Before the District Consumer Disputes Redressal Commission, Rohtak.
Complaint No.: 61.
Instituted on : 7.2.2018.
Decided on : 28.07.2021.
Sh. Dharamvir, aged 51 years son of Shri Chander Bhan, resident of House No.535/33, Kath Mandi, Rohtak.
………..Complainant.
Vs.
- Exide Life Insurance Company Limited (Earlier ING Vysya Life Insurance Company Limited), through its Managing Director, 3rd Floor, JP Techno Park No.3/1, Millers Road, Bangaluru-560001.
- Exide Life Insurance Company Limited(Earlier ING Vysya Life Insurance Company Limited), through its Branch Head/Manager, Ashoka Plaza, Rohtak-124001.
……….Opposite parties.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
MS. TRIPTI PANNU, MEMBER.
Present: Shri Ankur Dua, Advocate for the complainant.
Shri Naveen Chaudhary, Advocate for the opposite parties.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Brief facts of the case are that the officials of the opposite parties met with the complainant and introduced ING Vysya, as Insurance Company of great repute and providing trouble free insurance services, vide policy named “ING MY TERM PLAN”. The complainant gave his consent and availed the policy through the officials of the respondents at Rohtak, vide policy No.02677657 on 12.4.2013 for the term of 10 years on valuable consideration i.e. premium of Rs.1502.26/- monthly for sum assured value of Rs.25 lakhs and in case of critical illness sum assured of Rs.4 lakhs. The complainant got renewed his policy timely. In the month of May, 2014, the complainant felt discomfort and as such he approached Department of Generic Medicine, BPS GMC for Women, Khanpur Kalan, Sonepat, there the complainant underwent for the diagnose of the cerebrovascular accident. It is also averred that it was a case of the emergency/critical situation and it was necessary for the life of the complainant. After discharge from the hospital, he submitted all the necessary/required documents pertaining to his hospitalization and diagnose of the disease well within the time and approached the opposite parties to release the benefit/claim amount but the opposite parties had rejected his claim on account of the no evidence of permanent neurological symptoms vide letter dated 25.09.2017. The alleged letter is false as the complainant submitted the independent physician statement of Dr. Navtej Singh, Assistant Professor & Head Department of Generic Medicine, BPS GMC for Women Khanpur Kalan, Sonepat, in which it is specially mentioned that patient is likely to have chronic/permanent deficits. Hence, this complaint and the complainant has prayed that opposite parties be directed to pay the amount of Rs.4 lakhs alongwith interest @ 18% p.a. from the date of payment till its realization and also to pay an amount of Rs.50,000/- on account of harassment and mental agony to the complainant.
2. After registration of complaint, notices were issued to the opposite parties. Opposite parties in their reply has submitted that the complainant himself approached the respondent company and proposed for taking the policy. Thereafter, all the terms of the policy were duly explained to the complainant and he signed the proposal form after admitting the contents thereof to be correct. In the proposal form he also gave the declaration regarding good health. Upon believing the declaration and disclosure made by the complainant in the proposal Form the respondent issued policy no.02677657 dated 12.04.2013 for a term of 10 years. Under the said policy, the complainant was required to pay monthly premium of Rs.1502/-. The complainant also opted the critical illness riders having sum assured Rs.4,00,000/-. It is wrong that the complainant was regularly paying the premium. The complainant did not pay the premium regularly and consequently the policy was lapsed. Even on 21.5.2014 on the alleged dated of occurrence the policy was in lapse condition. It is wrong that the complainant was medically examined before the issuance of the policy. It is also submitted that the complainant submitted the claim with respondent regarding the alleged treatment taken by him. The respondent received the intimation regarding the alleged treatment in the month of January, 2017 after the lapse of more than 2 years from the treatment. After getting the intimation the complainant vide letter dated 31.01.2017 was asked to provide the certain documents. The complainant did not provide the same and then vide letter dated 12.04.2017, he was again asked to provide the documents and also intimated that the policy was already in lapsed condition when the alleged disease was diagnosed i.e. 21.05.2014. The complainant very cleverly reinstated the policy on 23.05.2014. The respondent also got investigated the treatment taken by the complainant and came to know that the complainant was having the history of hypertension and diabetes mellitus and even underwent surgery at Soni Hospital for the period 15.02.2004 to 11.03.2004. The complainant failed to produce any evidence regarding permanent neurological symptoms as per terms and conditions of the policy. Therefore, the claim of the complainant was repudiated vide letter dated 12.04.2017 and vide letter dated 25.9.2017 as per terms and conditions of the policy. All the other contents of the complaint were stated to be wrong and denied and opposite parties prayed for dismissal of complaint.
3. Complainant in his evidence has tendered affidavits Ex.CW1/A and Ex.CW2/A, documents Ex.C1 to Ex.C5 and has closed his evidence on dated 20.12.2018, tendered document Ex.C6 in additional evidence and further tendered documents Ex.C7 to Ex.C9 in additional evidence and closed his evidence on dated 28.06.2021. Ld. counsel for the opposite parties has tendered affidavit Ex.RW1/A and documents Ex.R1 to Ex.R12 and has closed his evidence on dated 29.07.2019. At the time of arguments respondent officials placed on record Annexure ‘JN-A’, copy of policy schedule, premium receipt alongwith endorsement and terms and conditions of the policy detail from page 1 to 40.
4. We have heard learned counsel for the parties, perused all the documents placed on record by both the parties and have gone through the material aspects of the case very carefully.
5. The claim of the complainant was repudiated by the insurance company vide letter dated 12.04.2017 placed on record as Ex.R8 and dated 25.09.2017 placed on record as Ex.R9. As per letter dated 12.04.2017 Ex.R8, the claim of complainant was denied on the ground that the complainant was hospitalized for headache and subsequent diagnosis with Cerebrovescular accident on dated 21.05.2014 and the policy was subsequently re-instated on dated 23.05.2014. On dated 21.05.2014 the policy was in lapse condition. It is further stated in that letter that the date of diagnosis falls within the waiting period of 90 days. Hence they are unable to admit any liability of the claim of the complainant as per clause no.9.3 of the terms and conditions of the policy. We have perused the terms and conditions placed on record at the time of arguments as ‘JN-A’. There are two types of terms and conditions placed on record. First for the life insurance policy which are mentioned from page no.6 to page no.13 and thereafter the terms and conditions regarding critical illness rider which are from page no.14 to page no.23. The claim of the complainant was repudiated vide terms and condition no.9.3 i.e. under head 9(Termination). The waiting period is described in the terms and conditions of critical illness rider upon page no.15 which is as under: “Waiting period’ is a period of the first 90 days from the effective date”. Here the word effective date is again described upon page no.14 which is as under :- “Effective date’ refers to the date of risk commencement or Risk Commencement Date as specified in the Base policy schedule, or the date on which the rider is incorporated and as mentioned in the Rider Endorsement Letter or the Endorsement on Addition of rider or the date of reinstatement, whichever is the latest”. In the present complaint the main policy was purchased by the complainant on dated 12.04.2013 and the date of policy commencement was 12.04.2013. The rider was also purchased by the complainant on the same day but the date of risk commencement is 20.05.2013. Meaning thereby the rider policy was started from 20.05.2013 and as per the definition, effective date of waiting period of the illness was upto 90 days i.e. 20.05.2013 plus 90 days i.e. 18.08.2013. So the claim of the complainant was wrongly repudiated by the respondent insurance company after mentioning that critical illness condition within a waiting period. Hence the respondent insurance company wrongly calculated the waiting period as grace period and on dated 21.05.2014 the policy was neither terminated nor was in lapse condition. We have also placed reliance upon the judgment dated 28.07.2016 of Hon’ble Supreme Court of India cited by ld. Counsel for the complainant titled as M/s Galada Power and Telecommunication Ltd. vs. UIIC Ltd. and another etc. which is fully applicable on the facts and circumstances of the case.
6. The respondent insurance company again denied the claim of the complainant vide letter dated 25.09.2017 i.e. Ex.R9 on the following ground:
i). “On perusal of the treatment records submitted by you, we note that you were hospitalized for headache and subsequently diagnosed with Cerebrovascular accident on 21.05.2014. We regret to inform you that we are unable to admit any liability on you claim as there is no evidence of permanent neurological symptoms required as per the terms and conditions of the policy”.
ii) “Further, it was also noted that you were admitted at Soni Hospital from dated 15.02.2004 to 11.03.2004 for injury on your left leg and undergone surgery for the same and there was residual deficit in the left leg post–surgery and this material information was not disclosed on the application from dated 12.04.2013 at the time of applying for the policy with us.”
Regarding the first objection, the complainant has placed on record the treatment record which continued for 6 months and as per doctor observation given on Ex.C4 there was a continuous treatment, which is also proved from the treatment record Ex.C2 dated 23.05.2014 and from other documents placed on record as Ex.C7 dated 12.02.2015, OPD card issued by Dr. Pawan Sharma and thereafter Ex.C8 dated 06.04.2015 and Ex.C9 dated 13.05.2015. Meaning thereby after considering documents Ex.C1 to Ex.C3 and Ex.C7 to Ex.C9, it is established that the complainant was under the treatment for more than 6 months. Moreover as per Ex.C4, opinion of doctor, Dr. Navtej Singh, Assistant Professor & Head Department of Generic Medicine, BPS GMC for Women Khanpur Kalan, Sonepat, “Patient is likely to have chronic/permanent deficits”.
7. Regarding the second objection, we have perused the proposal form placed on record as Ex.R3 having 11 pages. On page no.5 the condition no.72 is mentioned as under:-“ Have you suffered from any illness, disorder or injuries during the past 5 years which has required any form of medical or specialized examination. Meaning thereby the complainant has to disclose past 5 years treatment to the insurance company on the date of purchase of the policy. It is pertinent to mention here that the complainant has purchased the policy on 12.04.2013 and the five years back comes to 12.04.2008 whereas the complainant had taken the treatment in the year 2004, so as per the proposal form itself, the respondent officials have not sought any information from the complainant regarding the treatment for the year 2004. So the objection taken by the opposite party is hereby turned down. Moreover, we have perused the investigation report placed on record by the respondent as Ex.R2 and on page no.5 the investigator admits that the medical report and other documents were found genuine. Meaning thereby medical record is genuine. Hence there is deficiency in service on the part of opposite parties in repudiating the claim of the complainant and the complainant is entitled for the rider benefit under the policy Ex.C5 and the rider sum assured is Rs.400000/-.
8. In view of the facts and circumstances of the case we hereby allow the complaint and direct the opposite parties to pay the amount of Rs.400000/-(Rupees four lacs only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e.07.02.2018 till its realization and shall also pay a sum of Rs.5000/-(Rupees five thousand only) as compensation on account of deficiency in service and Rs.5000/-(Rupees five thousand only) as litigation expenses to the complainant within one month from the date of decision.
9. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
28.07.2021 ................................................
Nagender Singh Kadian, President
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Tripti Pannu, Member.
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