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Has ICICI Prudential Life Taken To Fake Doctors Prescriptions To Avoid Paying Out Claims?


So Manoj Nagpal highlights a consumer forum case in which:

  • Mihan Kisku takes policies worth Rs. 13 lakh from ICICI Pru Life in August 2008
  • He dies of a heart failure in October 2008 (RIP)
  • In September 2009 – note: ONE YEAR after Mr. Kisku’s death – ICICI Pru Life refuses to pay, saying “material information was not disclosed”. They say he didn’t tell them he had blood pressure problems.
  • His wife took the case to the district consumer forum, where she won and was awarded the full 13 lakh plus 3 lakh compensation. On 31 Jan 2012, more than three  years after Mr. Kisku’s death. ICICI tried more stunts here, claiming that Mr. Kisku didn’t provide the right age proof, but was overruled.
  • ICICI then appealed to the state forum which decided, after THREE YEARs in Feb 2015, that ICICI needs to pay.
  • ICICI Pru Life then took this to the National Commission, which has again ruled in Ms. Kisku’s favour.

And what the judge says in the report is: To avoid paying up, ICICI Prudential is using an unreliable ‘prescription’ from a random doctor, who claims to have treated Mr. Kisku for hypertension (high blood pressure).

9. In order to substantiate its case that the petitioner was actually suffering from high blood pressure and hyper-acidity, the insurance company has relied upon the prescription purporting to be issued by one Dr. J.B. Ghosh, DHMS (Hons.) to one Mihan Kisku on 25-08-2005, 10-10-2006 and 21-03-2007. The petitioner company also relied upon a certificate purporting to be issued by         Dr. J.B. Ghosh stating therein that Mihan Kisku aged about 40 years was under his treatment from 25-06-2005 to 21-03-2007 as he was suffering from hyper tension and hyper acidity.

10.    Admittedly, the insurance company has not examined either       Dr. J.B. Ghosh or the investigator who collected the aforesaid document from Dr. Ghosh. In our opinion, in order to prove the case set up by it, it was incumbent upon the insurance company to file affidavit either of    Dr. Ghosh or at least of the investigator who allegedly collected the aforesaid prescription from him. That having not been done, it would be difficult to say that the insurance company has been able to discharge the onus placed on it to prove that the insured had suppressed the material information with respect to the state of his health, while taking the insurance cover.

11.    More importantly, we fail to appreciate how the copies of prescriptions which Dr. J.B. Ghosh allegedly issued to the insured could have been in possession of Dr. Ghosh after 3-4 years of having been issued to the patient. The prescription purporting to be issued by          Dr. J. B. Ghosh which are hand written and not typed or computer typed prescriptions. They are supposed to be in possession of the patient and not in possession of the doctor who issued them. There is no explanation from the insurance company as to how the aforesaid documents came to be possessed by Dr. J.B. Ghosh till 16-08-2009 when a certificate was issued by him certifying that Mr. Mihan Kisku was under his treatment from 25-06-2005 to 21-03-2007. This is yet another reason, for which we would not like to rely upon the aforesaid documents in order to deny the claim preferred by the complainant.

Oh wait. Let me see. We don’t want to pay this claim, so let’s find a pliant doctor, tell him to handwrite a prescription dated in the past, and just take that to the consumer court as proof. They did not even bring the doc as a witness, or even an affidavit from him! And they found the prescription with the doctor, which is usually with the patient.

Essentially, the judge questions the reliability of the prescription, on whose basis the claim was denied. It appears, looking from the above, that the document was a fake one and it’s very unlikely that the officials of ICICI Pru Life were unaware of these being fake.

Why isn’t the consumer forum getting contempt and fraud charges on ICICI Prudential Life and charging them with 100 cr. fines? Every such incident should attract a Rs. 100 crore fine – if you attempt to forge a document to bolster your case, your executives will go to jail and the company will pay a fine of Rs. 100 crores. Yes, that will wipe out its capital, and that’s how it should be.

And, Goodness: SEVEN YEARS.

ICICI Prudential and the consumer forums made a widow wait seven years to get her money, and she doesn’t even get any interest. If ICICI had sent aside the money and placed it in a deposit at 10% (in 2008 those were the rates) the money would have doubled till now and they can just pay her out of the interest.

This is unfair. At the very least, the judgement should have given her 18% interest till the money is paid, just to make such cases more expensive on delays.

And making a widow wait seven years is just bad faith. I will personally avoid taking an insurance policy from them. If I die, who knows, they might make my family run around courts with some other kind of fake document.

Further Notes:

  • The first judgement, in 2013 (five years after the incident) is here at the Burdhwan district consumer court. The Judge mentions here too about how ICICI Pru Life tries to “harass” the claimant. 
  • The next judgement is from the State Consumer Court in Feb 2015, where it’s clear that the judges thought the evidence of the doctor’s prescription was very shady.
  • There are two basic points: ICICI Pru Life had real proof of the person’s age (the PAN card) and decided to question claim on another age proof anyway. This is bad faith. 
  • The second point is that they had no real proof of the doctor’s prescriptions, which cannot be explained in any legal way. And all courts have noticed that having “hypertension” or “hyperacidity” and visiting a doctor 4 times in three years is not proof enough to deny a claim.
  • I have been called by ICICI Pru’s actuarial team who have promised a full statement which I will produce verbatim. Only after that call did I read the earlier judgements. In that call, it was clear to me that:
    • They thought this was a case of fraud but couldn’t prove it
    • They decided to play God and instead of paying up after the first judgement, decided to fight it all the way possible so that they could delay the claim. This is my belief and I said so on the call, that this is pure bad faith. 
    • They said they paid 9% interest along with the amount so it’s at least some justice.
  • When ICICI’s statement comes I will paste it here. I encourage you to read though it and make your personal views clear too, and I’ll place my comments. 

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