Haryana

StateCommission

A/917/2015

ICICI PRU. LIFE INSURANCE CO.LTD. - Complainant(s)

Versus

DAVINDER SINGH BALI - Opp.Party(s)

K.S.CHEEMA

01 Mar 2017

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

HARYANA PANCHKULA

 

 

First Appeal No.917 of 2015

Date of the Institution:20.10.2015

Date of Decision:01.03.2017

 

1.      M/s ICICI Prudential Life Insurance Company Limited, ICICI PruLife Towers 1089, Appasahed Marthe Marg, Prabhadevi Mumbai-400025.

2.      Mr. Sachin Gupta, Associate Manager,

3.      Mr. Vikas Sharma, Business Manager, ICICI Prudential Life Insurance Company Ltd., SCO No.256, Sector-12, Urban Estate Karnal.

                                                                             .….Appellants

Versus

Davinder Singh Bali S/o Late Sh. Kishan Singh Bali, resident of House No.10, Minar Road, Karnal, Haryana.

                                                                             .….Respondent

CORAM:    Mr.R.K.Bishnoi, Judicial Member

                    Mrs. Urvashi Agnihotri, Member

 

Present:-    Mr.Hitender Kansal, proxy counsel for Mr. K.S. Cheema, Advocate for the appellants.

Mr. Vishal Kundli & Mr. Ajay Bhardwaj, Advocates for respondent.

 

O R D E R

URVASHI AGNIHOTRI, MEMBER:

 

1. M/s ICICI Prudential Life Insurance Co. Ltd. and Ors.-OPs are in appeal against the Order dated 24.08.2015, passed by the learned District Consumer Disputes Redressal Forum, Karnal (for short ‘District Forum’), whereby complaint of Davinder Singh Bali has been allowed, by directing the OPs as under:-

“OP No.1 to make the payment of Rs.4,28,135/- to the complainant alongwith interest @ 9% from the date of filing of the present complaint i.e. 21.08.2013 till its actual realization. The complainant shall also be entitled for a sum of Rs.10,000/- for the mental agony and harassment suffered by him and litigation expenses.”

 

2. Briefly stated, according to the complainant, he purchased a medical insurance policy No.1670573 on 13.06.2012 from opposite party (in short ‘OP’) for Rs.40,000/-. The OPs No.2 and 3 got singed some blank forms from him on the pretext that they would fill details themselves and get policy issued. In the application for the said policy, they included name of his wife Smt. Sarabjit Kaur and their three children. He had disclosed to OPs No.2 and 3 that onone of his family members had medical history except his wife, who was recently hospitalized for treatment of fever. He and his wife were called for medical check up, which was conducted by the doctor duly authorized by the OPs. When the complainant received the policy, he found that some wrong information were mentioned in the proposal form and he immediately informed the OPs No.2 and 3 in that regard and asked them to get those information rectified. They promised to do so, but the information were never corrected. In January, 2013 his wife felt some uneasiness and after thorough check up she was diagnosed of Arterial septal defect commonly known as ASD and a case of left and right chambers of heart having opening between them. She was admitted in the hospital on 06.2.2013 and surgery was conducted. The policy was cashless one and he told the hospital authorities about the same but at the time of discharge, hospital authorities told that OPs had refused to provide cashless benefit, therefore, he had to make the payment of Rs.4,28,145/- as per bill dated 08.02.2013. OP No.1 had assured for early settlement of the claim, but on 17.05.2013 he received letter regarding repudiation of the claim on the ground that medical history prior to proposal was not disclosed in the proposal form. Even the complainant requested for re-consideration of the repudiation of the claim but vide letter dated 11.07.2013, the OP refused to do so. Aggrieved by this, the complainant approached the District Forum for the redressal of her grievance.
3. Pursuant to notice, the opposite parties appeared and filed the written reply pleading that the policy was issued by the OPs on the basis of information provided by the complainant and his wife in the proposal form. The complainant did not disclose that his wife was diagnosed of type II Diabetes Mellitus with Hypertension, with Hypovitaminosis D with Urosepsis with Diabetic Ketosis with Uncontrolled Hyperglycemia and was given treatment for the same on March 21, 2012. Thus, life assured had knowledge of her adverse medical condition and suppressed the same from OPs, which led to issuance of the policy. the claim was repudiated by a speaking order and there was no deficiency in service on the part of OPs. However, the learned District Forum rejected the pleas raised by the OPs and accepted the complaint vide order dated 24.08.2015 by granting the aforesaid relief to the complainant. 
4. Against the impugned order, the OP/appellants have filed appeal before us reiterating their pleas as raised before the District Forum. We have heard the learned counsel for the appellant and have gone through the record.  The learned District Forum in its detailed and well reasoned order has thoroughly considered the relevancy and the alleged seriousness of the ailment of which the complainant’s wife was suffering. No doubt the wife of the complainant was suffering from diabetes mellitus-type II, but she was fully examined by the doctor deputed by the insurance company before the policy was issued to her husband. No objection whatsoever was raised by the doctor at that time, nor was the complainant apprised of the fact that his wife was suffering from ASD. Otherwise also, ASD had no direct relation with diabetes mellitus-type II for which the wife of the complainant had taken treatment from Apollo Hospital. Thus, there was not concealment of any material fact whatsoever on the part of the complainant and the repudiation of the claim was therefore, wholly illegal, without any basis. The conclusions arrived at by learned District Forum are in accordance with law and the repudiation of the claim is wholly in called for. The insurance company is, therefore, certainly liable for the deficiency in service on their part. Accordingly the appeal filed by them is dismissed and order passed by learned District Forum is upheld.
5.   The statutory amount of Rs.25,000/- deposited at the time of filing the appeal be refunded to the appellants against proper receipt and identification in accordance with rules.

 

March 01st, 2017

Urvashi Agnihotri, Member, Addl.Bench

R.K.Bishnoi, Judicial Member Addl.Bench