BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.
Consumer Complaint No. 313 of 2014
Date of Institution: 3.6.2014
Date of Decision: 27.04.2016
Mr.Jaspreet Singh S/o Sh. Kuldip Singh R/o 57, Sant Nagar, Akhara Kallu, Gate Bhagtanwala, Amritsar
Complainant
Versus
HDFC Standard Life Insurance Co.Ltd., through its Chairman/Managing Director/Principal Officer service through its Branch office at SCO 25, District Shopping Complex, Ranjit Avenue, Amritsar through its Branch Manager
Opposite Party
Complaint under sections 12 & 13 of the Consumer Protection Act, 1986
Present: For the Complainant : Sh. Deepinder Singh,Advocate
For the Opposite Party :Sh.Munish Kohli, Advocate
Coram
Sh.S.S.Panesar, President
Ms.Kulwant Kaur Bajwa, Member
Sh.Anoop Sharma,Member
Order dictated by:
Sh.S.S. Panesar, President.
1. Jaspreet singh, complainant has brought the instant complaint under section 12 & 13 of the Consumer Protection Act, 1986 on the allegations, that the complainant obtained insurance policy from the opposite party covering risk for the period w.e.f. 18.6.2003 for covering risk period for next 20 years by paying the premium amount of Rs. 4280/-, copy of the cover note is annexed. As such complainant is a consumer as provided under the Act and is competent to invoke the jurisdiction of this Forum. The complainant unfortunately fell ill having severe cardiac disorder and was to be hospitalized for the period from 20.8.2012 morning till 27.8.2012 late evening at AIMS, New Delhi. The complainant underwent cardiac surgery in critical condition and the hospitalization amount raised by the said hospital for hospitalization is to the tune of Rs. 92,500/- excluding the medication . Whereas the complainant was insured for an amount of Rs. 1,00,000/-. The complainant filed the claim with the opposite party. But the opposite party did not inform the complainant about the fate of his claim despite repeated visits by the complainant. Claim of the complainant has been later on repudiated on frivolous grounds vide letter dated 5.12.2012 stating that the treatment of cardiac surgery was not covered under the critical illness clause . The ground is not sustainable in the eye of law. Copy of repudiation letter is annexed . It is pertinent to mention here that opposite party has not communicated anything to the complainant as alleged in their status report, no letter has ever been received by the complainant, as alleged. Opposite party failed to go through the medical treatment taken by the complainant and the status of the insurance obtained by the complainant. Repudiation of the genuine claim of the complainant without ascertaining the correct facts by the opposite party is arbitrary act of the opposite party. The complainant has complied with all the formalities as required by the opposite party from time to time for settlement of his genuine claim. But the claim was repudiated on frivolous grounds which amounts to deficiency in service, unfair trade practice and mal-practice on the part of the opposite party. The complainant has prayed for the following reliefs against the opposite party:-
(a) The opposite party be directed to pay the amount of Rs. One lac alongwith interest @ 12% p.a from 30.9.2011 till realization.
(b) The opposite party be directed to pay the compensation of Rs. 50000/- to the complainant.
(c ) The opposite party be directed to pay the adequate cost of litigation.
Any other relief to which the complainant is found entitled to under the law, equity and justice be also allowed.
2. Upon notice, opposite party appeared and contested the complaint by filing written reply taking certain preliminary objections therein inter alia that the complaint is malafide and has been filed with a view to harass and pressurize the opposite party ; that there is no deficiency in service on the part of the replying opposite party and the opposite party have acted in due course in a lawful manner while discharging their official duties ; that the complainant has not approached this Forum with clean hands and as such the complaint is liable to be dismissed. The real facts are that the complainant had taken HDFC Money Back Assurance Policy dated 18.6.2003 for a term of 20 years by paying half yearly premium of Rs. 4280/-. The complainant had duly signed a proposal form for the purchase of HDFC Insurance Policy. The proposal was accepted on the standard rates based on the information provided by the complainant and consequently policies were issued bearing No. 000000197192 to the complainant. At the time of taking the policy the official of the opposite party well elaborated all the terms and conditions of the policy to the complainant and the complainant in the complaint is well aware of the rider of Critical Illness Benefit. Critical Illness Benefit has been denied in the additional policy provision in critical illness benefit in column No. 2. Critical illness which is covered is (a) Cancer- A malignant tumor characterized by the uncontrolled growth and spread of malignant cells and the invasion of tissue. The diagnosis must be histological confirmed. The term cancer includes leukemia but the following cancers are excluded : all tumors which are histological described as pre-malignant, non-invasive or carcinoma in situ ; al forms of lymphoma in the presence of HIV ; Kaposi’s Sarcoma in the presence of any HIV ; any skin cancer other than invasive malignant melanoma ; and early prostrate cancer which is histological described as T1 (including T1 and T1b) or another equivalent or lesser classification (b) Coronary Artery bypass Graft surgery (CABGS) the undergoing of open heart surgery on the advice of a consultant cardiologist to correct narrowing or blockage of one or more coronary arteries with bypass grafts. Angiographic evidence to support the necessity of the surgery will be required. Balloon Angioplastry, laster or any catheter based procedures are not cover (c) Heart Attack- The death of a portion of heart muscle as a result of an inadequate blood supply as evidenced by an episode of typical chest pain, new electro cardio graphic changes and by elevation of the cardiac enzymes (d) Kidney failure- End stage renal failure presenting as chronic irreversible failure of both kidneys to function, as a result of which either regular renal dialysis or renal transplant is undertaken. Evidence of end stage kidney disease must be provided and the requirement for dialysis or transplantation must be confirmed (e) Major Organ Transplant-The actual undergoing as a recipient of a transplant of a heart, liver, lung, pancreas or bone marrow as a result of chronic irreversible failure. Evidence of end stage disease must be provided and the requirement for transplantation must be confirmed (f) Stroke- A cerbro vascular incident resulting in permanent neurological damage. Transient ischemic attacks are specifically excluded. That the present complaint has been presented in such a manner so that it presents a distorted and twisted picture only with an intention to misguide and confuse this Forum and to extract a favourable decision. On merits , facts narrated in the complaint have been specifically denied and a prayer for dismissal of the instant complaint with cost was made.
3. In his bid to prove the case Sh. Deepinder Singh,Adv.counsel for the complainant tendered into evidence affidavit of Jaspreet Singh, complainant Ex.C-1 reiterating the facts stated in the complaint, copy of the policy document Ex.C-2, copy of repudiation letter Ex.C-3,discharge summary Ex.C-4, payment receipts Ex.C-5 and Ex.C-6 and closed the evidence on behalf of the complainant.
4. To rebut the aforesaid evidence Sh.Munish Kohli,Adv.counsel for the opposite party tendered into evidence affidavit of Sh. Amit Khanna Ex.OP1, copy of policy schedule Ex.OP2, nomination schedule Ex.OP3, copy of proposal form Ex.OP4, copy of standard policy provisions Ex.OP5 and Ex.OP6, additional policy provisions Ex.OP7 and closed the evidence on behalf of the opposite party.
5. We have heard the ld.counsel for both the parties and have carefully gone through the record .
6. On the basis of evidence on record, ld.counsel for the opposite party has vehemently contended that no doubt the complainant obtained the Insurance policy in dispute copy whereof is Ex.C-2 on record, from the opposite party by depositing six monthly premium to the tune of Rs. 4280= on 18.6.2003 for a term of 20 years. It is also not disputed that the complainant was hospitalized for the period from 20.8.2012 morning till 27.8.2012 late evening at AIMS , New Delhi and underwent cardiac surgery there. It is also not disputed that the complainant spent an amount of Rs. 92500/- on his treatment at the hospital. But, however, according to the additional policy provisions, copy whereof is Ex.OP7, Cardiac surgery is not covered under critical illness benefit. It is the case of the opposite party that the complainant was made fully award at the time of obtaining the Insurance policy in dispute that it was cancer or other related diseases which are covered under critical illness claim. It is further contended that the claim of the complainant has rightly been declined vide letter dated 5.12.2012 , copy whereof is Ex.OP5 and there is no deficiency in service on the part of the opposite party. Instant complaint is nothing but an abuse of the process of the court and the complaint being meritless is liable to be dismissed.
7. But,however, from the appreciation of the facts and circumstances of the case, it becomes amply clear that the complainant obtained Insurance policy, copy whereof is Ex.C-2 on record for a period of 20 years on payment of six monthly instalments to the tune of Rs. 4280/- on 18.6.2003. It is also not disputed that the complainant fell ill and had to be hospitalized at AIMS ,New Delhi w.e.f 20.8.2012 morning till 29.8.2012 late evening. The ground on which the claim of the complainant has been repudiated , has been that the disease of cardiac disorder was not covered under the term critical illness and for that purpose a reference has been made to document Ex.OP7 i.e. additional policy provisions. But, however, there is nothing on record that those provisions were brought to the notice of the complainant at the time of the issue of the policy. The onus was upon the opposite party to prove that fact to successfully absolve it from the liability. We stand fortified on this point from the case Ravneet Singh Bagga Vs. M/s. KLM RoyalDutch Airlines and another, 2000(1) CLT (SC) wherein it has been held by the Hon'ble Apex Court that in case deficiency in service is alleged, then burden of proof is upon the person, who alleges it.
8. Since the opposite party has tried to draw the benefit of exclusion clause without proving the factum that the same was brought to the notice of the complainant. Therefore, repudiation made on the exclusion , is not sustainable at law. The complainant has adduced on record the bill/invoice of the AIMS Hospital,New Delhi which is for a tune of Rs. 92,500/-, whereas the Insurance cover was to the tune of Rs. 1,00,000/-. Therefore, the claim made by the complainant was within the scope of the Insurance cover.
9. In our considered opinion, the complainant is entitled to recover the amount of Rs. 92,500/- from the opposite party and the opposite party is directed to make payment of the granted amount within a period of 30 days from the receipt of copy of this order ; failing which, the awarded amount shall carry interest @ 9% p.a from the date of passing of the order until full and final recovery. Copies of the orders be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.
Announced in Open Forum
Dated : 27.4.2016
/R/ ( S.S.Panesar )
President
( Kulwant Kaur Bajwa) (Anoop Sharma)
Member Member
