DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, JALANDHAR
Complaint No.146 of 2017 Date of Instt. 10.05.2017 Date of Decision: 09.03.2021
Sunil Kumar r/o House No. 27-B, Mission Compound, Near Batra Hospital Jalandha 144001 Punjab
….. Complainant
Versus
1. Bharti AXA Life Insurance Co.Ltd., Unit 701 to 708, 7th Floor, Wellington Business Park 1, Andheri Kurla Road, Andheri (E) Mumbai 400 059.
2. Bharti AXA Life Insurance Co.Ltd, Eminent Maul, IIIrd Floor, Near Passport Sewa Kendra, Jalandhar.
3. Grievances Redressal Cell, Bharti AXA Life Insurance Co. Ltd, Unit 701 to 708, 7th Floor, Wellington Business Park 1, Andheri – Kurla Road, Andheri (E), Mumbai 400 059
4. Managing Director/Directors of the Company Bharti AXA Life Insurance Co. Ltd., Unit 701 to 708, 7th Floor, Wellington Business Park, I, Andheri Kurla Road, Andheri (E) Mumbai 400 059.
5. Insurance Regulation Authority of India, New Delhi
…Opposite parties
Complaint under the Provisions of Consumer Protection Act
QUORUM:
SH. KULJIT SINGH, PRESIDENT
Smt. JYOTSNA, MEMBER
ARGUED BY:
For complainant : Sh.Amit Singh Sandha, Advocate
For OPs : Sh.K.S.Minhas, Advocate
ORDER:-
KULJIT SINGH, PRESIDENT
The present complaint has been filed by complainant against the OPs on the averments that OPs floated a Medical Scheme and advertised the same in different newspaper under the name and style of Jeewan Surkasha Ka and given the name Bharti AXA. The complainant claimed the insurance amount and expenses incurred and damages etc from OPs no.1 to 4. OP no.5 is the authority who controlling the affairs of the insurance companies. By seeing the advertisement given by company in various newspapers, TV Channels OPs provided Jeevan Suraksha Ka. He is not well educated be fooled by the said advertisement and insured himself for a sum of Rs.13,00,000/- for the policy term of 15 years on 28th March 2014 as he was not aware this fact that these private companies are befouling the innocent peoples of the country by way of such advertisements in the newspapers. He paid installments in time. Due to will of almighty, he fell ill and was diagnoses of End Stage of Renal Disease and Hem Dialysis on 14.07.2015 as critical illness. He approached OPs company and as per the stereo habits of the private insurance companies rejected his claim. Being aggrieved with the conduct of the OPs, he finally served a written representation dated 18.11.2015 asking the OPs to pay the insured amount, which is most emergent need. Neither he was replied by OPs nor did it paid the amount in question. It is strange that OPs rejected the claim of the complainant but continue the same as per terms and conditions for the purpose of collection of premium. This arbitrary, illegal and unjust action on the part of OPs speaks volume about the malafide intentions of the OPs and amounts to unfair trade practice. The complainant was treated by the doctors of PGI and his mother donated its kidney and the kidney was transplanted and expenses, which are borne for the same i.e. which are not included the expenses borne by the donor are mentioned as under :-
Particulars Payment | Payment made for the test for Dialysis before Transplantations | Payment made for the Test for Transplantation of the Donar and the Donnie | Payment to PGI |
Total payment made to PGI and other institutes for check up etc. | 3200x40=128,000/- 1200x40 = 48,000 1,76,000/- | 90,000/- | 2,32,000/- Rs.4000/- |
Medicines after kidney damaged. | 6000x10 = 60,000/- | | +Rs.60,000/- |
Test after kidney Damaged | 30,000/- | | |
National Kidney, Jalanhar | 20,000/- | | |
Travelling expenses for the patient, attendant, and donor | 2500x40= 82,000/- | | |
Misc expenses | 22,000/- | | |
Medicine at the time of transplant | 3,05,000+ | | Rs. +04,50,000/- |
Total Payment | | | 7,55,000/- |
Due to above said act and conduct of OPs, he has filed the present complaint and prayed that OPs be directed to pay Rs.1,00,000/- for mental tension and harassment and Rs.21,000/- as litigation expenses.
2. Upon notice, OPs appeared and filed written reply and contested the complaint of the complainant by raising preliminary objections that complaint is not maintainable. As per terms of the policy contract if the policy is not suitable holder may get his/her policy reviewed by returning the policy and policy documents within 15 days (free look period) from the day of the policyholder received the policy. The insurance company will return the premium paid to the policyholder after making certain deductions specified therein. The policy documents were dispatched to the policyholder and same was duly received as admitted. The premium installment falling due on or after 28.03.2015 was not paid by the complainant, as a result of which policy was lapsed on 28.03.2015. The policy was later reinstated by the complainant by paying outstanding premium on 19.05.2018. Thus the policy remained in lapsed stage from 28.03.2015 till 19.05.2015 i.e. for a period of almost 2 months. As per the terms and conditions of the policy document,, which were duly received by the complainant, any expenses incurred during the 90 days from the policy commencement date or revival date in case shall not be payable for diseases or surgeries under the Critical Illness Benefit. The relevant clause is stated below:-
9 Policy benefits
9.1 Critical Illness Benefits
The critical illnesses are classified into three groups as mentioned hereunder:-
Group A | Group B | Group C |
Heart Attack | Coma | Cancer |
Coronary Artery Bypass Graft Surgery | Multiple Sclerosis | Benign Brain Tumour |
Major Organ Transplant (Kidney or Heart) | Major Organ Transplant (Liver or Lung) | Major Organ Transplant (Bone Marrow) |
Renal (Kidney) Failure Heart Valve Surgery Stroke Paralysis Paralysis | | |
The critical illness benefits under the policy is stated below:-
Coverage event | Critical illness benefit | Waiting period condition |
First Critical Illness Claim | 100% of sum assured. Failure premium payments towards the policy are waived off. | The date of diagnosis of the first critical illness claim must have occurred after a waiting period of 90 days from the policy issuance date. |
Second Critical Illness claim | 100% of sum assured of critical illness event is not included in the same group for which benefits was paid for the first critical illness claim. | The date of diagnosis of the second critical illness claim must have occurred after a no benefit period of 365 days from the diagnosis date of the first claim. |
Third Critical illness claim | 100% of Sum Assured if critical illness event is not included in the same group for which benefits were paid for the first and second critical illness claim. | The date of diagnosis of the third critical illness claim must have occurred after no benefit period of 365 days from the diagnosis date of the second claim. |
If premium is not paid on the due date or even during the grace period from the due date, the policy shall lapse with effect from the date of such unpaid premium. The company shall notify about lapse of the policy. Lapsation of the policy shall extinguish all rights and benefits under the policy. Rest of the averments of the complainant were denied by OPs and they prayed for dismissal of the complaint.
3. The complainant has tendered in evidence his affidavit Ex.CW-1/A along with copies of the documents Ex.C-1 to Ex.C-7. On the other hand, OPs tendered in evidence affidavit of Sachin Kalra Associate Vice President Legal as Ex.OPA along with copies of documents Ex.OP-1/1 to Ex.OP-1/5 and closed the evidence.
4. We have heard learned counsel for the parties and have also gone through the record of the case very minutely.
5. The glance at evidence is required by us to settle the controversy in this case. The complainant has tendered in evidence his affidavit Ex.CW-1/A. He alleged deficiency in service on the part of OPs. Ex.C-1 is booklet of policy. Ex.C-A is copy of premium receipt. Ex.C-3 is copy of policy specification. Ex.C-5 is copy of claim rejection letter. Ex.C-6 is copy of letter. Ex.C-7 is copy of letter dated 18.11.2015.
6. To refute this evidence of the complainant, OPs tendered in evidence affidavit of Sachin Kalra Associate Vice President Legal of Bharti AXA Life as Ex.OP-A. Ex.OP-1/1 is copy of proposal form. Ex.OP-1/2 is copy of policy bond. Ex.OP-1/3 is copy of premium notice. Ex.OP-1/4 is copy of health claim intimation form.
7. It is an established fact that the complainant had purchased Bharti AXA Life Triple Health Insurance Plan from OPs for a sum of Rs.13,00,000/- for the policy term of 15 years. The issue date is 31.03.2014 and maturity date is 28.03.2028. The premium amount is Rs.6412/-. This fact was also admitted by OPs. The policy document was received by complainant, this fact is clear from Ex.C-1 on the record. This document placed on record by complainant himself. In document Ex.C-3 policy specification the renewal premium amount is mentioned as Rs.5287.66. The diagnosis of End Stage of Renal Disease and Hem Dialysis given to complainant on 14.07.2015 as critical illness. The policy of the complainant lapse since 28.03.2015 which was reinstated on 19.05.2015. The detailed policy with conditions Ex.C-1 placed on record. This document of OPs and they cannot wriggle out from the same. In this document sub clause c of Colum No. 1A Definitions – pertaining to critical illnesses :
C Kidney Failure Requiring Regular Dialysis
End Stage renal disease presenting as chronic irreversible failure of both kidneys to function, as a result of which either regular renal dialysis (hem dialysis or peritoneal dialysis) is instituted or renal transplantation is carried out. Diagnosis has to be confirmed by a specialist medical practitioner.
The diagnosis of End Stage of Renal Disease and Hem Dialysis was given to the complainant on 14.07.2015 as critical illness. This illness include in the above conditions of the policy. This disease relating to the kidney, this also mention in Clause no.2 Benefits Payable. “Kidney failure requiring regular dialysis”
8. The main controversy involved in this case is that the complainant has not paid the premium in time. As per conditions of the policy, if the policy has not acquired a surrender value and premium is not paid on the due date during grace period., then the policy lapse w.e.f. the date of such unpaid premium. The company shall notify the policyholder regarding lapse of the policy. Lapsation of the policy extinguish all the rights and benefits which the policyholder is entitled to under the policy. In case of critical illness being diagnosed during the reinstatement period, no critical illness benefit will be payable. The application for reinstatement is made within two months from the date of the first unpaid premium. This fact was within the knowledge of the complainant. He himself produced on record the detailed terms and conditions of the policy, which is Ex.C-1. The terms and conditions binding upon both the parties and no one wriggle out from the same. The lapsation of the policy due to non-payment of premium paid to OPs. The complainant paid only first premium amount to OPs, as per record. The complainant has not made application for reinstatement of the policy within two years from the date of first unpaid premium.
9. The diagnosis of End Stage of Renal Disease and Hem Dialysis was given to the complainant on 14.07.2015 as critical illness. The policy date is 28.03.2014 and issue date is 31.03.2014, maturity date is 28.03.2029. OPs received the first premium installment for the year 28.03.2014. The premium installment falling due on or after 28.03.2015. The diagnosis was given to complainant on 14.07.2015 and policy lapsed on 28.03.2015 for non-payment of premium amount. The complainant kept mum for almost four years but he has not deposited the premium amount with OPs. The complainant suffered from above disease after four months of lapsation of the policy but he has not made any effort to pursue the policy.
10. The learned counsel for the complainant placed on record judgment titled as John K.O versus United India Insurance Company Ltd reported in 2004(ILR)(Kerala) 59 of Kerla High Court wherein it has been held that insurance companies are bound to renew the policy in the same terms and conditions without imposing onerous conditions or higher premium. These companies are also bound to ensure that they serve the public in securing health care. Further case titled as Dr. Shanthi Rengarajan versus Oriental Insurance Company Ltd and others decided on 09.03.2018 of Hon’ble Madras High Court .The above cited judgments produced by counsel of the complainant are not applicable in the present case.
11. The learned counsel for OPs placed on record judgments :
i) Hon’ble National Commission in case titled as “Prema and others versus Life Insurance Corporation of India reported in IV (2006) CPJ 239 (NC).
ii) Kishore Chandrakant Rathod vs. Managing Director ICICI Prudential Life Insurance Company Ltd and others reported in Revision Petition no. 3390 of 2013.
iii) United India Insurance Company Limited vs. Harchand Rai Chand Rai CHandanlal 1(2003) CPJ 393 of Hon’ble Supreme Court & Vikram Greentech (1) Ltd & Another vs. New India Assurance Co. Ltd reported in II(2009) CPJ 34 of Hon’ble Supreme Court that as insurance policy is to be construed strictly as per terms and conditions of the policy document, which is a binding contract between the parties and nothing can be added or subtracted by giving a differing meaning to the words mentioned therein.
iv) Export Credit Guarantee Corporation of India Ltd vs. Garg Sons International (2013)(1) SCALE 410 of Hon’ble Supreme Court that while construing the terms of the contract of insurance, the court must given paramount important to the terms used in the said contract.
12. From perusal of entire record, it has transpired that the complainant is aware about the terms and conditions of the policy. The complainant alleged in para no.2 of the complaint that he is not well educated be fooled by the advertisement and insured himself with OPs. We do not agree with this submission of the complainant, he is not a layman. He signed the proposal form by himself in English Language, it seems that he is educated person and not a illiterate. The both parties are bound by the terms and conditions of the policy. The above cited judgments of Hon’ble Supreme Court in case titled as Export Credit Guarantee Corporation of India Ltd
United India Insurance Company Limited & Vikram Greentech (supra)
are applicable in the present case. The insurance policy is to be construed strictly as per terms and conditions of the policy document, which is a binding contract between the parties and nothing can be added or subtracted therein. The complainant is guilty of suggest vari and supresso falsi. The complainant has with malafide. The terms of the policy are in the nature of a contract and their interpretation has to be made in accordance with the strict construction of the contract. As per terms and conditions of the policy if premium is not paid on the due date or even, during the grace period from the due date, the policy shall lapse w.e.f. the date of such unpaid premium. This fact was within the knowledge of the complainant. He has himself placed on record the policy document Ex.C-1. Proposal form Ex.OP-1/1 is also signed by the complainant himself in English language. He signed the same with terms and conditions of the policy. The complainant paid only first premium amount to OPs, as per record. Further he has not paid the premium amount to OPs, as such OPs lapse his policy due to non-payment of premium amount as per terms and conditions of the policy. The complainant has also not made any application for reinstatement of the policy to OPs as per norms. He should submit application for reinstatement of the policy within framed time period. But he has failed to do so, so lapse on the part of complainant himself not on the part of OPs.
13. In the light of our above discussion, we are of the considered opinion that no deficiency in service is proved on the part of OPs, as such, the present complaint is hereby dismissed with no order as to costs.
14. Let copies of the order be sent to the parties, as permissible, under the rules.
15. File be indexed and consigned to the record room.
Dated : (Jyotsna) (Kuljit Singh)
09.03.2021 Member President
