ultimately he denied, rejected and repudiated the cashless facility claim of the complainant on flimsy ground. The complainant was discharged from the hospital and a sum of Rs. 180511/- was paid by the complainant. Thereafter. Complainant had been requesting opposite party through his authorized agent too to release and reimburse the above said amount to complainant as opposite party was under legal obligation to make the payment. The complainant sent legal notice dated01.06.2021 to the opposite parties but all in vain. 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 payment of claim amount of Rs.18051/- alongwith interest @ 24% from the date of bill till itsr ealization.
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, it was established from the relied upon documents by the complainant pertaining to treatment w.e.f. 13.10.2020 to 15.10.2020 that the complainant was having history of known case of hypertension since 2014 but the complainant had not disclosed as to said pre existing disease at the time of insurance policy inception i.e.29.10.2019, which amply prove on record that the claim of the complainant falls within the Exclusion clause as well as General Condition NO.1 (incontestability and Duty of Disclosure) of Part III so incorporated in the insurance policy. The complainant neither had any cause of action nor locus standi to file the present complaint. The complainant was got admitted in NIIMS Hospital Faridabad on 13.10.2020 for which cashless request supported by the relevant documents was forwarded to the insurance company. Upon scrutiny, it had been detected from the relied upon documents, so sought through additional information request form, that the complainant was having history of known case of hypertension since year 2014 but the complainant had not disclosed as the said pre-existing disease at the time of insurance policy inception i.e.29.10.2019, which amply prove on record that the claim of the complainant falls within the Exclusion clause as well as General condition No.1 (incontestability and duty of disclosure) of part III so incorporated in the insurance policy. As such, the insurance company had rejected the said cashless request vide letter dated 14.10.2020 by suggesting therein 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 adherence of policy terms & conditions but despite such suggestion the insured had not lodged his claim for re-imbursement
thus the present matter was re-mature in nature .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) make the payment of claim amount of Rs.18051/- alongwith interest @ 24% from the date of bill till its realization. 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/A – affidavit of Braham Pal, Ex.C-1 – insurance policy, Ex.C-2 – discharge summary,, Ex.C-3 – Summary Bill, Ex.C-4 – denial letter, Ex.C-5 – legal notice, Ex.C-6 & 7 – 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 Roshan 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, Ex.R-1 – insurance policy, Ex.R-2 – Request for cashless hospitalization for health insurance policy Part – C (Revised), Ex.R-3 – Discharge summary, Ex.R-4 – Summary Bill, Ex.R-5 – Additional information request form, Ex.R-6 – letter to ICICI Lombard, , Ex.R-7 – email regarding additional
information request form, Ex.R-8 – letter to ICICI Lombard, Ex.R-9 discharge summary, Ex.R-10 – Denial of cashless access.
6. It is evident from policy certificate vide Ex.R-1 which was issued on 29.10.2019 to 29.10.2021. As per Discharge summary vide Ex.R-3, the patient was admitted in the hospital from 13.10.2010 to 15.10.2020. As per letter issued by National Institute of Medical Sciences to ICICI Lombard vide Ex.R-8 in which it has been mentioned that “No medicines for hypertension since last few years. As per DOR vide Ex.R-9, the last admission which was in the year 2014 for the hypertension . It is evident from denial of cashless acesss letter dated 14.10.2020 vide Ex.R-10 on the ground that “based on the documents submitted in support of the claim, insured is suffering with (Hypertension) prior to policy commencement. The insured has not disclosed the same at the time of policy commencement. The claim stands rejected and the policy shall be null and void due to non disclosure. For details of applicable policy terms refer part III, Clause (1) of policy schedule.
7. In this case, the complainant has obtained the policy since 2014 and thereafter it was ported from different company to ICICI Lombard General Insurance Co. The age of the patient is 48 years. After going through the evidence led by the complainant, the Commission is of the opinion that hypertension is not a disease today it is a life style and as per letter issued by National Institute of Medical Sciences to ICICI Lombard vide Ex.R-8 in which it has been mentioned that “No medicines for hypertension since last few years”. It is settled law from the Hon’ble Apex Court the hypertension now-a-days is not a disease is a part of life style. In the interest of justice, the bill are only Rs.18,051/- and the patient is paying premium since 2014.. It is already 2022. Keeping in view of the above, the complaint is allowed.
8. After going through the evidence led by the parties, the Commission is of the opinion that the complaint is allowed. Opposite parties are directed to process the claim of the complainant as per the T&C of the policy within 30 days of receipt of the copy of order and pay the due amount to the complainant along with interest @ 6% p.a. from the date of filing of complaint till its realization. The opposite parties 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. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 11.01.2023 (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.
