Judicial Analysis Court Copy Headnote Facts Arguments Court observation

NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION, NEW DELHI
Ajit Bharihoke, Presiding Member, Mrs. Rekha Gupta, Member
Jyoti Rungta —Petitioner
versus
ICICI Prudential Life Insurance Company Ltd. —Respondent
Revision Petition No.628 of 2014
(Against the Order dated 08/11/2013 in Appeal No. 565/2011 of the State Commission Delhi)
Decided on 6.10.2015

Advocates:
Counsel for the Parties:
For the Petitioner:Ms Rachitta Priyanka, Advocate
For the Respondent:Mr Avanish Kumar, Advocate

IMPORTANT POINT
Accepted policy knowing benefits allowed under hospital care policy as, also benefit she entitled under Plan ‘A’ and paid amount of premium accordingly.

Headnote:Consumer Protection Act, 1986 — Section 2 (d) —Hospital Medi Care Policy — Petitioner suffered from seizure and admitted in hospital — Petitioner opted for Hospital Care Policy under Plan ‘A’ — Entitlements under Plan ‘A’ clearly given in policy and reproduced in order of State Commission as given — Accepted policy knowing benefits allowed under hospital care policy as also benefit — HELD — She entitled under Plan ‘A’ and paid amount of premium accordingly. (Para 14)
Result: Revision dismissed.

ORDER

Mrs. Rekha Gupta, Advocate—Revision petition no. 628 of 2014 has been filed against the judgment dated 08.11.2013 of the Delhi State Consumer Disputes Redressal Commission, Delhi (‘the State Commission’) in First Appeal no. 565 of 2011.

2. The facts of the case as per the petitioner/ complainant are that the petitioner purchased Plan-A Hospital Medi Care Policy of ICICI Prudential Life Insurance Company (OP), bearing No.08275215 for a term of 20 years, commencing from 17.03.2008. As the petitioner was not feeling well on 19.09.2008, she was rushed to Max Devki Devi Heart & Vascular Institute, Saket, New Delhi and the petitioner was admitted there at 7.20 PM with a Seizure Disorder.

3. On 20.09.2008, the doctor prepared a pre-authorisation request form and faxed it to the Mumbai office of the respondent. On request of the respondent, additional information was faxed to it twice in the evening of 22.09.2008. The petitioner was discharged from the hospital at 6.00 PM on 22.09.2008. Hospital charged a sum of Rs.71,218/-.

4. On 23.09.2008, the hospital received a fax as also a letter from the respondent to deny the pre-authorisation request since she had already been discharged from the hospital on 22.09.2008. On 03.10.2008, the petitioner submitted the complete details of the medical bills of treatment taken in the hospital. However, the respondent vide letter, dated 10.10.2008 passed the claim only for Rs.3000/- and sent a cheque for that amount. The petitioner did not accept the said cheque.

5. The petitioner had referred to Clause 5, i.e., Exclusion Clause and had pleaded that as per clause, the respondent was not right in reimbursing only the Daily Hospital cash benefit of Rs.1000/- for each day spent in the hospital instead of all the expenses incurred for treatment in the hospital. It amounts to deficiency in service, harassment, pain and mental agony. The petitioner claimed hospital expenses of Rs.71,219/- with 18% interest; compensation for mental torture, agony and harassment to the tune of Rs.1,00,000/- and legal expenses of Rs.25,000/-.

6. The insurance company filed their reply to the complaint to oppose it. It denied that it had caused any deficiency in service and that any cause of action arises against it. In the complaint, the allegation of fraud, dishonesty, inducement and cheating had been levelled and as such the forum has no jurisdiction to decide the matter. The medi-claim policy was issued to the petitioner subject to the terms and conditions as mentioned in the policy documents. The payment of Rs.3000/- was made to the petitioner towards settlement of her claim. The amount was offered as per terms and condition of the policy. The preauthorization request was received but it was denied as the petitioner had already been discharged from the hospital. On receipt of the claim and documents, the claim of the petitioner was processed. It was revealed that the petitioner was diagnosed of generalized seizure (Tonic–clonic) idiopathic. According to the terms of the policy, benefit of DHCB for 3 days @ Rs.1000/- each amounting to Rs.3000/- was sent to the petitioner by way of cheque, bearing No. 002567 dated 10.10.2007, drawn on ICICI Bank Limited.

7. The District Consumer Disputes Redressal Forum (Central), Delhi vide its order dated 01.07.2011 allowed the complaint and gave the following order.

“The Sub-clause-3 speaks that benefit payable is limited to an amount equivalent to 90 times of DHCB in any one policy year. If the amount calculated on the basis of DHCB even then the claim would have been Rs.90,000/- as company offered Rs.1000/- per day. The petitioner restricted her claim only to the amount paid to the hospital authority i.e., Rs.71,218/- only. In these circumstances, the decline of the petitioner to accept Rs.3,000/- only as offered by the OP company to satisfy claim, is wholly justified. The act of the respondent in allowing the claim only to the tune of Rs.3,000/-, is nothing but negligence to examine c

Click Here to Read the rest of this document

IMPORTANT POINTAccepted policy knowing benefits allowed under hospital care policy as, also benefit she entitled under Plan ‘A’ and paid amount of premium accordingly.

Cases Referred (1)

IMPORTANT POINT
Accepted policy knowing benefits allowed under hospital care policy as, also benefit she entitled under Plan ‘A’ and paid amount of premium accordingly.