State Commission Sets Aside Order Of DCDRC; Allows Appeal By ICICI Lombard

State Commission Sets Aside Order Of DCDRC; Allows Appeal By ICICI Lombard

The bench noted that the insurance company provided the complainant the opportunity to review the policy document, but he did not respond to the communication

The State Consumer Disputes Redressal Commission (SCDRC) Maharashtra has allowed an appeal filed by ICICI Lombard General Insurance Company on noting that the medical claim of the complainant was settled as per duly agreed policy terms.

The bench of Dr Satish A. Munde (Presiding Officer) and V.C. Premchandani (Member) held that when the complainant was provided the opportunity to review and dispute the policy terms, he did not respond to the communication, indicating a lack of effort on his part.

The complainant, a practicing advocate, residing in Mumbai, approached ICICI Lombard for a 'Health Protect Insurance Policy' covering hospitalization for himself, his wife, and two daughters.

The insurance company issued the policy from 02.08.2014 to 01.08.2016, with a total sum assured of Rs.3,60,000.

The complainant contended that on 16.02.2015 he was diagnosed with Bilateral Inguinal Hernia, which required immediate hospitalization and surgery and he duly informed the insurance company.

Despite submission of the Claim Form and mandatory documents the insurance company allowed the claim partly and issued a cheque for Rs.1,20,000.

The complainant argued that the policy covered hospitalization and the insurance company wrongfully rejected the claim.

Aggrieved by the situation, he approached the District Consumer Disputes Redressal Commission (DCRDC), Central Mumbai, Maharashtra, and filed a consumer complaint against the insurance company.

The insurance company argued that the claim was partly allowed in accordance with the policy's mandatory extensions, which capped the liability for hernia-related surgeries at Rs.60,000. It added that the complainant's Bilateral Inguinal Hernia fell under this limit, and any excess amount was rightly rejected as per the policy's terms and conditions.

The District Commission allowed the complaint and directed the insurance company to pay Rs.87,774 to the complainant along with interest and additional compensation.

However, dissatisfied with the order, the insurance company appealed before the SCDRC.

The State Commission noted that the insurance company had issued a letter to the complainant, providing him the opportunity to review the policy document and raise any discrepancies within a specified timeframe. However, he did not respond to this communication, which indicated a lack of effort on his part.

The State Commission held that an insurance policy constitutes a binding contract between the insurer and the insured. Therefore, an adjudicating authority does not possess the power to alter or rewrite the terms and conditions of the policy.

The terms presented to the complainant, including the extension clause specifying a cap of Rs.60,000 for hernia-related medical expenses, were acknowledged by the complainant upon acceptance of the policy.

Furthermore, the State Commission held that the District Commission failed to consider the specific terms and conditions outlined in the policy.

It held that the insurance company had appropriately adhered to the policy's terms and conditions by reimbursing the complainant up to the specified limit of Rs.1,20,000. Thus, while setting aside the order of the District Commission, it allowed the appeal.