Order Name: Mr. Rakesh Kumar vs ICICI Lombard General Insurance Company Limited
The District Consumer Disputes Redressal Commission in Karnal, Haryana, made a significant ruling recently where they found ICICI Lombard General Insurance Company Limited guilty of service deficiency. The bench, consisting of Jaswant Singh (President), Vineet Kaushik (Member), and Dr Suman Singh (Member), made the ruling. The insurance company was ordered to pay the remaining claim of Rs. 1,67,969 to the complainant along with a compensation of Rs. 25,000 and Rs. 11,000 towards litigation costs.
Here’s a simplified breakdown of the case –
Rakesh Kumar, the complainant, had a Group Health Insurance Policy (Medi-Claim) from ICICI Lombard General Insurance Company. This policy covered himself, his wife, and daughter, and was valid from 26.04.2019 to 25.04.2021 with a sum assured of Rs. 5 lakh.
Come March 2021, Mr. Kumar fell ill and incurred medical expenses of Rs. 1,92,969 at Virk Hospital, Karnal. This included the cost of treatment, medicines, and hospitalization. When he submitted his claim to the insurance company, he was only reimbursed Rs. 25,000. The remaining amount of Rs. 1,67,969 was left unpaid.
Despite several attempts to seek clarification from the insurance company, Mr. Kumar was left in the dark. No satisfactory explanation was provided for the unpaid amount. This led him to file a complaint against the insurance company at the District Consumer Disputes Redressal Commission in Karnal.
The insurance company defended itself by stating that the deductions of Rs.1,67,969 were due to admission or registration charges, non-submission of an investigation report, and exhaustion of sub-limits. They argued that the complaint involved intricate questions of fact necessitating extensive evidence and trial. They suggested that this case should be under the jurisdiction of a Civil Court and not the Consumer Protection Commission.
The Commission, however, held that the onus was on the insurance company to prove their claims. They found that the insurance company failed to provide proof that they had explained and supplied the policy schedule and Key Information sheet to the complainant. They also faulted the insurance company for not clarifying the criteria used to deduct a large amount from the medical bills.
The Commission observed a prevalent tendency among insurance companies to hide behind policy clauses to avoid liabilities. They declared such practices as a deficiency in service. As a result, they held the insurance company liable for the service deficiency.
In conclusion, the District Commission ordered the insurance company to pay the remaining claim of Rs. 1,67,969 with a 9% per annum interest from the date of filing the complaint. They were also instructed to pay Rs. 25,000 for causing mental agony and harassment to the complainant and an additional Rs. 11,000 for litigation expenses.
The takeaway? This case underlines the importance of insurance companies providing clear, detailed explanations to policyholders about the terms of their policy. It also emphasizes the need for them to justify any deductions made, especially when such deductions form a significant portion of the claim amount. This ruling serves as a reminder that companies cannot evade their responsibilities and liabilities by hiding behind jargon-filled policy clauses.
