(Per Shri Narendra Kawde, Hon’ble Member)
(1) This consumer complaint has been filed by the complainant alleging deficiency in service on the part of opponents HDFC Standard Life Insurance Co.Ltd. for repudiation of the mediclaim under insurance policy subscribed by the complainant and issued by the opponent No.1(a) & (b) i.e. HDFC Standard Life Insurance Co.Ltd.
(2) Factual matrix of the case is that the policy No.11801154 was subscribed by making payment of premium with sum assured of `2 lacs titled as HDFC UNIT LINKED ENDOWMENT PLUS II POLICY SCHEDULE. The policy is issued by the opponent No.1(a) & (b) [since they are one and same party hereinafter referred to as ‘the HDFC Insurance Company’). The policy was issued with certain terms & conditions to extend Extra Health Benefit condition. In order to avail Extra Health Benefit admissible under the policy, the condition reads as below:-
Extra Health Benefit – We will pay the Extra Health Benefit only if this benefit has not been cancelled or terminated; and the critical illness has not occurred within 6 months of the date of commencement or the date of issue or date of revival whichever is later; and has occurred before the expiry of this benefit, and you produce to us a duly completed claim form within 26 weeks of the illness, disability, operation or other circumstance giving rise to the claim; and all relevant documents in support of your claim have been provided to our satisfaction. These would normally include the fully completed claim form; and original policy document; and originals of any medical reports by the family physician on the critical illness and its treatment; and any medical report the doctor may have on the Life Assured that we consider relevant to the critical illness; and originals of any medical reports from hospitals, specialists and other doctors that we consider relevant to the critical illness. Depending on the circumstances of the illness, disability, operation or other circumstance giving rise to the claim, further documents may have to be provided as we might reasonably require.
(3) Condition incorporated in the policy is self-explanatory which stipulates that extra health benefit is available only if critical illness has not occurred within 6 months from the date of commencement of the policy or from the date of policy whichever is later. The complainant diagnosed ‘PLEOMORHIC LIPOSARCOMA’(Self tissue – rare cancer) on 20/10/2008 which was the first date of medical consultation. The details of the diagnosis clarified as ‘Low grad active disease in mars in right lateral abdominal wall muscle and right sartorius, soft tissue.’ The sample for smear biopsy was sent on same day i.e. 20/10/2008 and also CT scan/MRI was carried out on the very day i.e. 20/10/2008 at Mumbai. However, biopsy report is not available on the record, but CT scan/MRI report is placed on record which was carried out at Piramal Diagnostics. On getting knowledge of the disease, complainant left for further treatment to US on 22/10/2008 and admitted in the Memorial Cancer Hospital at New York and discharged on 09/11/2008. After having undergone the treatment, the patient returned to India on 23/11/2008. Thereafter, mediclaim was lodged with opponent HDFC Insurance Company on 28/02/2009 claiming an amount of `30,81,800/- on account of treatment of medical expenses. The claim under the policy was repudiated by the opponent insurance company stating that it is not admissible under the terms & conditions of the policy. Critical illness has occurred within the period of first 6 months from the date of commencement of the policy and further insurance policy was cancelled intimating that the policy issued is no longer valid and shall be treated as null & void. The complainant issued legal notice to the opponent insurance company pressing for honouring the mediclaim payable under the insurance policy as the premium was paid in the month of March 2008, though the policy was issued with date of commencement i.e. 11/05/2008 and further decision to know as to why the insurance proposal that submitted in the month of March 2008 along with payment of first premium was not processed and finalized within 15 days from the receipt of proposal as a reasonable period as specified under regulation 4 (6) of IRDA (Policy holders’ interest) Regulations 2002. Even then, there was no re-consideration on the part of the opponent insurance company; aggrieved thereby complainant filed consumer complaint before this Commission.
(4) Opponent insurance company denied the contentions of the complainant and contested the claim by filing written version. It is stated in the written version that though from date of receipt of the proposal on 24/03/2008 at Udaipur Branch, the complainant was required to submit copies of income tax return, balance sheet of his firm and profit & loss account statement for the last 3 financial years as pre-requisite to process the proposal. The complete proposal with all these required documents was submitted by the complainant on 08/05/2008 at Udaipur Branch office of the opponent and all the said documents reached to Hub Mumbai on 10/05/2008. On the basis of the complete proposal received at Mumbai Hub office in respect of both the policies on 08/05/2008 and 10/05/2008, two separate insurance policies bearing Nos. 11801154 & 11801422 with annual premium of `2 lacs each and sum assured of `20 lacs each were received by the complainant in the month of May 2008 with date of commencement as 11/05/2008. There was 15 days’ free look period incorporated in the policy which was intimated by a letter dated 28/05/2008 clarifying that if the insured person is not agreeable to any of the provisions stated in the policy and the details in the proposal form, the insured person has the option of returning the policy to insurer stating the reasons thereof, within 15 days from the date of receipt of the policy. The policies were sent to the complainant along with terms & conditions by the said letter dated 28/05/2008. However, no grievance was made by the complainant in respect of date of commencement of the policy either by returning the said product or by a simple letter/e-mail to register any grievance in this regard. This option has not been exercised by the complainant as provided under Regulation 9(3) of IRDA (Policy Holders’ interest) Regulation 2006. Prior to issue of policy, routine medical check-ups were carried out. However, the complainant was not required to undergo any specialized medical examination for cancer. Routine examination was carried out on 26/03/2008. On receiving the proposal papers with required documents from Udaipur branch, policy was issued from the Mumbai Hub office. There is not dispute about commencement date of police as 11/05/2008. As per the extra health benefit as specified in the policy document, one of the pre-condition to be fulfilled under the same is that critical illness of cancer should not have occurred within 6 months from the commencement of the policy. The complainant underwent Whole Body Pet CT Image on 26/10/2008 and diagnosed that he was suffering from the critical illness of cancer. The first consultation on 22/10/2008 diagnosed that the complainant is suffering from critical illness of cancer. This diagnose was within 6 months from the date of commencement of the policy and therefore as stipulated in the terms & conditions of the policy, the insurance company has vehemently justified repudiation the mediclaim under the policy.
(5) Heard Mr.Ashutosh Marathe-advocate for the complainant and Mr.A.S.Vidyarthi-advocate for the opponents. Perused the record placed before us.
(6) The learned counsel for the complainant submitted that the Unite Linked Endowment Policy was not issued in the month of March, 2008. However, the insurance company instead of issuing the policy in the month of March itself delayed the same and subsequently issued with date of commencement i.e. 11/05/2008. However, there is no rebuttal evidence to establish that all the documents as enumerated in the written version in the opponent insurance company i.e. income tax return for last three years together with balance sheet and profit & loss statement were submitted to the opponent insurance company’ office at Udaipur prior to 08/05/2008. Therefore, only on receipt of pre-requisite documents along with insurance proposal, Udaipur Branch office forwarded the documents to Mumbai Hub Office which were received on 10/05/2008. Subject policy was issued with date of commencement as on 11/05/2008 which was forwarded by letter dated 28/05/2008 inviting attention towards provision of free look period. There is no evidence coming forward from the complainant that he has exercised the option of free look period within 15 days from the date of policy to return/cancel the policy if the date of policy was not agreeable. Undisputedly, first medical consultation on 22/10/2008 and the sonography report on the said date diagnosed the complainant with cancer. Though, the smear was sent for biopsy on the same day, no biopsy report is available on the record. Without waiting for this report, the complainant proceeded to US for cancer treatment where he was admitted in the Memorial Hospital for Cancer and Allied Diseases for the period from 04/11/2008 to 09/11/2008.
(7) What we find that the complainant as a pertinent consumer, he did not exercise due care after receiving the policy product together with stipulations with riders to avail extra health benefit. Policy was issued with date of commencement as on 11/05/2008 whereas complainant was for the first time diagnosed with ‘PLEOMORHIC LIPOSARCOMA’ on 22/10/2008 i.e. within the period of 5 months 11 days, the period which is less than 6 months from inception of policy. This critical illness occurred within first 6 months of the policy, hence not covered under the provisions of ‘Extra Health Benefit’ stipulated in policy. Further more, no documentary evidence is adduced to establish that the option of free look period as provided under Regulation 9(3) of IRDA (Policy Holders’ interest) Regulation 2006 was exercised by the complainant. Insurance company, therefore, is justified in repudiating the insurance claim under the policy on account of expenses incurred for treatment of cancer. There is no merit in the complainant and the complainant could not make out any deficiency in service against the opponent insurance company. We hold accordingly and pass the following order.
ORDER
(1) Complaint stands dismissed.
(2) Under the circumstances, parties to bear their costs.
(3) Certified Copies be furnished to the parties.
Pronounced on 18th March, 2013.
