DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Mrs. Santosh Bansal W/o Sh. Krishan Lal Bansal, R/o H.No. 1008, Sector 9, Panchkula.

                   --- Complainant

V E R S U S

[1]     Aviva Life Insurance Co. India Ltd. Head Office: Aviva Tower, Sector Road, Opposite DLF Gold Course, DLF, Phase V, Sec. 43, Gurgaon – 122003, through its M.D.

[2]     Punjab & Sind Bank, SCO No. 62, Sector 26, Chandigarh, through its Branch Manager.

---- Opposite Parties

BEFORE:        MADHU MUTNEJA                                       PRESIDING MEMBER

                        SH.JASWINDER SINGH SIDHU                     MEMBER

Argued By:             Sh. Hitender Kansal, Counsel for Complainant.

Sh. Sandeep Suri, Counsel for Opposite Party No.1.

Opposite Party No.2 ex-parte.

PER JASWINDER SINGH SIDHU, MEMBER

1.                Setting aside the order dated 23.07.2012, passed by this Forum, vide which the Consumer Complaint No. 28 of 2012 was dismissed in default of appearance of the Complainant, the Hon’ble State Commission, vide its order dated 01.11.2012, remanded the case back to this Forum, with a direction to restore the same to its original number, proceed further from the stage at which it was dismissed and decide the same on merits, in accordance with the provisions of law.

2.                Briefly stated, the Complainant had purchased Aviva Health Policy bearing No. NHP 3069387 through Opposite Party No.2 by paying a premium of Rs.15,628/- vide Cheque No. 561891 dated 30.3.2011 for the sum assured of Rs.1,50,000/-. The Complainant was medically examined by the competent doctor of OP Company Dr. Vikas Vohra, who submitted his report on 02.04.2011. The Complainant claims that despite the proposal form having been filled on 30.3.2011, and the cheque for the premium issued on the same date, and medical examiner’s report dated 02.04.2011; the first premium receipt was issued by the Opposite Parties on 19.04.2011. It is averred that on 14.7.2011, the Complainant started acute onset of chest pain radiating to left arm with sweating and she was rushed to the Alchemist Hospital, Panchkula for further evaluation & management. As per Hospital Course, she was admitted in CCU with acute AWMI, for which she was managed anticoagulants, antiplatelets, statins, LMWH and urgently she was taken up for CAG which was done through right femoral route which revealed Single Vessel Disease and was advised for PTCA/ Stenting to LAD which was successfully done through right Femoral route on 14.7.2011. The Complainant was discharged on 16.7.2011. At the time of discharge, Alchemist Hospital charged Rs.2,33,741/- dated 16.7.2011 (Annex.C-6). The Complainant accordingly lodged claim with the Insurance Company seeking reimbursement of the amount under the Policy. However, to her utter dismay, her claim was repudiated by the Opposite Party, vide letter dated 05.10.2011, on the ground that no benefit was payable to her as the claim fell within the waiting period of 90 days as per Article 3-D-ii of the policy as the date of commencement was 19.4.2011 and the hospitalization happened on 14.7.2011. Hence, the present complaint. 

3.                Notice of the complaint was sent to Opposite Parties seeking their version of the case.  However, despite service, nobody has appeared on behalf of Opposite Party No.2, therefore, it was proceeded against exparte on 4.1.2013.

4.                Opposite Party No.1, in its reply, while admitting the factual matrix of the case, pleaded that the cheque was encashed on 15.4.2011. The date of commencement of the policy was 19.4.2011. The ailment took place on 14.7.2011. The benefits under the critical illness were only covered after the period of 90 days i.e. after 18^th July, 2011. It is asserted that mere filing of the proposal does not tantamount to an automatic acceptance of coverage by the insurer.  Hence, the repudiation was strictly as per the policy terms. It is further pleaded that the policy was well within the knowledge of the Complainant and he had an option to return the same in case she was not satisfied within 15 days from the date of receipt of the policy. Denying all other allegations and stating that there is no deficiency in service on its part, opposite party No. 1 has prayed for dismissal of the complaint.  

5.                Parties were permitted to place their respective evidence on record in support of their contentions.

6.                We have heard the learned counsel for the parties and have perused the record.

7.                The Complainant has preferred the present complaint against the Opposite Parties on the ground that she had subscribed for a health policy from Opposite Party No.1 by filling up a proposal form dated 31.3.2011 and also forwarding a cheque of Rs.15,628/-, along with it as necessary premium, to be realized from her account, maintained with the Opposite Party No.2. The Opposite Party No.1 issued a policy dated 19.04.2011. The Complainant suffered a pain in her chest on 14.7.2011, and was hospitalized at Alchemist Hospital, Panchkula and was discharged on 16.7.2011, after a procedure of CAT/PTA/Stenting of LAD having been conducted on her. The treating hospital raised a bill of Rs.2,33,741/- on account of her treatment. The Complainant duly lodged the claim with Opposite Party No.1 for reimbursement of her expenses incurred for her treatment by submitting all the relevant required documents and copy of the bills. The Complainant is aggrieved of decline of her claim by Opposite Party No.1  through its letter dated 5.10.2011, wherein Opposite Party No.1 has claimed that since the date of commencement of the policy in question is 19.4.2011 and the Complainant’s hospitalization happened on 14.7.2011, hence as per Critical Illness Rider Article 3-D-ii, of the terms and conditions of the policy, in question, the claim of the Complainant is not payable.   

8.                The Opposite Party No.2, which was duly served, was initially represented by one Sh. Jagjit Singh Khubber, its Authorized Agent, but on subsequent date, i.e. 4.1.2013, failed to put in appearance on behalf of Opposite Party No.2, nor Opposite Party No.2 was represented by its counsel, hence, Opposite Party No.2 was proceeded against ex-parte vide order dated 4.1.2013. However, on minute perusal of the averments of the complaint, it is noticed that the Complainant had only impleaded Opposite Party No.2 as a necessary party to substantiate the payment of premium amount through her account maintained with Opposite Party No.2, which is proved from Annexure C-2 (Pg.57) and that no deficiency in service has been alleged by the Complainant against Opposite Party No.2. Hence, in the given situation, not finding any merit, the present complaint is dismissed qua Opposite Party No.2, without costs.  

9.                The Opposite Party No.1 has contested the claim of the Complainant on the aforementioned grounds, and had defended its decision of declining the claim of the Complainant. However, the only point of contention is whether the Complainant is entitled for the reimbursement of her expenses, and that whether the Opposite Party No.1 are well within its rights to deny the same. From a bare perusal of the documents tendered by the Complainant, as well as Opposite Party No.1, it is apparent that the claim of the Complainant lies within the Critical Illness Rider 3-D-ii which mentions that any claim arising out of the critical illness suffered by the Complainant within a period of 90 days of commencement of the policy, is not payable.

10.              However, it would not be out of place to mention that the very policy, in question, which was subscribed for by the Complainant, on 31.3.2011, with Opposite Party No.1, and had also paid the premium by way of a Cheque of Rs.15,628/-, was to be processed by the Opposite Party No.1, within the mandatory 15 days time, and the Complainant was to be intimated about its decision, within this mandatory period, as per Regulation 4(6) of the Insurance Regulatory & Development Authority  (Protection of Policy Holders’ Interests) Regulations 2002, which reads as under:-

                   4.       Proposal for insurance:

                   (6)     Proposals shall be processed by the insurer with speed and efficiency and all decisions thereof shall be communicated by it in writing within a reasonable period not exceeding 15 days from receipt of proposals by the insurer.”

                   However, it is noticed that the Opposite Party No.1 failed to adhere to the provisions of Regulation 4(6) of the Regulations ibid and issued the policy in question on 19.04.2011, well past the mandatory period. Hence, in the given situation, the Opposite Party No.1 at the very onset is found deficient in rendering proper service to the Complainant for having delayed the process and its intimation to the Complainant. As the premium amount of Rs.15,628/- was handed over to the insurance company, along with the proposal form, hence, we feel that the policy, in question, is deemed to have been issued, within the mandatory 15 days period, which completes on 14.04.2011, and that the Complainant having suffered the critical illness on 14.07.2011 the claim of the Complainant is beyond the exclusion clause of 90 days as the 90 days period starting from 14.4.2011 is completed by mid night of 13.4.2011. Hence, the claim of the Complainant which falls exactly after the mandatory 90 days period of exclusion, is maintainable and deserves to be entertained and processed by the Opposite Party No.1. It is, therefore, held that the Opposite Party No.1 being deficient in rendering proper service to the Complainant, at the time of issuing of the policy in question, cannot be allowed to shield itself behind the provisions of the policy, which it had issued at a belated stage, beyond the mandatory period during which it was to be processed and the Complainant was to be duly informed about such decision by Opposite Party No.1.                          

11.              In the light of above observations, we are of the concerted view that the Opposite Party No.1 is found deficient in giving proper service to the complainant. Hence, the present complaint of the Complainant deserves to succeed against the Opposite Party No.1, and the same is allowed, qua it alone. The Opposite Party No.1 is directed:-

[a]     To pay the claim amount of Rs.1.50 lacs to the Complainant, as per her entitlement;

[b]     To pay Rs.25,000/-on account of deficiency in service and causing mental and physical harassment to the Complainant; 

[C]    To pay Rs.10,000/- as cost of litigation;

12.              The above said order shall be complied within 45 days of its receipt by the Opposite Party No.1; thereafter, it shall be liable for an interest @18% per annum on the amount mentioned in per sub-para [a] & [b] of para 11 above, apart from cost of litigation of Rs.10,000/-, from the date of institution of this complaint, till it is paid.  

13.              Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced

10^th April, 2013.                                           

Sd/-

 (MADHU MUTNEJA)

PRESIDING MEMBER

Sd/-

 (JASWINDER SINGH SIDHU)

MEMBER

 “Dutt”