Haryana

Yamunanagar

CC/157/2013

Kewal Krishan s/o Sh.Mulakh Raj, - Complainant(s)

Versus

Bajaj Allianze Life Insurance Co. Ltd. - Opp.Party(s)

Harvinder Aneja,

24 Oct 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, YAMUNA NAGAR AT JAGADHRI.

 

                                                Complaint No.157 of 2013.

                                                Date of Institution:26.2.2013.

                                                Date of Decision: 24.10.2017.

 

Kewal Krishan s/o Sh.Mulakh Raj, age 50 years, r/o H.No.1050, Barrack No.31, Camp, Yamuna Nagar.

                                                                                              …Complainant.

                                Vs.

1.     Bajaj Allianz Life Insruance Co. Ltd. situated opposite Madhu Petrol Pump, Jagadhri road, Yamuna Nagar through its Branch Manager.

2.     Bajaj Allianz Life Insurance Co. ltd. Regd. & Head office GE Plaza, Airport road, Yarawada, Pune.

…Respondents.

 

                                Complaint under section 12 of the

                                Consumer Protection Act.

 

CORAM:     SH.SATPAL………..PRESIDENT,

                    SH.S.C.SHARMA,         MEMBER.

                    SMT. VEENA RANI SHEOKAND, MEMBER.

 

Present:     Sh.Harvinder Aneja, Adv. for complainant.

                 Sh.Rajiv Gupta, Adv. for OPs.

 

ORDER:     (SH.SATPAL PRESIDENT)

 

1.             The complainant has filed this complaint under section 12 of the Consumer Protection Act against the respondents (hereinafter the respondents shall be referred as OPs).

2.             Brief facts of the complaint, as alleged, are that the agent of the Ops contacted the complainant and shown many plans regarding health of complainant and assured that in case the complainant was hospitalized, then the Ops will pay 100% of all expenses as per the bills of the hospital.  Upon the assurance of the Ops, the complainant paid Rs.50,000/- of first installment and at that time the Ops issued policy No.0044399191, dated 28.3.2007 valid up to 28.3.2027 and the complainant was insured up to 28.3.2027 after paying three installments of Rs.50,000/- each and complainant paid three installments without any default.  In the month of December, 2012, the complainant was suffering some heart problem and he firstly approached to Kapil Hospital as well as Santosh Hospital and Dashmesh Hospital and thereafter approached to Max Health Care Super Specialty Hospital on 2.1.2013 where the complainant was hospitalized and angiography was done.  The complainant was discharged on the same day and paid Rs.10,700/-.  As per the report of angiography, the complainant was advised for angioplasty as his arteries were blocked up to 90%.  Thereafter, on 5.1.2013, the complainant was admitted in the hospital and angioplasty was done by the doctors and during this period the complainant was hospitalized up to 7.1.2013 and following treatment were given to the complainant:

PTCA stunting of LCx lesion

AO Processur:130/90 mm of Hg

Final diagnosis:

                   Successful PTCA and Stenting of LCx Lesion Done. 

Recommendation:

                  Medical Management.

                The complainant was discharged on 07.01.2013 and at that time, the total amount paid by complainant was Rs.4,57,361.02 paise under IPID No.4823.  Thereafter, the complainant submitted all the history with the Ops and lodged a claim of Rs.4,57,361.02 paise+Rs.10700/- i.e. Rs.4,68,061.02 paise but the complainant was astonished to receive letter dated 01.02.2013 in which the Ops have not passed the claim of the complainant and declined on the ground i.e. “That illness suffered by complainant is not covered under 11 critical illnesses mentioned in the Policy Terms and conditions and Medical documents did not show evident of first heart attack” moreover same plan also availed by the complainant from the LIC insurance company and they paid Rs.2,00,000/- regarding his claim.  Thereafter, the complainant approached the Ops with the request to pay the total amount of Rs.4,68,061.02 paise as per hospital bill but of no use, which amounts to deficiency in service on the part of the Ops and prayed for acceptance of complaint by directing the Ops to pay Rs.2,68,061.02 paise alongwith interest and to pay Rs.20,000/- as compensation for mental agony, harassment and financial loss. 

3.             Upon notice, the Ops appeared and filed their written statement by taking some preliminary objections alleging therein that no cause of action has arisen in favour of complainant against the Ops as the complainant Mr.Kewal Krishan Bhalla underwent PTCA (Coronary Angiplasty) +stenting of LCx & LAD at Max Super Specialty Hospital, Mohali where he remained admitted from 05.01.2013 to 07.01.2013 and submitted critical illness claim under policy No.0044399191 knowing well that the claim lodged by him is neither covered nor admissible as per the terms and conditions of the contract of insurance.  The illness suffered by the complainant is not covered under any category of 11 Critical Illnesses Covered under the critical illness-Rider Benefit of the policy and critical illness claim lodged by the complainant w.r.t. the alleged treatment taken by him is not covered.  The claim for critical illness lodged by the complainant has therefore, legally and rightly been declined by the Ops vide letter dated 1.2.2013 being in-admissible and the complaint is prima-facie to be dismissed; the complainant has concealed the true and correct facts from this Hon’ble Forum just to derive illegal financial gains contrary to the express and agreed terms and conditions of the policy document received by him.  Thus, the complainant has not approached this Hon’ble Forum with the clean hand and he lodged a false critical illness claim knowing well that the illness suffered by him is neither covered under any critical illnesses mentioned in the terms and conditions of the policy nor the claim lodged by him is admissible as per contract of insurance; the complainant is estopped to file the instant complaint due to his own act and conduct  as he being a prudent businessman proposed for Unit Linked Regular Premium “Capital Unit Gain” policy vide proposal dated 22.3.2007 and opted for death cover of Rs.5,00,000/-.  The complainant further opted for critical illness Rider to the tune of Rs.2,00,000/- apart from other rider benefits.  The proposal of the complainant was accepted by the Ops as proposed and a policy bearing No.0044399191 was issued to the complainant with the date of commencement as 22.3.2007.  The original policy bond containing express terms of the contract of insurance including Critical Illness Rider Benefit was sent to the complainant and the receipt of the documents of the policy has never been disputed.  The complainant was offered 15 days “Free Look Cancellation” period to review the terms of the contract and to submit written request for cancellation of the policy if any commitment made at the solicitations of the policy was not part of the express terms of the policy.  The complainant however, continued to enjoy the benefits of the policy and did not make any request for cancellation which clearly indicates that he was fully satisfied with the terms and condition of the policy document received by him.  The complainant being satisfied with the policy purchased by him paid several premiums for subsequent years without raising any dispute with regard to the terms and conditions of the policy and is continuing to enjoy the death benefit cover to the tune of Rs.5,00,000/- apart from other Rider Benefits.  Thus, the terms and conditions of the said policy which is still in the custody of the complainant is binding on the complainant; the relief sought by the complainant is illegal, untenable and contrary to the express and agreed terms and conditions of the contract of insurance; the contract of insurance is an agreement between the proposer and the Ops wherein both the parties to the contract accepts to abide by the express terms and conditions of the contract; the complainant has no locus-standi to file the present compliant; the complaint is not maintainable as the Ops disputes and deny their liability to pay any amount and compensation to the complainant; this Hon’ble Forum has no jurisdiction to try and entertain the instant complaint as it involves the intricate question of law and elaborate evidence and pleadings are required to adjudicate the matter as per Civil Procedure Code; the present complaint is bad for mis-joinder and non-joinder of proper and necessary parties; the complainant has not exhausted the other efficacious remedies available and provided under the insurance Act 1938; the Ops craves the leave of this Hon’ble Forum.  On merits controverted the plea taken by the complainant and reiterated the stand taken in the preliminary objections.  There is no deficiency in service on the part of the Ops and prayed for dismissal of complaint with costs. 

4.             To prove his case the counsel for the complainant tendered into evidence affidavit of complainant as annexure C.X, documents such as letter dated 5.4.2007 as annexure C.1, copy of settlement receipt as annexure C.2, record of hospital and report of tests as well as receipt of Rs.9500/- as annexure C.3 to C.14, copy of cheque of Rs.2,00,000/- as annexure C.15 and closed the evidence on behalf of complainant.

5.             The counsel for the Ops tendered into evidence affidavit of Shri Anil Kumar Walia, D.M as annexure R.X, documents such as copy of letter dated 1.2.2013 as annexure R.1, copy of proposal form as annexure R.2, copy of discharge summary as annexure R.3, copy of critical illness claim form as annexure R.4, copy of certificate of hospital treatment as annexure R.5, copy of letter dated 10.12.2012 as annexure R.6, copy of Coronary Angioplasty Report as annexure R.7, copy of letter dated 5.1.2013 as annexure R.8, copy of letter dated 13.4.2015 as annexure R.9 and closed the evidence on behalf of Ops.

6.             We have heard the learned counsel for the parties and gone through the pleadings as well as documents placed on the file. 

7.             After hearing the learned counsel for the parties and going through the pleadings as well as documents placed on the file, it is clear that the complainant purchased the above said policy and paid the premium for three years.  The plea taken by the Ops that the complainant opted for death cover of Rs.5,00,000/- and further opted for critical illness Rider to the tune of Rs.2,00,000/- apart from the other rider benefits has nowhere been controverted by the complainant.  As per the version of the Ops, the complainant had free look period of 15 days from the issuance of policy in which the complainant was at liberty to get refund the amount of premium but the complainant without going through the conditions of the policy made false allegation regarding the claim of treatment which was got taken by the complainant from the hospital.  Not only this, since the complainant himself opted for death cover and for critical illness Rider then the complainant had to prove the illness as Critical illness which is not done so by the complainant.  The foremost question which arises before us for consideration is that whether the undergoing heart surgery of the complainant was covered under the policy in question or not?

                The version of the complainant is that the complainant had one another medi-claim policy of Life Insurance Corporation of India and Life Insurance Corporation of India had settled the claim of the same surgery of heart to the tune of Rs.2,00,000/- and as such, the complainant is entitled for the claim amount from the Ops-insurance company.  The Ops-insurance company illegally repudiated the claim of complainant on the false and frivolous ground.  Ld. Counsel for the complainant submitted case law reported in 2015(1) CLT page 590 (Haryana State Commission) titled as Star Health & allied Insurance Co. Ltd. Vs. Asha & others, wherein the Hon’ble State Commission held that ”Insurance policy-Terms and conditions-Exclusion clause-Held-It is the duty of the insurance company to prove that these terms and conditions were explained to the insured when cover note was issued-No where mentioned therein that the insured was explained about this exclusion clause-With very small letters clauses, warranties, endorsement, etc. are mentioned-Insurance policy is issued by the company lateron-It is well settled that the company, who is taking specific plea about repudiation of any claim is to prove that the exclusion clause was explained the consumers-When the Ops have failed to prove this fact they cannot derive any benefit from this exclusion clause.”  Similarly, ld. Counsel for the complainant has also relied upon the case law reported in 2000(1) CPJ page 1 (SC) titled as M/s. Modern Insulators Ltd. Vs. Oriental Insurance Co. Ltd., wherein the Hon’ble Supreme Court held that “Appellant in its affidavit filed confirmed that it was supplied only with cover note and schedule of policy-Other terms and conditions containing exclusion clause not communicated-Exclusion clause did not form part of contract of insurance-Respondent cannot claim benefit of said exclusion clause-Finding of National Commission not tenable in law.”  Ld. Counsel for the complainant also relied upon the case law reported in 2001(1) RCR (Civil) page 347 (SC) titled as Life Corporation of India Vs. Asha Goel; 2016(4) CLT page 372 (State Commission, U.T., Chandigarh) titled as S.B.I. General Insurance Co. Vs. Balwinder Singh Jolly & others; 2015(2) PLR page 75 (P&H High Court) titled as Oriental Insurance Co. Ltd. Vs. Naresh Sharma & others and 2005(1) CLT page 88 (P&H High Court) titled as Vidya Vs. Life Insurance Corporation of India, wherein the similar question of law has been discussed.   

                  On the other hand, the plea of the Ops is that as per terms and conditions of policy, the surgery which the complainant had undergone was not covered and as such, the claim of complainant has  rightly been repudiated. 

                We have perused the document Annexure-R9, wherein the terms and conditions of Critical Illness Benefit is defined.  The clause-2 of the said condition is reproduced as under:-

        “Coronary Artery Disease requiring surgery.

          The undergoing of heart surgery to correct narrowing of blockage of left main coronary artery or three or more coronary arteries with bypass grafts in persons with limiting anginal symtoms and compromise of blood supply supported by investigation but excluding non-surgical technique such as balloon angioplasty, laser relief of obstruction or other forms of coronary artery clearing through catheters or similar device.  Narrowing of the effected artery should be more than 75% (seventy five percent).”

                Meaning thereby, as per the above-said condition, only open or bypass surgery is covered under this clause.  The non-surgical techniques such as balloon angioplasty, laser relief of obstruction or other forms of coronary artery clearing through catheters or similar device were not covered.  In the present case, the complainant underwent surgery of PTCA (Coronary Angioplasty) with stenting of LCx and LAD, which is non-surgical technique and the life assured is not covered under any category of 11 (Critical Illnesses) covered under the Critical Illness Rider Benefit.  It is also relevant to mention here that it is well settled law that both the parties to an agreement are bound to abide by the terms and conditions contained in the agreement and none of the parties can travel beyond the stipulated/prescribed terms and conditions of the agreement.  The Hon’ble National Commission in LIC of India Vs. Giriraj Mehta in revision petition No.3123 of 2008 vide judgment dt. 25.05.2010 has held that “the Courts should give true import of terms and conditions of policy, without making any addition or even stretching those terms and conditions”.  In the present case, the complainant in his pleadings nowhere alleged that the Ops-insurance company did not supply the terms and conditions of the policy.  The authorities submitted by ld. Counsel for the complainant are not disputed but not applicable to the facts and circumstances of the present case.  Hence, there is no deficiency in service on the part of Ops.           

8.             Thus, as a sequel of above discussion, we find no merit in the complaint of the complainant and the same is hereby dismissed with no order as to costs.  A copy or order be supplied to the parties free of cost.  File be consigned to the record-room.

Announced in open Court:24.10.2017.

                                                                (SATPAL)

                                                                PRESIDENT

 

       (VEENA RANI SHEOKAND)     (S.C.SHARMA)

        MEMBER                                     MEMBER.