DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II

U.T. CHANDIGARH

Sushil Kansal s/o Sh. Som Nath, r/o H.No. 4524, Ward No.13, Kharar.

                                                 ---Complainant.

V E R S U S

1]    ICICI Lombard General Insurance Company Limited, 2^nd Floor Zenith House, Kesharao Khadye Marg, Mahalaxmi, Mumbai – 400034 through its Manager/ Authorized Representative.

2]    ICICI Lombard General Insurance Company Limited, Quite Office No.10, Sector 40-B, Chandigarh, through its Manager/ Authorized Representative.

---Opposite Parties.

BEFORE:          SH. LAKHMAN SHARMA               PRESIDENT

MRS.MADHU MUTNEJA             MEMBER

                    SH.JASWINDER SINGH SIDHU          MEMBER

Argued By:  Sh. Sandeep Bhardwaj, Advocate for the Complainant.

                                Sh. Sandeep Suri, Advocate for the Opposite Parties .

PER JASWINDER SINGH SIDHU, MEMBER

1]           Complainant has filed the present complaint against the Opposite Parties, on the ground that the Complainant paid a premium of Rs.14,055/- and subscribed for a medi-claim insurance policy for the whole family for the period from 25.7.2007 to 24.7.2009. A copy of bank statement through which the payment of premium was made is annexed as Annexure C-1 and the copy of the policy is at Annexure C-2. The Complainant renewed this policy on 16.7.2009 by paying a premium of Rs.23,507/-. A copy of bank statement is annexed at Annexure C-3.

              The Complainant during the existence of this policy caught fever and remained hospitalized at PGI, Chandigarh for a period from 11.5.2009 to 18.5.2009 thereafter, from 21.5.2009 to 11.6.2009 and from 6.7.2009 to 13.7.2009. The Complainant submitted the claim form No. L741315 with the Opposite Parties amounting to Rs.74,161/- and another claim of Rs.37,206.92P was also submitted. As such, a total amount of Rs.1,11,367.92P was claimed under the said insurance policy. The copies of the claim form are attached at Annexure C-4 & C-5. The medical certificates given by the concerned doctors regarding the treatment are annexed at Annexure C-6 and C-7.

              The Complainant is aggrieved of non-settlement of his rightful claim by the Opposite Parties, despite repeated visits. The Complainant had also written a letter dated 6.2.2010 (Annexure C-9) requesting the Opposite Parties to do the needful, but failed to elicit any response. Thus, aggrieved of the non-settlement of his claim, the Complainant citing deficiency in service on the part of the Opposite Parties seeks the following relief:- 

[1] Payment of Rs.1,11,367.92P spent on his treatment;

[2] Compensation of Rs.1.00 lakh for mental agony and harassment;

[3]        Pay Rs.20,000/- against litigation expenses;

2]           On notice, Opposite Parties have filed their joint reply/ version contesting the claim of the Complainant and has taken preliminary objections to the effect that the Complainant has not come to the Forum with clean hands and has failed to provide the full facts with regard to him suffering from diseases of Sarcoidosis and Hypertension much before subscribing for the Policy. As it amounts to a case of pre existing disease and any treatment with regard to such a disease is not covered under the present policy, hence no claim is made out against the Opposite Party. The Opposite Parties have also reproduced clause 3.1 the wordings of which clearly states that such a claim is not covered under this policy. 

              While replying on merits para 1, 2 and 3 are not answered as the same pertains to a matter of record. While replying to para 5 Opposite Parties have stated that the Complainant had a fever at the time of admission with the PGI and the fever as such was attributable to a pre-existing disease which the Complainant was suffering from even prior to the policy. That the present policy does not cover any expenses for illnesses arising on account of a pre-exiting disease.

              The Opposite Parties claims that the assessment with regard to the claim of the Complainant was done by the TTK Health Care TPA Pvt. Ltd. which is a Third Party Assessee of all such claims and the same is mandated by the IRDA. Hence, the actual repudiation of the claim of the Complainant was done by the TTK and there is no deficiency in service on the part of the Opposite Parties on this count. The Opposite Parties have also taken a strong objection to the fact that the Complainant purposely did not bring the discharge certificate on record which was a very important document. Complainant also failed to bring any medial certificate so as to fortify his claim. Hence, in the present circumstances the repudiation of the claim of the Complainant is on the lines of the terms & conditions of the policy. Opposite Parties pray for the dismissal of the complaint with exemplary costs in favour of the Opposite Parties.

3]           Parties led their respective evidences.

4]           Having gone through the entire complaint, version of the Opposite Parties, the evidence of the parties and with the able assistance of the ld. Counsel for the parties, we have come to the following conclusions.

5]           While going through the present complaint the fact with regard to the Complainant having subscribed for the Medi-Claim Insurance Policy from the Opposite Parties from 25.7.2007 to 24.7.2009 is established. The Opposite Parties has not denied that the Complainant is not a Consumer. At the same time the Opposite Parties have also not denied that the Complainant had lodged a claim of Rs.1,11,367.92P under two different claims. 

6]           The Opposite Parties have however denied any responsibility with regard to the claim of the Complainant because the final decision about all such claims is taken only after the same is investigated by a “Third Party Assessee” and in the present case TTK Health Care TPA Pvt. Ltd. had processed the claim of the Complainant. After a detailed investigation by  TTK Health Care TPA pvt. Ltd. it was revealed that the Complainant had actually undergone a similar treatment for the same disease prior to having subscribed for the present policy. In order to substantiate the Opposite Parties have highlighted Annexure C-6 brought on record by the Complainant wherein in Clause 7 of “Past History of illness” is mentioned as “Sarcoidosis x 2 years”.  Hence, it becomes clear from the document of the Complainant itself that the Complainant was suffering from this disease at the time when he had subscribed for the Policy. Opposite Parties have also alleged that the Complainant was in the knowledge of himself suffering from this disease and has withheld this information from the Opposite Parties. Such an act of the Complainant clearly amounts to suppression of material fact. Thus, the repudiation of the claim of the Complainant is just and legal.

7]           The Opposite Parties have further alleged that the Complainant has also failed to bring on record certain documents for example “DISCHARGE AN follow-up card” as well as the “Discharge Summary” of the treating hospital, in the present case the PGI Chandigarh. According to the Opposite Parties the Complainant has deliberately tried to mislead this Forum while hiding crucial information which was very much available on these documents. While going through the evidence placed on record by the Opposite Parties it is very much clear from the document annexed at page 18 of the reply/ version wherein under the heading “treatment and investigation ordered”, the treating Doctor has appended a few lines under the title of Past History of Illness that states as follows:-

              “H/o Sarcoidosis since ‘98.

              H/o (L) Renal Calculi

              Operated in PGI

                              (Lithotripsy)”

Hence, the Opposite Parties is successful in establishing the fact that the Complainant was suffering from the same disease for which the claim was lodged even prior to his subscription of the policy under which this claim was lodged.      

8]           In the light of these observations, we feel that the Complainant has miserably failed to prove any deficiency in service on the part of the Opposite Parties. Hence, the present complaint is dismissed. The parties are left to bear their own costs.            

9]           Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced

24^th January, 2012.                                                                   

Sd/-

(LAKSHMAN SHARMA)

PRESIDENT

Sd/-

(MADHU MUTNEJA)

MEMBER

Sd/-

 (JASWINDER SINGH SIDHU)

MEMBER