Punjab

Ludhiana

CC/19/578

Abha Khanna - Complainant(s)

Versus

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

Sandeep Kapoor Adv.

21 Jul 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No: 578 dated 16.12.2019.                                                        Date of decision: 21.07.2022.

 

Abha Khanna, aged 39 years, wife of Shri Gaurav Khanna, resident of 58-R, Model Town, Ludhiana                                                                                                                                                                       ..…Complainant 

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1. ICICI Lombard General Insurance Company Ltd., having its registerd office at ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai-400025, through its Director./Managing Director/Manager.
2. ICICI Lombard General Insurance Company Ltd., having its Branch Office at TF 1-5, 3^rd Floor, 88, Kunal Tower, The Mall Road, Ludhiana, through its Branch Manager.                                                                                                                                                …..Opposite parties 

Complaint under Section 12 & 14 of the Consumer Protection    Act, 1986.

QUORUM:

SH. K.K. KAREER, PRESIDENT

SH. JASWINDER SINGH, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Amarjyot Singh, Advocate.

For OPs                          :         Sh. Rajeev Abhi, Advocate.

 

ORDER

PER K.K. KAREER, PRESIDENT

1.                Briefly stated, the case of the complainant is that in the year, she purchased a cashless insurance policy from the OPs on 08.09.2011 which was renewed from time to time and lastly the complainant was holding policy No.4128i/HP/107083197/02/00 which was valid from 21.09.2017 to 20.09.2019. The policy covered the complainant, her husband and minor children. A premium of Rs.25,397/- was paid at the time of renewal of the said policy.

2.                It is further alleged that on 19.09.2019, the complainant was admitted in Fortis Hospital, Ludhiana due to chest pain. She applied for cashless treatment but the OPs denied the same vide letter dated 20.09.2019 on false and frivolous grounds and on the ground that the complainant was a known case of diabetes for last 8 years which was prior to the inception of the policy and this fact was not disclosed at the time of taking the policy. As a result, the complainant had to incur expenses of Rs.2,57,348/- + Rs.6,351/- from her own pocket on her treatment even though she had been holding the policy for the last 8 years. The complainant never suffered from disease of diabetes prior to the inception of the policy. The complainant was discharged from the hospital on 22.09.2019. Thereafter, the husband of the complainant sent a cheque bearing No.005862 dated 17.09.2019 amounting to Rs.25,398/- drawn on ICICI Bank, Model Town, Ludhiana for renewal of the policy but the OPs refused to accept the said cheque.  As a matter of fact, the complainant was suffering from the disease of diabetes only for last 8 months when she was admitted in Dayanand Medical College and Hospital on 06.08.2018. The complainant even furnished a medical certificate from the family physician in this regard and DMC Hospital also sent a letter to the OPs for review of the cashless claim but despite that the OPs did not honour the claim. The OPs did not consider the certificate dated 06.08.2018 issued by the family physician namely Dr. Ashwani Sharma. The OPs also ignored the letter sent by DMC, Ludhiana whereby also it was specifically mentioned that the complainant was suffering from diabetes for the last 8 months when she was admitted in DMC Hospital on 06.08.2018 and the period of diabetes was mistakenly mentioned as 8 years instead of 8 months. It is further alleged that on 06.04.2019, the complainant visited Cardiology Department of Fortis Hospital, Ludhiana as she was felling chest pain and breathlessness. The doctor advised her admission in the Fortis Hospital for the treatment as she could not be treated in OPD. Therefore, the complainant was admitted in Fortis Hospital, Ludhiana on 09.04.2019 and also applied for cashless treatment but the same was rejected vide email dated 08.04.2019 on false and frivolous grounds and the complainant had to incur all the expenses to the tune of Rs.3,49,982/- + Rs.2869/- + Rs.6678/- from her own pocket. In this regard also, the complainant has filed a separate complaint before the Consumer Forum.

3.                It is further alleged in the complaint that the complainant never concealed any facts from the OPs and all the material facts were duly disclosed at the time of issuance of the policy. Moreover, the OPs renewed the policy only after obtaining medical opinion from their own authorized medical practitioner/doctor. The complainant is now under regular follow up treatment of Fortis Hospital, Ludhiana and has spent a sum of Rs.40,000/- on her post  treatment from her own pocket. The repudiation of the claim clearly amounts to deficiency of service on the part of the OPs. In the end, it has been requested that the OPs be directed to reimburse the claim of Rs.2,93,699/-  (Rs.2,57,348/- + Rs.6,351/- + Rs.30,000/-) along with interest @18% per annum and be also made to pay compensation of Rs.2,00,000/- and litigation expenses of Rs.11,000/-.

4.                The complaint has been resisted by the OPs. In the joint written statement filed on behalf of the OPs, it has been, inter alia, pleaded that the complaint is not maintainable. According to the OPs, on receipt of the claim, the same was registered and processed. As per part III of schedule 1 of the policy, no benefit is payable in the event of any untrue or incorrect statement, misrepresentation, mis-description or on non-disclosure of any material particular in the proposal form, personal statement, declaration and connected documents. The OPs have further pleaded that M/s. Hero DMC Heart Institute had sent a pre-authorization for cashless treatment of the complainant on 06.08.2018. The same was scrutinized and after due application of mind, the cashless claim was declined vide letter dated 06.08.2018 on the ground that as per the documents furnished, the patient was a known case of diabetes since 8 years which comes prior to the policy inception and this fact was not disclosed at the time of taking the policy and, therefore, as per the terms and conditions of the policy no benefit was payable. The OPs have further pleaded that after denial of the cashless claim dated 06.08.2018, the complainant procured a false medical certificate from Dr. Ashwani Sharma stating that Abha Khanna was suffering from diabetes only from 8 months. The said certificate of Dr. Ashwani Sharma was further submitted with M/s. Hero DMC Heart Institute with a request to change the record but the hospital never changed the record. However, the hospital forwarded the letter of the complainant dated 08.08.2018  along with certificate of Dr. Ashwani Kumar. Thus, the cashless authorization has been rightly declined and there is no deficiency of service. The complainant has, however, till date not lodged any regular claim.

5.                It is further pleaded by the OPs that M/s. Medanta, the Medicity-Global Health Pvt. Ltd., Gurugram sent another cashless authorization for the treatment of Abha Khanna on 11.08.2018. The same was also scrutinized and declined vide email dated 11.08.2018 on the same grounds that as per documents furnished, the patient is a known case of diabetes since 8 years prior to the policy inception and this fact was not disclosed at the time of taking the policy. It has been further pleaded in the written statement that the complainant has also sent a cashless authorization through Fortis Hospital, Ludhiana on 08.04.2019 and the said pre-authorization request was also declined vide letter dated 08.04.2019 on the same grounds that the complainant was a known case of diabetes for the last 8 years which falls prior to the inception of the policy.

6.                As regards the cashless claim received through Fortis Hospital on 20.09.2019 for the treatment of complainant Abha Khanna, it has been pleaded by the OPs that the same was also considered and scrutinized and was declined vide email/letter dated 20.09.2019 under the same grounds that the complainant was a known case of diabetes since 8 years which she was not disclosed at the time of taking the policy and as such, as per part III of schedule I no benefit was payable in case an untrue or incorrect statement is given. It has further been added that the complainant till date has not lodged regular claim. It was clearly written in the email dated 20.09.2019 that the denial of authorization for cashless treatment does not imply denial of the treatment and does not in any way prevent the insured from seeking necessary medical attention. Moreover, the claim of Fortis Hospital was not payable as the same pertains to treatment of the complainant after the expiry/cancellation of policy and no policy was in existence on 22.09.2019. The OPs had also canceled the policy as per terms and conditions of the policy by serving a 15 day notice. Therefore, the present complaint is not maintainable. The other allegations made in the complaint have been denied as wrong and a prayer for dismissal of the complaint has also been made.

7.                In evidence, the complainant tendered her affidavit Ex. CA along with documents Ex- C1 to Ex- C30 and closed the evidence.

8.                On the other hand, learned counsel for the OPs tendered affidavit Ex. RA of Sh. Nishant Gera, Manager Legal of the OPs along with documents Ex. R1 to Ex. R23 and closed the evidence.

9.                We have heard the arguments advanced by the counsel for the parties and have also gone through records.

10.              By way of this complaint, the complainant has challenged the denial of pre-authorization claim in respect of her hospitalization with Forts Hospital, Ludhiana on 19.09.2019 to 22.09.2019 and has also claimed that since the cashless authorization request was declined, she had to pay Rs.2,57,348/- + Rs.6,351/- from her own pocket. In this regard, it has been contended by the counsel for the OPs that the pre-authorization request was rightly declined on the ground that the treatment papers including investigation reports of Hero DMC Heart Institute, Ludhiana and the said hospital’s letter dated 06.08.2018 clearly indicates that the patient had a history of diabetes for the last 8 years and on the basis of such information, the cashless claim was declined. As the patient was found to be suffering from diabetes for the last 8 years and since prior to the inception of the policy and this fact was not disclosed at the time of taking the policy.

11.              We have thoughtfully considered the above contentions of the counsel for the OPs.

12.              It is not disputed that the policy was taken for the first time in the year 2018. The pre-authorization request has been declined on the basis of the letter dated 06.08.2018 which is Ex. R11 on the file wherein it has been mentioned that the complainant had history of diabetes mellitus for the 8 years. In this regard, the complainant has relied upon a certificate Ex. C14 issued by Dr. Ashwani Sharma, a family physician of the complainant wherein it is mentioned that the complainant was found to be suffering from diabetes 8 months prior to 06.08.2018, date of the certificate Ex. C14. The complainant has further relied upon the certificate Ex. C19 issued by Hero DMC Heart Institute wherein it is mentioned that at the time of admission of the patient, history was recorded as 8 years but as per their statement and certificate issued by the family physician, the history of diabetes of the complainant Abha Khanna is 8 months. The OPs have not considered the certificates Ex. C14 and Ex. C19. Moreover, apart from a mere observation in Ex. R11, no other tangible evidence has come on record which could conclusively show that the complainant was suffering from diabetes mellitus prior to inception of the policy in the year 2011. Therefore, merely on the basis of observation of Ex. R11 which was later on altered by the hospital authorities in the certificate Ex. C19 based on the certificate Ex. C14 of the family physician of the complainant, the pre-authorization request should not have been repudiated.

13.              The complainant on her part has not chosen to file a regular claim for reimbursement of the expenses in respect of her hospitalization from 19.09.2019 to 22.09.2019. The rejection of pre-authorization request is not final as has been candidly admitted by the counsel for the OPs at the time of arguments. In the given facts and circumstances of the present case, in our considered view, it would be just and proper if the complainant is directed to submit the claim in respect of her hospitalization from 19.09.2019 to 22.09.2019 with Fortis Hospital, Ludhiana within a period of 30 days from the date of receipt of copy of this order following which the OPs shall consider and reimburse the same strictly in accordance with the terms and conditions of the policy within a further period of 30 days. The cancellation of the policy is also not justified on the part of the OPs.

14.              As a result of above discussion, the complaint is disposed of with direction to the complainant to submit the claim in respect of her hospitalization from 19.09.2019 to 22.09.2019 with Fortis Hospital, Ludhiana within a period of 30 days from the date of receipt of copy of this order following which the OPs shall consider and reimburse the same strictly in accordance with the terms and conditions of the policy within a further period of 30 days. Keeping in view the peculiar circumstances, there shall be no order as to costs. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

15.              Due to rush of work and spread of COVID-19, the case could not be decided within statutory period.

 

                             (Jaswinder Singh)                            (K.K. Kareer)

                    Member                                           President

 

Announced in Open Commission.

Dated:21.07.2022.

Gobind Ram.

Abha Khanna Vs ICICI Lombard GIC                            CC/19/578 

Present:       Sh. Amarjyot Singh, Advocate for complainant.

                   Sh. Rajeev Abhi, Advocate for OPs.

 

                   Arguments heard. Vide separate detailed order of today, the complaint is disposed of with direction to the complainant to submit the claim in respect of her hospitalization from 19.09.2019 to 22.09.2019 with Fortis Hospital, Ludhiana within a period of 30 days from the date of receipt of copy of this order following which the OPs shall consider and reimburse the same strictly in accordance with the terms and conditions of the policy within a further period of 30 days. Keeping in view the peculiar circumstances, there shall be no order as to costs. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

 

                             (Jaswinder Singh)                            (K.K. Kareer)

                    Member                                           President

 

Announced in Open Commission.

Dated:21.07.2022.

Gobind Ram.