DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION ERNAKULAM

       Dated this the 27th day of January, 2023

                           Filed on:  07/02/2022

PRESENT

Shri.D.B.Binu                                                                          President

Shri.V.Ramachandran                                                              Member Smt.Sreevidhia.T.N                                                             Member

      C.C NO.  79/2022

COMPLAINANT

Dr. Paul Korah, S/o Late Korah, 23/660, Mattamana House, Puzhayoram Residency, East Kadathy, Market Post, Muvattupuzha, Ernakulam Distinct-686673.

VS

OPPOSITE PARTY

ICICI Lombard General Insurance Company Limited, Kannankeri Estate, 3^rd Floor, Shanmugham Road, Marine Drive, Kochi - 682031 represented by its Branch Manager

F I N A L   O R D E R

D.B.Binu, President.

1)      A brief statement of facts of this complaint is as stated below:

The complaint was filed under section 35 of the Consumer Protection Act, 2019. The brief facts, as averred in the complaint, are that the complainant is a Doctor and presently working as Associate Professor at Government Medical College, Palakkad. The opposite party is the Branch Office of the Insurance Company wherefrom the complainant took two "Accidental Hospitalisation Expenses Reimbursement" Insurance Policies for Rupees Fifty Thousand each. In case of death or Permanent Total Disablement resulting from an accident, the complainant is entitled to get Ten Lakhs each from the said policies. The policies are numbered 4111/BAH/184283630/00 and 4111/BAH/184718024/00. The policies have valid coverage till October 2022. While so, on 15/04/2021, the complainant was working in the Medical College hospital taking care of out patients who suddenly fell down from a chair and sustained injury. After diagnosis; it was advised to get admitted on 24/04/2021 for surgery. Accordingly, the complainant got admitted to Thankam (PMRC) Hospital, Palakkad, and underwent surgery on 26/04/2021. The complainant remained there as an inpatient till 30/04/2021. The details of the hospitalization were intimated to the opposite party in May 2021. Further details requested by the opposite party were also served, thereafter to the Opposite Party. Following this, the claims were numbered by the Opposite Party as BAF043908717 and BAF043909270 respectively.  The complainant received two e-mails from the Opposite Party on 01/07/2021 with copies of the attached rejection letters for the above two claims. Both the said rejection letters are seen dated 28/06/2021 and the relevant portion of the same is read as hereunder:

“On scrutiny of the documents, we regret to inform you that the claim stands rejected for the following reason(s) as per the policy terms & conditions.

In case of any concern(s)/clarifications(s), feel free to write to us at the below-mentioned address or email us at ihealthcare@icicilombard.com within 8 weeks from the date of this letter, failing which the claim would be treated as closed in all aspects with no further obligation from our end.”

The complainant sent detailed objections to the rejection letters in the e-mail address served with the rejection letter, on 15/07/2021. The Complainant stated that Implant failure and hypertension have no connection and that was a wrong reason for the rejection of a valid claim. It is also stated that the Insurance Regulatory Development Authority of India has put a clear restriction of 48 months for pre-existing diseases prior to the issuance of policy and in the case of the complainant, the surgery is undergone, because of an accident, was about 23 years before in 1997 and for the said reason the Opposite Party cannot reject the claims of the Complainant. Since there was no response to the said e-mail, the complainant again sends another e-mail with the address healthcare@iciclombard.com to the Opposite Party on 23/08/2021 referring to the earlier e-mail. The Opposite Party did not reconsider nor has replied to the e-mails sent. Instead, the Opposite Party sends the same rejection letter, served on the complainant earlier, dated 28/06/2021 through a Courier Service. The complainant received the same through Blue Dart Courier Service on 11/10/2021. It is relevant to note that, disallowing the claim amount without proper or valid reasons; and by stating false reasons amounts to a deficiency in service and unfair trade practice.

The Opposite Party has not reconsidered the claims even after repeated e-mails sent by the complainant in July and August 2021. It is relevant also for the reason that the complainant has stated that he is having in his possession x-rays from 1997 onwards evidencing no symptoms of non-union or implant failure. The delay in admission to the hospital was the result of abundant caution taken by the hospital authorities because the causality happened during Covid Pandemic Period.  The Exclusion clause in the policy is "Any injury existing before the Policy state date as stated in Part 1 of the Schedule to this policy, whether or not if the same has been treated, or for which medical advice, diagnosis, care or treatment has been sought before the commencement of this policy" stated in the rejection letter is subject to the condition of the maximum period of 48 months as declared by the Insurance Regulatory and Development Authority of India. The definition of the term Pre-existing Disease according to the Opposite Party itself means "any condition, ailment or injury or related condition(s) for which you had signs or symptoms, and/or were diagnosed, and/or received medical advice/treatment, within 48 months prior to the first policy issued by the insurer” The statement for rejection of the claim that the injury is pre-existing is false. No time in the last 48 months, has the complainant needed any medical help for the reasons stated in the rejection letter.  The statement that the complainant was having hypertension from 1997 onwards is false.  Hypertension has no connection with 'Non-Union Right Femur with Implant Failure'.

The complainant had approached the Commission seeking an order directing the Opposite party to provide Accidental Hospitalisation Expenses Reimbursement of Rupees One Lakh to the Complainant for the medical expenses incurred during hospitalization from 24/04/2021 to 30/04/2021, to provide all eligible reimbursements/allowances including Accidental Hospital Confinement Allowance' to the Complainant for hospitalization from 24/04/2021 to 30/04/2021, compensation of Rs.25,000/- for acts of the Opposite Party by wrongful rejection and for causing unnecessary delay for effecting valid claims of the Complainant and the costs of the proceedings of the complaint.

2) Notice

Notice was issued from the Commission to the opposite party. The opposite party received the notice but did not appear before the Commission and not filed a version. Consequently, the opposite party is set ex-parte.

3). Evidence

          The complainant had filed a Proof affidavit and 8 documents that were marked as Exhibits-A-1- to A-8.

Exhibit A-1: The true copy of the Policy Certificate in Policy No. 4111/BAH/184283630/00.

Exhibit A-2: The true copy of the Policy Certificate in Policy No. 4111/BAH/184718024/00.

Exhibit A-3: The printout of the rejection letter in Claim Reference No. BAF043908717.

Exhibit A-4: The printout of the rejection letter in Claim Reference No. BAF043909270

Exhibit A-5: The printout of the e-mail forwarded to the Opposite Party dated 15/07/2021.

Exhibit A-6: The printout of the e-mail sent to the Opposite party dated 23/08/2021.

Exhibit A-7: The printouts of pages 1, 6, and 7 of the Guidelines on standardization of Exclusions in Health Insurance Contracts with reference IRDAI/HLT/REG/CIR/117/09/2019 dated 27/09/2019 issued by Insurance Regulatory and Development Authority of India.

Exhibit A-8: The printout of pages 4, 5, 8, 12, and 13 in the Key Information Sheet attached to the Terms and Conditions of the policy of the Opposite Party.

4) The main points to be analysed in this case are as follows:

i)       Whether the complaint is maintainable or not?

ii)      Whether there is any deficiency in service or unfair trade practice from the side of the opposite party to the complainant?

iii)     If so, whether the complainant is entitled to get any relief from the side of the opposite party?

iv)     Costs of the proceedings if any?

5)      The issues mentioned above are considered together and are        answered as follows:

          In the present case in hand, the complaint was filed under Section 35 of the Consumer Protection Act, 2019. The complaint is regarding the wrongful rejection of Mediclaim.

According to Section 2(7) of the Consumer Protection Act, 2019, "CONSUMER" means any person who buys any goods or hires or avails of any services for a consideration which has been paid or promised or partly paid and partly promised, or under any system of deferred payment. The complainant produced Copies of the Policy Certificate in Policy No. 4111/BAH/184283630/00 and 4111/BAH/184718024/00 issued by the opposite party (Exhibit A-I and A-2). Therefore, we are only to hold that the complainant is a consumer as defined under the Consumer Protection Act, 2019 (Point No. i) goes against the opposite party.

The complainant has filed the Proof Affidavit and 8 documents which are marked as Exbt.A-1 to A-8. 

The counsel for the complainant submitted that the evidence, in this case, the complainant has 2 valid. "Accidental Hospitalisation Expenses Reimbursement" Insurance Policies- Exhibit A1 and A2 Vide Exhibit A1 and A2 he is eligible for Rs. 1,00,000/- (Rs. 50,000/- each) as reimbursement of hospital expenses due to accident. The complainant met with another accident and underwent surgery in 1997 (23 years before) therefore the injury is pre-existing and therefore denied - Exhibits A3 and A4 are the rejection letters. Clause extracted in Exhibit A3 and A4 as (iii)(d). 13/22 of Exhibit A8 under Exclusions and Limitations head as 6.1(iii)(d). The definition of "PRE-EXISTING DISEASE" in page 8/22 of Exhibit A8 reads as follows:

"Pre-existing Disease means any condition, ailment or injury or related condition(s) for which you had signs or symptoms, and/or were diagnosed, and/or received medical advice/treatment, within 48 months prior to the first policy issued by the insurer."

This would show there is a restriction of 48 months (4 years). Whereas the Complainant is denied for the reason he met with an accident and underwent surgery 23 years before in 1997. Thus, the reason stated cannot stand and the complainant is eligible for reimbursement. Apart from this, Exhibit A5 e-mail sent by the Complainant to the Opposite Party as a reply to Exhibit A3 and A4 rejection letters worded as under:

"To elaborate, I have been working continuously from 1997 and have been able to do all activities including doing surgeries, and have not had a period of absence from work for the above condition in all these years." HENCE the reason for the denial of reimbursement is arbitrary and not proper. The complainant is therefore entitled to reimbursement of Rs.1,00,000/- as "Accidental Hospitalisation Expenses Reimbursement" as he had to expend more than the said amount (Rs. 1,30,039/- as hospital inpatient bill).

“The complainant is also entitled to "Accident Hospital Confinement Allowance" as seen in Sl. No. 2 (v) on page 4/22 of Exhibit AB. (The restriction of 7 days is stated in Sl. No. 2(v) and 2(vi) is not applicable in the case since the same was the peak Covid-19 Pandemic period. The Opposite Party also has not stated the said restriction in the rejection letters)

Disallowing claims without proper or valid reasons and; stating false reasons for denial amounts to unfair trade practice. When the complainant is served with Exhibit A3 and A4 rejection letters on 01/07/2021 via e-mail, the complainant replied on 15/07/2021 (marked as Exhibit A5) stating that the accident occurred (in 1997) 23 years back and not within 48 months. To this e-mail, there was no response from the Opposite Party. Again, the complainant sends another e-mail on 23/08/2021 (marked as Exhibit A6) to which also the Opposite Party did not respond. Thereafter in October 2021, the Opposite Party send the same rejection letters to send to the complainant on 01/07/2021 via Courier Service. This will show the ill attitude of the opposite party toward its customers. This also amounts to a deficiency in service.

The complainants who had availed the services of the opposite party were made to suffer due to the deficiency of service on part of the opposite parties.  The opposite parties are liable to compensate the complainants for the deficiency of service on their part.

We have also noticed that Notice was issued from the Commission to the opposite party but did not file their version. Hence the opposite party set ex-parte. The complainant has filed the Proof Affidavit and 8 documents which are marked as Exbt.A-1 to A-8.  All in support of his case. But the opposite party did not make any attempt to appear in the case and participate in the above proceedings before this commission and did not make any attempt to set aside the ex-prate order passed against it.

The opposite parties’ conscious failure to file their written versions in spite of their having received the Commission’s notice to that effect amounts to an admission of the allegations leveled against them. The Hon’ble NC held a similar stance in its order cited 2017(4) CPR page 590 (NC).

It was further stated that this illegal, arbitrary and unjustified act of the Opposite Party amounted to deficiency in service, indulgence in unfair trade practice, and caused mental agony and physical harassment to the complainant. Hence this complaint was filed. Despite due service, none appeared on behalf of the Opposite Party, hence, they proceeded against ex parte vide order dated 07.06.2022.

The Opposite Party has inadequately performed the service as contracted with the complainant and hence there is a deficiency in service, negligence, and failure on the part of Opposite Party in failing to provide the Complainant desired service which in turn has caused mental agony and hardship, and financial loss, to the Complainant.

We find the issue Nos. (II), (III) and (IV) are found in favour of the complainant for the serious deficiency in service that happened on the side of the opposite party. Naturally, the complainant had suffered a lot of inconvenience, mental agony, hardships, financial loss, etc. due to the negligence on the part of the opposite party.

In view of the above facts and circumstances of the case, we are of the opinion that the opposite party is liable to compensate the complainant.

Hence the prayer is partly allowed as follows:

i.       The Opposite Party shall pay Rs.1,00,000/- (Rupees one lakh only) to the Complainant for the medical expenses incurred during hospitalization from 24/04/2021 to 30/04/2021.

ii.     The Opposite Party shall pay Rs.25,000/- (Rupees twenty five thousand only) as compensation for acts of the Opposite Party by wrongful rejection and for causing unnecessary delay of valid claims of the Complainant.

iii.  The Opposite Party shall also pay the complainant Rs.5,000/- (Rupees five thousand only) towards the cost of the proceedings.

The above-mentioned directions shall be complied with by the Opposite Party within 30 days from the date of the receipt of a copy of this order. Failing which the amount ordered vide above (i) shall attract interest @5.5% from the date of receipt of a copy of this order till the date of realization.

Dictated to the Confidential Assistant Smt. K.P. Liji transcribed and typed by her corrected by me and pronounced in the Open Commission dated this 27^th day of January, 2023.

Sd/-

                                                                        D.B.Binu, President

Sd/-

                                                                   V.Ramachandran, Member

                                                                             Sd/-

Sreevidhia.T.N, Member

Forwarded/by Order

                                                                   Assistant Registrar.

APPENDIX

COMPLAINANT’S EVIDENCE

Exhibit A-1: The true copy of the Policy Certificate in Policy No. 4111/BAH/184283630/00.

Exhibit A-2: The true copy of the Policy Certificate in Policy No. 4111/BAH/184718024/00.

Exhibit A-3: The printout of the rejection letter in Claim Reference No. BAF043908717.

Exhibit A-4: The printout of the rejection letter in Claim Reference No. BAF043909270

Exhibit A-5: The printout of the e-mail forwarded to the Opposite Party dated 15/07/2021.

Exhibit A-6: The printout of the e-mail sent to the Opposite party dated 23/08/2021.

Exhibit A-7: The printouts of pages 1, 6, and 7 of the Guidelines on standardization of Exclusions in Health Insurance Contracts with reference IRDAI/HLT/REG/CIR/117/09/2019 dated 27/09/2019 issued by Insurance Regulatory and Development Authority of India.

Exhibit A-8: The printout of pages 4, 5, 8, 12, and 13 in the Key Information Sheet attached to the Terms and Conditions of the policy of the Opposite Party

OPPOSITE PARTIES’ EVIDENCE

Nil

Despatch date:

By hand:     By post  

kp/

CC No. 79/2022

Order Date: 27/01/2023