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National Consumer Commission Directed ICICI Prudential To Pay Rs. 5 Lakh To A Consumer For Denying Claim

National Consumer Disputes Redressal Commission (NCDRC) the apex consumer forum has directed ICICI Prudential Life Insurance Co Ltd to pay over Rs 5 lakh to a Maharashtra resident for providing deficient services by rejecting his claim for reimbursement of medical expenses on the ground that he had not disclosed a pre-existing disease.

In 2008 Dattatrey Bhivsan Gujar had taken an insurance policy named ICICI-Pru Hospital Care. He had no illness from 2008 to August 2012. On September 18, 2012, he was admitted in the hospital due to abdominal pain and was diagnosed with renal (kidney) ailments.

Gujar, who underwent dialysis, and subsequently a kidney transplant, approached the insurance company for reimbursement of hospitalisation expenses, which was repudiated on the ground of "non-disclosure of pre-existing medical condition".

The claim was rejected based on a certificate issued by Dr Rajendra G Chandorkar which stated that Gujar was a known patient of diabetes and hypertension for the last 10 years. However, when Gujar approached the Commission, it noted that Chandorkar was a pediatrician, and not a physician, or an endocrinologist, to certify a person as diabetic and hypertensive. Gujar had moved the district forum which had passed an order in his favour on October 31, 2015.

Read the detailed report of the case

Apex consumer forum has directed ICICI Prudential Life Insurance Company Limited to pay over Rs 5 lakh to a Maharashtra resident for providing deficient services by repudiating his claim for reimbursement of medical expenses on the ground that he had not disclosed a pre-existing disease.

Commission was hearing a revision petition of the insurance company to set aside the order of the State Commission which had upheld the order of the District Forum. While passing the order, the Commission said that it find the Order dated 8.9.2017 of the State Commission to be well-appraised and well-reasoned. The State Commission concurred with the District Forum in its findings of deficiency in service. It further said it that they do not find any jurisdictional error, or a legal principle ignorance, or miscarriage of justice. While directing the company to pay Dattatrey Bhivsan Gujar 75 per cent of his claimed amount, that is Rs 4,15,030, along with Rs 1 lakh for mental, financial and physical hardship, it said that it is an unfair and deceptive act and amounts to unfair trade practice. The National Commission directed that the amount be paid within four weeks from June 14.

In the instant case, Gujar had in 2008 taken an insurance policy named ICICI-Pru Hospital Care. He had no illness from 2008 to August 2012. On September 18, 2012, he was admitted in Bombay Hospital due to abdominal pain and was diagnosed with renal (kidney) ailments. Gujar, who underwent dialysis, and subsequently a kidney transplant, approached the insurance company for reimbursement of hospitalisation expenses, which was repudiated on the ground of "non-disclosure of pre-existing medical condition". The insurance company repudiated his claim by relying principally on a certificate issued by one Dr Rajendra G Chandorkar which stated that Gujar was a known patient of diabetes and hypertension for the last 10 years. The commission noted that Dr Chandorkar was a pediatrician, and not a physician, or an endocrinologist, to certify a person as diabetic and hypertensive.

Bench of S M Kantikar and Dinesh Singh of National Commission said that nothing is on record that the said Dr Chandorkar has either examined or treated the complainant for diabetes or hypertension in the past 10 years. Ex facie, a suspicious medical certificate was issued. It is not viewed favourably.  The Commission further said it would not like to turn a blind eye on the issuance of the ex facie suspicious medical certificate by the said Chandorkar to unduly help the insurance company in taking its principal ground for repudiation of the insurance claim. Issuance of such medical certificate is unethical and amounts to professional misconduct, which needs suitable action from the concerned professional regulatory body.  It directed Registrar of the Commission to refer the matter to Maharashtra Medical Council, Mumbai, for appropriate action against Dr Chandorkar, according to the rules.

Written by:
Ankur Saha
Head- Legal VOICE

Divya Patwal

VOICE

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