C.C. No.77/2021

Ranjan Kumar Swain,

S/o. Late Dhuleswar Swain,

Vill.- Kalioda,

P.O.- Mohiuddinpur,

P.S./Dist.- Jagatsinghpur.                                         ..………. Complainant

                                 (Versus)

1. Branch Manager,

Aditya Birla Sun Life Insurance Co. Ltd.,

Near Suryamandir Fashion, Sanabazar,

Jagatsinghpur- 754103.

2. Aditya Birla Sun Life Insurance Co. Ltd.,

Having registered office

One Indiahulls Centre, Tower-1,

841, Senapati Bapat Marg,

Elphinstone Road,

Mumbai- 40013.…..…..… Opposite parties

For Complainant ………..Mr. H.K. Barik & Associates

For Opposite Parties……….. Mr. S.K. Nayak & Associates

ORDER BY HON’BLE PRESIDENT- MR. P.K. PADHI:

                                                                            JUDGMENT

            Complainant has filed this consumer complaint U/s.35 of C.P. Act, 2019 seeking following reliefs;

            “Direct the opposite parties pay the claim amount of Rs.11,50,000/- along with interest and cost”.

            The brief fact of the case is that, the complainant motivated by the agent of opposite parties availed an insurance policy under opposite parties bearing No.007316504 on 05.7.2017 and the said policy was valid for a period of five years commencing from 16.6.2017. As per terms and conditions of the policy the complainant has paid the premium annually a sum of Rs.1,206/- on 31.5.2017, 29.6.2018, 27.8.2019 and 15.7.2020 and obtained receipts. As per terms and conditions if the complainant suffer from any disease like kidney or heart within the policy period he will get a sum of Rs.10,00,000/- from the opposite parties. Unfortunately the complainant suffered from heart attack on 29.6.2020 and admitted at Apolo Hospital as indoor patent from 29.6.2020 to 06.7.2020 and informed the opposite parties immediately. After recovery and discharge from the medical the complainant submitted all the required documents from the hospital along with the required papers issued by the treating Doctor on 29.7.2020.  The opposite parties by practicing unfair trade practice adopting delayed procedure for settlement of the claim made by the complainant and on 28.12.2020 refused to pay any claim to the complainant.

            Opposite party filed written version stating as under;

            The policy was issued to the complainant on 16.6.2017 and total premium amount of Rs.49,235/- was paid by the complainant. However, on 16.6.2019 the policy of the complainant got lapsed due to nonpayment of renewal premiums. The complainant had to submit fresh certificate of insurability to renew its policy. Finally the policy was reinstated on 24.10.2019. On 29.7.2020 the opposite parties received claim intimation form from the complainant wherein it was stated that the policy holder suffered from heart disease and was admitted to Apollo Hospital on 29.6.2020. Also the policy holder underwent treatment for coronary artery disease and was admitted till 07.7.2020. On receipt of the claim intimation form the opposite parties scrutinized all the documents and it was found that the complainant/policy holder had history of Dyspnea on exertion form the past 6 months which clearly shows that the complainant was suffering from the said disease since Dec.2019 which is within waiting period as the policy holder/complainant had reinstated his policy on 24.10.2019. Since the complainant applied for the claim which was evaluated and found that the policy holder had signs and symptoms related to coronary artery disease within 180 days of reinstatement of the policy. Therefore the opposite parties rejected the claim of the complainant as per the terms and conditions of the policy and intimated the same to the complainant vide letter dtd.26.11.2020.  

            The policy was commenced w.e.f. 16.6.2017 and got lapsed on 19.6.2019 due to nonpayment of yearly premium but revived on payment of the policy on 27.8.2019 on payment of premium. The policy was revived on 27.8.2019 on payment of renewal premium and in the letter dt.26.11.2020 at Annexure- E of written version it is stipulated as under;

            “The above policy was issued on June 16, 2017 based on the proposal for insurance dated May 31, 2017 signed by you. The policy was lapsed on June 16, 2019 and was reinstated in October 24, 2019 based on certificate of insurance dated October 23, 2019 signed by you.

We have carefully evaluated the claim and noted that you were having signs and symptoms related to Coronary Artery Disease within 180 days of reinstatement of the policy.”

But we found that complainant was admitted in Appolo Hospital on 29.6.2020 and admitted till 07.7.2020 as such the date of admission in Appolo Hospital is after 6 months of revival of the policy as such the same is not applicable and rejection of claim on the said ground is not justified. Once the premium has been accepted by the opposite parties and the policy having been commenced from 16.6.2017 it is unfair on the part of opposite parties to entirely reject/repudiate the claim. The policy holder has paid the premium and at the time of paying premium he has suffered the disease but subsequently paid the premium and the policy was continued and treated to be in force as such we find that there is substantial force in the argument of complainant as such we allow the consumer complaint in part and held that balance of convince is in favour of complainant for which we direct the opposite parties to pay of the claim as complainant has already paid the premium, revival the policy and the same has been accepted by opposite parties. The claim shall be paid to complainant within 45 days from the date of receipt of the order or 60 days from the date of passing of the order. With the aforesaid observation and direction consumer complaint is disposed of. No cost.  

            Pronounced in the open Commission on this 7^th June,2024.