IN THE HON’BLE CONSUMER DISPUTES REDRESSAL COMMISSION
COMPLAINT UNDER SECTION 35 OF THE CONSUMER PROTECTION ACT, 2019
Complainant:
Radha Krishan Mani Tripathi (Policyholder)
Policy No. [protected] – ICICI Lombard Elevate Plan
Respondent:
ICICI Lombard General Insurance Co. Ltd.
Complaint Statement
Respected Sir/Madam,
I, Radha Krishan Mani Tripathi, am filing this complaint against ICICI Lombard General Insurance Co. Ltd. for deficiency of service, unfair trade practice, and wrongful denial of claim under my health insurance policy.
Afternoon (2–3 PM): Severe abdominal pain commenced; patient was immobile.
4 PM: A home doctor (Dr. Neeraj Dubey, Morepen Home) administered first aid, but condition worsened.
10:20 PM: Patient rushed to Sir Ganga Ram Hospital casualty ward due to non‑availability of gastroenterologist elsewhere. (we initially believed this was a minor gastric issue that could be treated at Sir Ganga Ram Hospital with an expense of ₹20, 000–30, 000, which we could manage. However, after examination by the hospital’s medical panel and diagnostic reports, the situation drastically changed.)
Early 3 May 2026: CT scan revealed descending colon perforation with peritonitis and sepsis. Emergency surgery was performed — exploratory laparotomy with colostomy and stoma bag attachment.
8 May 2026: Surgeon Dr. Tarun Mittal certified the surgery as life‑saving.
11 May 2026: Hospital issued a clarification letter confirming prior OPD papers (allergic bronchitis from a year earlier) were medically unrelated.
Despite clear medical evidence, ICICI Lombard rejected the cashless claim citing the old OPD record of bronchitis. This reasoning is arbitrary and medically baseless. The operating surgeon has categorically certified that allergic bronchitis has no correlation with colon perforation. The hospital confirmed this was a first‑time, sudden medical episode with no co‑morbidities.
By 22 June 2026, the hospital bill had escalated to ₹9.16 lakhs. Out of this, ₹5 lakhs was processed by my employer’s TPA. For the remaining ₹4.16 lakhs, I raised a reimbursement claim with ICICI Lombard. Even after more than a month, the insurer has failed to release payment.
Meanwhile, my father remained in ICU for over 11 days. Doctors have now advised a second surgery within 1–1.5 months to reconnect the intestine and remove the stoma bag. Without insurer support, this critical procedure is financially impossible for us.
We are now completely wiped out financially. As a middle‑class family, we borrowed heavily from friends and relatives to meet urgent medical expenses. Despite being first‑time policyholders, ICICI Lombard has not stood by us.
Adding to our distress, we have faced continuous harassment in follow‑up:
We called ICICI Lombard’s toll‑free number over 50 times.
We visited their regional offices in Noida and Connaught Place three times.
Each time, we were told that since the policy was purchased online, we must contact the online sales channel.
Every call required us to re‑explain the entire case, yet no resolution was provided.
This conduct amounts to:
Deficiency of Service under Section 2(11) of the Consumer Protection Act, 2019.
Unfair Trade Practice under Section 2(47), as false assurances were given at the time of policy sale and contractual obligations were dishonored.
Mental and Financial Harassment inflicted on a middle‑class family in dire circumstances.
Reliefs Sought
I respectfully request this Hon’ble Commission to:
Direct ICICI Lombard to immediately approve and release reimbursement for Claim No.[protected]₹4.16 lakhs).
Direct the insurer to cover the upcoming re‑operation expenses without delay.
Award compensation for mental agony, harassment, and financial hardship caused by wrongful denial and repeated non‑responsiveness.
Impose costs on the insurer for deficiency of service and delay.
Prayer
This is not merely a contractual dispute but a matter of humanitarian responsibility. Our middle‑class family has been financially devastated, and without insurer support, my father’s life remains at risk. I humbly pray that this Hon’ble Commission intervenes to protect consumer rights and ensure justice.
Warm regards,
Radha Krishan Mani Tripathi
Policyholder – ICICI Lombard Elevate
Policy No. [protected]
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