Haryana

Kaithal

363/19

Parmod Kumar - Complainant(s)

Versus

ICICI Lombard Gen Insurance company - Opp.Party(s)

Sh.Berjesh Rana

01 Aug 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KAITHAL.

                                                     Complaint Case No.363/2019.

                                                     Date of institution: 13.11.2019.

                                                     Date of decision:01.08.2023.

Parmod Kumar, age 45 years S/o Sh. Baldev Raj R/o 379 W.No.13, Gali No.1, Kaithal, Haryana-136027.

                                                                        …Complainant.

                        Versus

1. ICICI Lombard General Insurance Company Ltd., ICICI Lombard House, 414, Veer Savarkar Marg, near Siddhi Vinayak Temple, Prabhadevi, Mumbai-400025.
2. Vijay Rani Arora, Agent Code-118783, R/o Kaithal (M)-9896570700.

….OPs.

        Complaint under Section 12 of the Consumer Protection Act

CORAM:     SMT. NEELAM KASHYAP, PRESIDENT.

                SMT. SUMAN RANA, MEMBER.

                SH. SUNIL MOHAN TRIKHA, MEMBER.

       

Present:     Sh. Berjesh Rana, Advocate, for the complainant.   

                Sh. Arvind Khurania, Advocate for the OP.No.1.

                None for the OP No.2.

                (Defence of OP No.2 struck off).

               

ORDER

NEELAM KASHYAP, PRESIDENT

        Parmod Kumar-Complainant has filed this complaint under Section 12 of Consumer Protection Act, 1986 (hereinafter referred to as ‘the Act’) against the OPs.

2.             In nutshell, the facts of present case are that the complainant obtained one health insurance policy namely Health Protect bearing No.4128/HP/130020978/00/000 valid for the period 21.04.2017 to 20.04.2018 from OP No.1 through OP No.2 and the premium amount of Rs.17,178/- was paid by the complainant to OPs.  The said policy was renewed for the period 21.04.2018 to 20.04.2019.  On 03.01.2019, the son of complainant had met with a road-side accident and received multiple and grievous injury and he was treated by the doctor of Anaya Hospital and Diagnostic Centre, Opp. I.G. College, Karnal Road, Kaithal from 03.07.2019 to 05.02.2019.  The complainant spent about Rs.38,725/- upon treatment of his son.  The complainant lodged the claim with the OP No.1 and submitted all the bills and documents but the OP No.1 did not settle the claim of complainant.  So, it is a clear cut case of deficiency in service on the part of OPs and prayed for acceptance of complaint.     

3.            Upon notice, the OP No.1 appeared before this Commission and contested the complaint by filing their written version, whereas OP No.2 initially appeared and did not file written statement despite availing several opportunities, so, the defence of OP No.2 was struck off vide order dt. 25.08.2022 passed by this Commission.  In the written statement, OP No.1 raised preliminary objections with regard to locus-standi; maintainability; cause of action; that as per the insurance policy’s terms & conditions, there shall not be any pre-existing illness; that in the proposal form at Medical and lifestyle information, the policy-holder declared that all the family members are not having Diabetes History, whereas in the claim verification from Doctor mentioned that the insured was diabetic since February, 2017.  Accordingly, the answering OP rightly repudiated the claim No.22100497932 vide letter dt. 06.06.2019.  The said repudiation of claim is stated to be legal and valid.  There is no deficiency in service on the part of OP.  On merits, the objections raised in the preliminary objections are rebutted and so, prayed for dismissal of complaint.

4.             To prove his case, the complainant tendered into evidence affidavit Ex.CW1/A alongwith documents Annexure-C1 to Annexure-C17 and thereafter, closed the evidence.

5.             On the other hand, the OP No.1 tendered into evidence affidavit Ex.RW1/A alongwith documents Annexure-R1 to Annexure-R7 and thereafter, closed the evidence.

6.             We have heard the learned Counsel for both the parties and perused the record carefully.

7.             Ld. counsel for the complainant has argued that the complainant obtained one health insurance policy namely Health Protect bearing No.4128/HP/130020978/00/000 valid for the period 21.04.2017 to 20.04.2018 from OP No.1 through OP No.2 and the premium amount of Rs.17,178/- was paid by the complainant to OPs.  The said policy was renewed for the period 21.04.2018 to 20.04.2019.  It is further argued that on 03.01.2019, the son of complainant had met with a road-side accident and received multiple and grievous injury and he was treated by the doctor of Anaya Hospital and Diagnostic Centre, Opp. I.G. College, Karnal Road, Kaithal from 03.07.2019 to 05.02.2019.  It is further argued that the complainant spent about Rs.38,725/- upon treatment of his son.  The complainant lodged the claim with the OP No.1 and submitted all the bills and documents but the OP No.1 did not settle the claim of complainant.  So, it is a clear cut case of deficiency in service on the part of OPs.

8.             On the other hand, ld. counsel for the OP No.1 has argued that in the proposal form at Medical and lifestyle information, the policy-holder declared that all the family members are not having Diabetes History, whereas in the claim verification from Doctor mentioned that the insured was diabetic since February, 2017.  It is further argued that the OP has rightly repudiated the claim No.22100497932 vide letter dt. 06.06.2019.

9.             We have considered the rival contentions of both the parties.  The OP No.1 has taken the objection that in the Complete Health Insurance Proposal Form as per Annexure-R4, the policy-holder declared that all the family members are not having Diabetes History, whereas in the claim verification from Doctor mentioned that the insured was diabetic since February, 2017, so, the OP No.1 has rightly repudiated the claim No.22100497932 vide letter dt. 06.06.2019 as per Annexure-C3.  But it is pertinent to mention here that the OP No.1 has not produced any medical record of the insured to prove that he was taking treatment for the diabetes disease, referred to above, prior to taking the policy in question. In the case of Rajinder Singh Vs. The New India Assurance Co. Ltd. & Ors., 2018(3) CLT-187, the Hon’ble State Commission Haryana, has held that “the treating doctor mentioned that the complainant was suffering from diabetes and hypertension for the last about three years without mentioning his source of knowledge in this regard and has not mentioned as to whether the patient had himself told him that he was suffering from the abovementioned ailments- Repudiation of the claim was not justified”.  We can also rely upon case law titled as Life Insurance Corporation of India Vs. Sudha Jain 2007(2) CLT 423, wherein the Hon'ble Delhi State Consumer Disputes Redressal Commission, New Delhi has drawn conclusions in para 9 of the order and the relevant clause is 9(iii), which is reproduced as under:-

                "9(iii) Malaise of hypertension, diabetes occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is full of tension at the place of work, in and out of the house and are controllable on day-to-day basis by standard medication and cannot be used as concealment of pre-existing disease for repudiation of the insurance claim unless an insured in the near proximity of taking of the policy is hospitalized or operated upon for the treatment of these diseases or any other disease."

10.                  Keeping in view the ratio of the case laws laid down by the superior Fora in the aforesaid cases and the facts & circumstances of the present case, we are of the considered opinion that the OP No.1 has wrongly repudiated the claim of complainant.  So, we are of the considered view that there is deficiency in service on the part of OP No.1.  In the present case, the complainant has placed on file the medical bills amounting to Rs.38,725/- as per Annexure-C11 & Annexure-C15, so, he is entitled for the said amount.

11.                  Thus, as a sequel of aforesaid discussion, we direct the OP No.1 to pay the amount of Rs.38,725/- to the complainant within 45 days from today, failing which, the aforesaid amount shall carry interest @ 7% p.a. from the date of this order till its realization.  The OP No.1 is further directed to pay Rs.5,000/- as compensation on account of physical harassment and mental agony as-well-as Rs.5,000/- as litigation charges.  Hence, the present complaint is accepted accordingly against OP No.1 and dismissed against OP No.2. 

12.                  In default of compliance of this order, proceedings against OP No.1 shall be initiated under Section 72 of Consumer Protection Act, 2019 as non-compliance of court order shall be punishable with imprisonment for a term which shall not be less than one month, but which may extend to three years, or with fine, which shall not be less than twenty five thousand rupees, but which may extend to one lakh rupees, or with both.  A copy of this order be sent to both the parties free of cost.  File be consigned to the record room after due compliance.     

Announced in open court:

Dt.:01.08.2023.

                                                                (Neelam Kashyap)

                                                                President.

 

(Sunil Mohan Trikha),           (Suman Rana),          

Member.                            Member.

 

Typed by: Sanjay Kumar, S.G.