DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,<br /> BATHINDA <br /> <br /> CC. No. 137 of 08-05-2008<br /> Decided on : 23-04-2009 <br /> <br /> Lekh Raj Kataria aged about 49 years S/o Sh. Gobind Singh, R/o H. No. 4144, Qila Road, Opp. Arora Vansh Dharamshala, Bathinda. ... Complainant<br /> Versus<br /> 1.Branch Manager, HDFC Standard Life Insurance Company Limited, Ground Floor, 3038-A, Dalip Singh Walia Complex, Guru Kanshi Marg, National Highway No. 15, Bathinda.<br /> 2.Manager Claims, IInd Floor, 'A' Wing 'Trade Star' Junction of Kondivita & M.V. Road, Andheri- Kurla Road, Andheri (East) Mumbai.<br /> 3.Managing Director, IInd Floor, 'A' Wing 'Trade Star' Junction of Kondivita & M.V. Road, Andheri- Kurla Road, Andheri (East) Mumbai.<br /> <br /> ... Opposite parties<br /> <br /> Complaint under Section 12 of the Consumer Protection<br /> Act, 1986.<br /> <br /> QUORUM <br /> <br /> Sh. Pritam Singh Dhanoa, President<br /> Dr.Phulinder Preet, Member<br /> Sh. Amarjeet Paul, Member<br /> <br /> Present : Sh. Mithu Ram Gupta, Advocate, counsel for the complainant<br /> Sh. Vinod Garg, Advocate, counsel for opposite parties.<br /> <br /> O R D E R<br /> <br /> SH. PRITAM SINGH DHANOA, PRESIDENT <br /> 1. This complaint has been filed by Sh. Lekh Raj Kataria, son of Sh. Gobind Singh, a resident of Bathinda, under Section 12 of the Consumer Protection Act, 1986 ( in short called the 'Act'), against HDFC Standard Life Insurance Company through its Branch Manager, Bathinda and Manager (Claims) and Managing Director, Mumbai, for giving them direction to make him payment of “Extra Health Benefit Scheme” under the Insurance policy alongwith a sum of Rs. 20,000/- on account of damages in addition to costs of filing of instant complaint. Briefly stated the case of the complainant is as under :<br /> That he has secured Insurance policy namely “Young-star unit” linked No. 10292024 in the sum of Rs. 2,00,000/- containing “Extra Health Benefit” clause, from the opposite parties. As per terms and conditions of the policy, the Insurer is liable to pay compensation if Insured becomes critically ill under clause of “Extra Health Benefit”. The complainant had been paying the premium regularly in time which he was liable to pay per annum as per schedule of payment. In the year, 2006, he fell sick and as per diagnosis by the doctor concerned, posted in Garg Nursing Home, Bathinda, he suffered chest pain leading to heart attack. The complainant remained admitted in the said hospital and after discharge, he submitted the claim to the opposite parties under the policy alongwith requisite documents including prescription slips, opinion of the doctors and medical reports, but his claim was repudiated by them illegally and in arbitrary manner on 21-09-2006 on the ground that it does not satisfy the condition of policy which had already lapsed due to non-payment of amount of premium. However, the policy was revived by the opposite parties after the requisite amount was deposited by the complainant.<br /> 2. On 27-01-2008, the complainant again fell sick and doctor diagnosed his disease as chest pain leading to heart attack. Thereafter, he remained admitted in Garg Nursing Home, Bathinda, from 27-01-2008 to 01-02-2008. On his discharge, he again lodged the claim under the policy with the opposite parties, but they demanded documents from him. Ultimately, they repudiated his claim vide their letter dated 19-03-2008 on the ground that there are no changes in the state of his health than those reported in the month of August, 2006 or further deterioration of his health whereas in the letter dated 21-09-2006, opposite parties have accepted that medical record supplied by the complainant on 31-05-2006 satisfies the terms and conditions of the policy. However as the policy remained lapsed between 7th July, 2006 to 25th August, 2006, but had been revived by the opposite parties, as such, the same continues under “Extra Health Benefit Scheme” and complainant is entitled to payment of amount of claim for his sickness with effect from 27-01-2008. He has also been subjected to mental and physical harassment due to negligence and carelessness on the part of the opposite parties and repudiation of his just claim. Hence, this complaint.<br /> 3. On being put to notice, opposite parties filed written version resisting the complaint by taking preliminary objections; that complaint is not maintainable; that complainant is not consumer within the ambit of its definition given in the Act; that complaint is false and vexatious and has been filed to damage the reputation of the opposite parties; that he has no cause of action and locus standi to file the complaint; that intricate question of law and fact are involved for adjudication of which parties need to lead elaborate evidence, as such, matter can be properly decided by civil court and not by this Forum in summary manner; that complainant has concealed material facts from this Forum; that claim lodged by the complainant cannot be allowed beyond the scope of agreement, as such, his complaint is liable to be dismissed with special costs. On merits, it is admitted that complainant secured “Unit Linked Young Star Plan Policy: from the opposite parties w.e.f. 21-06-2005 with “Extra Health Benefit Scheme” as defined in clause 17 thereof. The claim lodged by the complainant has been repudiated because the same does not meet the requirements of the said provisions. It is denied that complainant is entitled to payment of Rs. 2,00,000/- on account of claim. It is admitted that policy secured by the complainant had lapsed on 21-06-2006 because he did not pay the premium in the sum of Rs. 2500/- even within the grace period but on being informed about the said fact vide letter dated 10-07-2006, policy was revived vide letter dated 25-08-2006. It is admitted that complainant lodged a complaint on 11-09-2006 on similar ground but as per documents submitted by the complainant his ECG taken on 03-08-2006 did not show sufficient changes leading to heart attack. It is denied that complainant suffered any heart attack in the years 2006 and 2008 or that he remained admitted in the hospital from 27-01-2008 to 01-02-2008 and he lodged claims on 23-02-2008 alongwith relevant papers. It is contended that as there was no further deterioration of his health or new changes in the ECG, as such, his claim was repudiated vide letter dated 19-03-2008. Rest of the averments made in the complaint have been denied and prayer has been made for dismissal of the same with compensatory costs.<br /> 4. On being called by this Forum, to do so, counsel for the complainant furnished his affidavit Ex. C-1 and copies of documents Ex. C-2 to Ex. C-14 before he closed his evidence. On the other hand, counsel for the opposite parties furnished affidavit of Sh. Raj Kumar, (Operations Manager), Ex. R-1, and copies of documents Ex. R-2 to Ex. R-4, before he closed their evidence.<br /> 5. We have heard, learned counsel for the parties and perused the oral and documentary evidence adduced on record by them, carefully, with their kind assistance.<br /> 6. At the outset, learned counsel for the complainant Sh. Mithu Ram Gupta, Advocate, has submitted that factum of issuance of policy, its lapse, revival and repudiation of claims preferred by the complainant are admitted by the opposite parties. Learned counsel has argued that complainant is entitled to the payment of claim lodged for the ailments suffered by him in the year, 2008, as per Clause 3(iii) of the policy, wherein it has been provided that “Extra Health Benefit” is payable if life insured becomes critically ill and suffers from one of the diseases defined under provision 17 and the policy shall continue to be in force until the date of its expiry. Learned counsel has argued that as per clause 17 (c) of the policy, chest pain suffered by the insured established by new electrocardiagraphic changes and by elevation of cardiac enzymes is sufficient for making payment of amount spent by him on his treatment but the opposite parties have repudiated claim lodged by the complainant in arbitrary and illegal manner and the reasons given by them are not inconsonance with the policy, as such there is deficiency in service due to whch complainant has been subjected to mental and physical agony, as such, he is entitled to payment of claim, waiver of his premium from the date of diagnosis and payment of compensation and costs incurred by him for filing of the instant complaint. Learned counsel has also drawn our attention to the document Ex. C-14, whereby payment of Rs. 15,261.80 has been paid in the name of Mrs. Renu Kataria against policy No. 10292024 and has argued that this fact substantiate the plea of the complainant that opposite parties were not justified in repudiating the claim of the complainant, otherwise there was no logic in payment of said amount, during pendency of complaint.<br /> 7. On the other hand, learned counsel for the opposite parties Sh. Vinod Garg, Advocate, has submitted that once the terms of the policy are reduced into writing, the parties are bound by the same. Learned counsel has argued that claim is payable under “Extra Health Benefit Scheme” in terms of clause 3 read with clause 17 of the policy if a portion a muscle of heart is proved to have become dead, but as per the documents furnished by the complainant, he just suffered from heart pain and has shown sufficient improvement at the time of his discharge from the hospital. Learned counsel has argued that initial onus was upon the complainant to establish that his case falls under the above said provisions, but he has failed to discharge the same, as such, onus never shifted on the opposite parties to prove to the contrary. Learned counsel has further argued that complainant has not examined the doctor who examined and treated him, as such, he has withheld the best evidence because of which reliance cannot be placed on the documents tendered in evidence by him. Learned counsel argued that amount paid vide Ex. C-14 does not pertain to any of the claim preferred by the complainant under “Extra Health Benefit Scheme”, as such, inference cannot be drawn that opposite parties accept the deficiency in service. Learned counsel has argued that there is no deficiency in service on the part of the opposite parties on account of which any amount may be paid to the complainant alongwith compensation and costs against claim preferred by him or further premium may be waived off. Learned counsel has urged that complaint, being false and vexatious, is liable to be dismissed with special costs.<br /> 8. The adjudication of the controversy involved in this complaint depends upon the interpretation of different clauses of Insurance policy and documents tendered in evidence by the complainant and furnished by him with his claim lodged with the opposite parties. As observed above, in earlier part of the order, as per Clause 3 (iii), of the Insurance policy the sum assured is payable to the claimant against “Extra Health Benefit Scheme” under the policy to the insured if he establishes that he remained critically sick and suffered from one of the diseases defined in Clause 17 thereof. In such a situation, the claimant is also absolved of his liability to pay future premium from the date of diagnosis of his disease till the date of expiry of policy. The Clause 17(c), policy provides that in case of heart attack , there shall be death of a portion of heart muscle as a result of an inadequate supply of blood as evidenced by an episode of typical chest pain, new electrocardiographic changes and by elevation of the cardiac enzymes. <br /> 9. The conjoint reading of the above said Clauses reveals that above said benefits are payable in the even of a death of part of heart muscle as a result of inadequate supply of blood has taken place after chest pain and established by electrocardiographic changes and by elevation of the cardiac enzymes but the perusal of the documents produced on record by the complainant including “Summary and Progress Report” Ex. C-12, goes to show that he was admitted in the hospital with chest pain which subsided after treatment in the Hospital. The ECG of the complainant demonstrate changes and initially it was detected that a part of muscle of inferior wall of heart had become dead due to non-supply of blood but it was revived after treatment after administration of injections of Molecule Weight Heparin. The ECG also became normal, as mentioned in the Discharge Summary Ex. C-12, and at the time of his discharge, complainant had no chest pain and was feeling comfortable. In view of these remarks given in the documents tendered in evidence by the complainant himself, we express our inability to accept his plea that he is entitled to payment of claim under “Extra Benefit Health Scheme” and waiver of amount of future premium in terms of Clause 17 of Insurance Policy.<br /> 10. The opposite parties while repudiating the claim lodged by the complainant in the year, 2008, have stated that there is no change in the condition of his health as mentioned in the documents over his condition in the year, 2006. The complainant has not claimed any relief in the instant claim for payment of his claim rejected in the year, 2006. These reasons given by the opposite parties in the letter of repudiation for his claim, lodged in the year 2008, in our opinion does not amount to admission on their part that any part of his muscle has become permanently dead. Since the ailment suffered by the complainant in the portion of his heart muscle, stands cured with treatment at the time of discharge from the hospital, therefore, repudiation of his claim can neither be termed as arbitrary nor illegal, on the part of the opposite parties. The payment in the sum of Rs. 1526.80 has been made vide Ex. C-14 in the name of Mrs. Renu Kataria and not in the name of the complainant himself although against the same policy. Had the said payment has any concern with the claim lodged by the complainant, then the cheque may have been issued in his name as he is still alive. Therefore, on the basis of this document, liability cannot be fastened upon the opposite parties.<br /> 11. In the light of our above discussion, we have come to the conclusion that there is no deficiency in service on the part of the opposite parties on account of which complainant might have been subjected to mental and physical agony and may be held entitled to seek any amount on that score or as compensation and expenses incurred by him for filing of instant complaint.<br /> 12. For the aforesaid reasons, we dismiss the complaint and leave the parties to bear their own costs. The copies of this order be sent to the parties, free of costs as permissible under the rules, on the subject. <br /> File be indexed and consigned. <br /> Pronounced :<br /> 23-04-2009 (Pritam Singh Dhanoa)<br /> President<br /> <br /> <br /> (Dr. Phulinder Preet)<br /> Member <br /> <br /> (Amarjeet Paul)<br /> Member <br /> <br /> <br />