ICICI Prudential directed by NCDRC to pay Rs 5L to policy holder for denying claim

Apex consumer forum NCDRC has directed ICICI Prudential Life Insurance Co Ltd 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.

The National Consumer Disputes Redressal Commission (NCDRC) observed that ICICI Prudential had obtained and used a "suspicious medical certificate" for denying the claim.

"It is an unfair and deceptive act and amounts to unfair trade practice", the commission said and directed 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.

The NCDRC directed that the amount be paid within four weeks from June 14.

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 a physician, or an endocrinologist, to certify a person as diabetic and hypertensive.

"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," Commission's Presiding member S M Kantikar and member Dinesh Singh said.

"We 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," the commission said.

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.

Gujar had moved the district forum which had passed an order in his favour on October 31, 2015.

The insurance company's petition challenging the lower fora's order was rejected by Maharashtra state commission, after which ICICI Prudential moved the NCDRC for review of the order.