BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.381 of 2014

Date of Instt. 30.10.2014

Date of Decision :01.06.2015

Suresh Kumari aged about 56 years wife of P.S.Kondal R/o 200-C, Guru Nanak Pura West Post Office Chugitti Jalandhar at present 431-A, Gali No.6, Guru Nanak Pura (Wesst) Jalandhar.

..........Complainant

Versus

1. Bajaj Allianz Life Insurance Company Limited, 501, Grand Mall, Near Reddison Hotel G.T.Road, Jalandhar through its Manager.

2. Bajaj Allianz Life Insurance Company Limited, Registered and Head Office Akurdi Pune-411035 through its Manager/MD/Office-incharge.

.........Opposite parties

Complaint Under Section 12 of the Consumer Protection Act.

Before: S. Jaspal Singh Bhatia (President)

Ms. Jyotsna Thatai (Member)

Sh.Parminder Sharma (Member)

Present: Sh.Jaipal Sharma Adv., counsel for complainant.

Sh.SC Sood Adv., counsel for the opposite parties.

Order

J.S.Bhatia (President)

1. The complainant has filed the present complaint under section 12 of the Consumer Protection Act, against the opposite parties on the averments that complainant had purchased a life insurance policy No.0014457538 on 28.12.2005 from opposite party insurance company. The date of commencement of said policy was 28.12.2005 and the date of maturity was 28.12.2020. Complainant has been paying the premium of the said policy regularly and no amount is due towards the complainant. The complainant paid a sum of Rs.8310/- premium on 7.12.2012. She has also paid Rs.8180/- on 31.12.2013. It is clearly mentioned in the certificate issued by the opposite parties that Rs.7200/- for life insurance and Rs.940/- for the health care premium. The sum assured of the insurer in the said policy is Rs.1,00,000/-. The supplementary benefits of the said policy also insured a sum of Rs.50,000/- in critical illness rider to the insurer. Said policy also covers medical ailments of complainant. The complainant also paid the premium on 28.12.2013. The complainant had undergone a Gall Bladder Stone surgery on 13.9.2013 from Bhargwa Hospital, Jalandhar. The complainant incurred a sum of Rs.28,612/- on the said surgery. The complainant moved an application to opposite parties No.1 to reimburse her medical bill alongwith medical bills and discharge certificate of doctor on 2.11.2013. The complainant a number of times visited the office of opposite party No.1 with a request to pass the claim of complainant but the opposite parties had been lingering the matter on the one pretext or other. On such like averments, the complainant has prayed for directing the opposite parties to pay her the claim amount of Rs.28612/-. She has also claimed compensation and litigation expenses.

2. Upon notice, opposite parties appeared and filed a written reply, inter-alia, pleading that complaint of the complainant is hopelessly pre-mature as no intimation of alleged treatment of any critical illness was ever given to the answering opposite parties and no proof of treatment/claim papers/medical documents or records to show that she suffered from any of the 11 critical illnesses covered under the terms and conditions of the policy, were ever submitted to the answering opposite parties by the complainant. Thus, the answering opposite parties had no opportunity to examine the admissibility of the critical illness claim as per the terms of the contract of insurance or to ascertain the bonafides of the claim. Thus, the complainant is estopped to file the instant complaint against the answering opposite parties due to her own act and conduct and the complaint is liable to be dismissed in limine, without going into the merits of the case. The admissibility of any claim can not be ascertained until and unless and company receive the required intimation of any such critical illness supported by medical treatment/hospital records/documentation from the complainant. The complainant admittedly underwent Gall Bladder Stone Surgery which is not covered under the terms and condition of the policy thus, the claim for the treatment of Gall Bladder Stone Surgery is not covered under any of the above mentioned 11 critical illnesses. It is stated that the invest gain economy policy opted by the complainant is not a mediclaim policy rather the complainant opted only for additional critical illness rider benefit of Rs.50000/- in addition to basic risk cover of Rs.1,00,000/-. The proposal of the complainant was accepted by the answering opposite parties and a policy bearing No.0014457538 was issued to her with date of commencement as 28.12.2005 with sum assured of Rs.1 Lac and critical illness rider benefit of Rs.50,000/-. They denied other material averments of the complainant.

3. In support of her complaint, learned counsel for the complainant has tendered into evidence affidavit Ex.CW1/A alongwith copies of documents Ex.C1 to Ex.C21 and closed evidence.

4. On the other hand, learned counsel for opposite parties has tendered affidavit Ex.OA alongwith copies of documents Ex.OP/1 to Ex.OP/16 and closed evidence.

5. We have carefully gone through the record and also heard the learned counsels for the parties.

6. Ex.C1 is policy schedule of the complainant. The policy commencement date was 28.12.2005 and maturity/termination date is 28.12.2020. Under the policy, basic benefit was to the extent of Rs.1 Lac and supplementary benefit i.e critical illness rider of Rs.50,000/-. According to the complainant, she underwent Gall Bladder Stone Surgery on 13.9.2013 and incurred a sum of Rs.28612/- on the said surgery and submitted all the necessary documents to the opposite party insurance company but opposite party insurance company has not passed the claim of the complainant till date. On the other hand, the version of the opposite party insurance company is that complaint of the complainant is pre-mature as no intimation of alleged treatment of any critical illness was ever given to the opposite parties and no proof of treatment/claim papers/medical documents or records to show that she suffered from the critical illness covered under the terms and conditions of the policy was ever submitted to them by the complainant and as such they had no opportunity to examine the admissibility of the critical illness claim as per the terms of the contract of insurance or to ascertain the bonafides of the claim. So, the opposite party insurance company has not decided the claim of the complainant one way or another i.e either to accept it or reject it. So, in these circumstances, we feel that the opposite party insurance company should be given an opportunity to decide the claim of the complainant on merits in accordance with the terms and conditions of the policy.

7. In view of above discussion, the present complaint is disposed off with the directions to the opposite parties to treat the present complaint as claim filed by the complainant and further the complainant is directed to submit any documents which she may desire to the opposite party insurance company within 15 days from the date of receipt of copy of this order and thereafter the opposite party insurance company shall positively decide the claim of the complainant one way or another either to accept it or reject it on the basis of documents, if any already submitted by the complainant and documents which she may further submit to the insurance company within above said period of 15 days and further on the basis of document produced by the complainant during the trial of the present complaint, within two months after the expiry of said period of 15 days failing which the claim of the complainant shall be deemed to have been accepted by the opposite parties. In the circumstances of the case, there shall be no order as to costs. Copies of the order be sent to the parties free of costs under rules. File be consigned to the record room.

Dated Parminder Sharma Jyotsna Thatai Jaspal Singh Bhatia

01.06.2015 Member Member President