The North Goa District Consumer Dispute Redressal Commission has directed ICICI Lombard General Insurance to pay a Porvorim resident compensation for hospital expenses incurred during two separate medical visits. The order mandates the insurance company to pay Rs 13,657 for the first visit on January 20, 2025, and Rs 13,209 for the second visit on February 8, 2025, along with an additional compensation of Rs 25,000 for deficiency of service. The total amount will carry an interest rate of 5% per annum from the date of filing the complaint until full payment.
Background of the Complaint
Ayesha Nasim, a resident of Porvorim, fell ill on January 20, 2025, experiencing severe stomach pain, vomiting, and diarrhoea that persisted for a week. Her condition led to complete dehydration and weakness, showing no signs of improvement despite initial home care. She was subsequently admitted to RG Stone Hospital, where she received treatment including antibiotics and saline drips.
After being discharged, Nasim approached ICICI Lombard, with whom she had held a health insurance policy since 2008. She informed the company officer about her hospitalisation and initiated a claim process.
Recurrence of Illness and Claim Rejection
Approximately a month later, Nasim fell sick again with similar symptoms and was treated with the same medication. She again approached the insurance company to claim health insurance benefits. Initially, the company accepted the claim. However, at the time of her discharge, hospital staff informed her that the insurance company had not accepted the claim, forcing her to pay the entire hospital bill out of pocket.
Nasim contacted ICICI Lombard to inquire about the rejection. The company informed her that the claim was rejected because she was required to co-pay as per the policy terms. Nasim argued that she had been a policyholder for 11 years and had never been required to co-pay before. She sent multiple emails and contacted the officer repeatedly, but the insurance amount was not paid.
Legal Notice and Company Defence
Nasim sent a legal notice to the company. In response, ICICI Lombard argued that as per the policy, any discrepancies or variations must be brought to the company's attention, and Nasim had not submitted any request or enquiry regarding the co-pay clause. The company further contended that the recent hospitalisation did not meet the criteria of 'medically necessary treatment' as defined in the policy, and therefore the cashless claim was rejected.
Commission's Observations and Order
The consumer commission examined the case and noted that the company provided a vague defence for rejecting Nasim's claim, especially considering her long association with the insurer. The commission observed that ICICI Lombard failed to prove that Nasim was required to co-pay under the policy. Consequently, the commission held the insurance company liable for deficiency of service and ordered the payment of the hospital expenses along with compensation and interest.
