Punjab

Ludhiana

CC/19/448

Gunwant Kaur - Complainant(s)

Versus

ICICI Lombard Gen.Ins.Co.Ltd - Opp.Party(s)

Varun Gupta Adv.

14 Mar 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:448 dated 18.09.2019.                                                        Date of decision: 14.03.2023.

Gunwant Kaur, aged 58 years wife of Sh. Gurjeet Singh, resident of House No.174A, Model Town Extension, A Block, LLudhiana-141002.                                                                                                   ..…Complainant

                                                Versus

1. ICICI Lombard Insurance Company Ltd., IRDA Regn. No.115, ICICI Lombard House, 414, Veer Sawarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai through its Manager.
2. ICICI Lombard Insurance Company Ltd., regional office, TFI-5, Third Floor, 88, Kunal Tower, Mall Road, Ludhiana, Punjab-141001 through its Manager.                                                                                                                                                                 …..Opposite parties 

Complaint Under Section 17 of the Consumer Protection Act, 2019.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant            :         Sh. Varun Gupta, Advocate.

For OPs                         :         Sh. G.S. Kalyan, Advocate.

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Tersely put, the facts of the case are that on 05.03.2012, the complainant purchased a cashless medical insurance policy from opposite parties bearing No.4413i/XOL/70009778/02/000 with sum assured of Rs.10 Lakhs and name of proposer of the policy was Sh. Gurjeet Singh, husband of the complainant. The complainant submitted that after two years of the insurance policy, she suddenly had chest pain and went to OPD for checkup which was initially done in Dayanand Medical College and Hospital, Ludhiana and she was admitted in the said hospital on 22.04.2014. Thereafter, seeing the gravity of the problem, she got admitted in Indraprastha Apollo Hospital, Delhi and on 28.04.2014, undergone Coronary Artery Byepass Graft Surgery and also had to get AICD implantation surgery (pace maker) on 02.05.2014 and discharged on 30.05.2014. The opposite party was informed about the developments but they did not fulfill their part of obligation and also wanted proof regarding implantation of Pace Maker. However, Reliance General Insurance had paid a sum of Rs.2,52,661/- against the same disease as insurance was with Reliance General Insurance and present policy was a Top Up policy with the opposite party. The policy with Reliance General Insurance was for sum assured of Rs.4 Lakh and the Top Up policy with opposite party was to the tune of Rs.10 Lakh. A legal notice dated 15.07.2018 was sent to the opposite party and sent emails, upon which the opposite party paid a sum of Rs.6,91,476/- on 30.10.2018 which was remitted directly to the account of the complainant. The complainant further submitted that she sent email dated 15.11.2018 through her counsel, contents of which are reproduced as under:-       

"With reference to our claim with your company, you have approved the claim for an amount of Rs.6,91,476/- on 30.10.2018 and the amount was credited in my client's account on 01.11.2018. At the time of approval, firstly, you have deducted Rs.25,922/- as discount given by the hospital, however, it is submitted that the said discount was already availed by Reliance General Insurance at the time of settling the claim, then how can you deduct the same amount again. Secondly, you have deducted Rs.1,26,471/- as deductible, however, the details of the same are not sent to us. Thirdly, the claim was raised in the month of May, 2014 and all the documents were submitted with your company by the month of June, 2014, but still the claim was not approved by your company till 30.10.2018 despite regular requests and representations made by my client. Rather you were delaying the claim on one pretext or the other asking the same documents again and again from my client which can be perused from your mail in the month of March, 2016 in which you have sent the scanned copy of original documents sent by you to my client. Forthly, you have not paid any compensation amount for mental and physical harassment and financial loss to my client which was claimed in the legal notice by my client for delay of claim of 4 years. It is, therefore, advised to you to firstly pay my client Rs.25922/- which you have wrongly deducted, secondly, send the details of deductibles and thirdly pay the penal interest as per the IRDA Regulations for delayed payment of claim for more than 4 years, fourthly, to pay compensation to an amount of Rs.5 lakhs for mental and physical harassment and financial loss to my client, within a period of 15 days, failing which I have instructions from my client to approach the competent court of law and the expenses for legal proceedings shall be borne by your company."

The complainant further submitted that whether the opposite party is bound to pay interest on amount of Rs.6,91,.476/- which was paid on 30.10.2018 whereas the claim was raised in the year 2014. Thus, there is delay of four years in settling the principal amount which itself tantamounts to deficiency in service and unfair trade practice. In the end, the complainant has sought interest @18% per annum on Rs.6,91,476/- for four years i.e. Rs.4,98,057/- along with litigation expenses of Rs.22,000/- and compensation of Rs.50,000/-.

2.                Upon notice, the opposite parties appeared and filed joint written statement and assailed the complaint on the ground of maintainability of complaint; lack of cause of action; lack of territorial jurisdiction and there is no deficiency on the part of the opposite parties. The opposite parties alleged that on receipt of claim intimation, entertained, tried and processed and settled the claim of the complainant vide settlement letter, which is reproduced as under:-

 "We write you with the reference to above health claim Number, we wish to inform you that we have received the papers & documents submitted by you. We have perused the documents and your claim is being settled for an amount of Rs.6,91,476/-. We enclosed a Cheque/EFT vide ref. no.CMS944769699 dated 31-10-2018 towards the full and final settlement of the claim. The amount deducted under TDS is Rs.0. The company hereby stands discharged of liabilities arising out of this claim.

Reason for Deductions:

Rs.2,47,607/- deducted as paid by TPA.

Rs.25,922/- deducted as discount given by hospital

Rs.1,26,471/- deducted as deductible SI applied.

The opposite parties further alleged that they have paid full and final payment to the complainant in view of the policy terms and conditions.

                   On merits, the opposite reiterated the crux mentioned in the preliminary objections. The opposite parties denied any deficiency in service on its part and in the end, prayed for dismissal of the complaint.

3.                In support of her claim, the complainant tendered her affidavit Ex. CA in which she reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents Ex. C1 is the copy of insurance documents, Ex. C2 is the copy of legal notice dated 15.07.2018, Ex. C3 are the copies of emails and closed the evidence.

4.                On the other hand, the counsel for the opposite parties tendered affidavit Ex. RA of Sh.  Aditya Pandey, Manager Legal of the opposite parties along with documents Ex. R1 is the copy of settlement letter, Ex. R2 is the copy of Annexure-I, Ex. R3 is the copy of risk assumption letter w.e.f. 05.03.2012 to 04.03.2014, Ex. R4 is the copy of insurance policy, Ex. R5 is the copy of free health check-up coupon, Ex. R6 are the copies of identity cards, Ex. R7 is the copy of risk assumption letter w.e.f. 07.03.2014 to 06.03.2016, Ex. R8 is the copy of insurance policy w.e.f. 07.03.2014 to 06.03.2016, Ex. R9 are the copies of identity cards, Ex. R10 is the copy of proposal form, Ex. R11 is the copy of ICLM investigation report, Ex. R12 is the copy of settlement details, Ex. R13 is the copy of questionnaire, Ex. R14 and Ex. R16 are the copies of receipts regarding receiving the file/documents, Ex. R15 is the copy of KYC form, again Ex. R16 is the reply to opposite parties,  Ex. R17 is the copy of KYC form, Ex. R18 is the copy of passport of Gurjit Singh, Ex. R19 is the copy of settlement details, Ex. R20 is the  copy of receipt/bill of Indraprastha Apollo Hospital, Ex. R21 is the copy of postal receipt and closed the evidence.

5.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written statement, affidavit and documents produced on record by both the parties.     

6.                Undisputably, initially the complainant was admitted on 22.04.2014 at Dayanand Medical College and Hospital, Ludhiana and thereafter, she was shifted to Indraprastha Apollo Hospital, Delhi where on 28.04.2014 she underwent Coronary Artery Byepass Graft Surgery. Further she also got AICD implant surgery (Pace Maker) and t\remained admitted from 02.05.2014 to 30.05.2014. The complainant had also availed policy from Reliance General Insurance Company having a coverage of Rs.4 Lac and the present policy was top-up policy issued by the opposite parties having an additional coverage of Rs.10 Lac. An amount of Rs.2,52,661/- was reimbursed by Reliance General Insurance Company and the remaining amount of Rs.6,91,476/- was paid by the opposite parties on 30.10.2018. During this period, there were series of exchange of emails between the complainant and the opposite parties with regard to submission of documents for the settlement of the claim. Even a legal notice dated 15.07.2018was also served upon the opposite parties. On 15.11.2018, after the receipt of payment of Rs.6,91,476/-, the complainant sent an email where she questioned the deduction of Rs.25,922/- and Rs.1,26,471/-. Her main grievance was that there is a delay of four years in settling the claim. The opposite parties explained the deductions as under:-

Rs.25,922/- deducted as discount given by hospital

Rs.1,26,471/- deducted as deductible SI applied.

The deductions made by the opposite parties are justifiable and calls for no interference of this Commission.

7.                Perusal of the documents on record shows that the complainant submitted all the required documents in March 2016. As per guidelines issued by IRDA  from time to time, in case of medi-claim reimbursement, they are required to complete the process of settlement within maximum 45 days from the receipt of last necessary documents. In the present case, the opposite parties have not brought on record any deficiency letter addressed to the complainant asking him to submit documents. However, during scrutiny of documents, it emerges that the opposite parties were required to settle the claim till the end of May 2016 but they settled and paid the amount on 30.10.2018. So the complainant is entitled to interest @ 6% per annum on the amount of Rs.6,91,476/- from 01.06.2016 till 30.10.2018. The complainant is further held entitled to composite cost of Rs.15,000/-.

8.                As a result of above discussion, the complaint is partly allowed with direction to the opposite parties to pay interest @ 6% per annum on the amount of Rs.6,91,476/- from 01.06.2016 till 30.10.2018 within 30 days from the date of receipt of copy of order failing which the opposite parties shall be liable to pay interest @8% per annum on the above said interest amount from the date of order till its actual payment. The opposite parties shall further pay composite cost of Rs.15,000/- (Rupees Fifteen Thousand only) to the complainant within 30 days from the date of receipt of copy of order. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

9.                Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

(Monika Bhagat)          (Jaswinder Singh)                      (Sanjeev Batra)                          Member                            Member                                       President         

 

Announced in Open Commission.

Dated:14.03.2023.

Gobind Ram.

Gunwant Kaur Vs ICICI Lombard Insurance Co. Ltd.            CC/19/448

Present:       Sh. Varun Gupta, Advocate for complainant.

                   Sh. G.S. Kalyan, Advocate for OPs.

 

                   Arguments heard. Vide separate detailed order of today, the complaint is partly allowed with direction to the opposite parties to pay interest @ 6% per annum on the amount of Rs.6,91,476/- from 01.06.2016 till 30.10.2018 within 30 days from the date of receipt of copy of order failing which the opposite parties shall be liable to pay interest @8% per annum on the above said interest amount from the date of order till its actual payment. The opposite parties shall further pay composite cost of Rs.15,000/- (Rupees Fifteen Thousand only) to the complainant within 30 days from the date of receipt of copy of order. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

 

(Monika Bhagat)          (Jaswinder Singh)                      (Sanjeev Batra)                       Member                     Member                                       President         

 

Announced in Open Commission.

Dated:14.03.2023.

Gobind Ram.