Before the District Consumer Disputes Redressal Forum, Rohtak.
Complaint No. : 01.
Instituted on : 02.01.2017.
Decided on : 05.12.2018
1 Ram Kumar son of Sh. Deep Chand,
2 Satto Devi @ Satwant wife of Sh. Ram Kumar,
Both residents of VPO Dadri Toe, District Jhajjar.
………..Complainants.
Vs.
1 ICICI Bank Ltd., Ashok Plaza, Rohtak through its Manager.
2 ICICI Lombard General Insurance Company Ltd., ICICI Lombard GIC Ltd, ICICI Lombard Health Care, ICICI Bank Tower, Plot No. 12, Financial District Nanakram Guda; Gachibowli, Hyderabad, Telangana-500032.
……….Opposite parties.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
SH. VED PAL, MEMBER.
SMT. SAROJ BALA BOHRA, MEMBER.
Present: Sh. DS Chauhan, Advocate for the complainant.
Sh. Naveen Chaudhary, Advocate for OP No. 1.
Sh. Yogesh Sharma, Advocate for OP No. 2.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Brief facts of the case are that life of complainant’s son
Baljeet Singh was insured vide policy No. 4065/ICICIAL/100673248/ 00/000 for a period from 13.02.2015 to 12.02.2020 for the respondent company and accordingly respondent company issued a policy in favour of Baljeet i.e. assured amount under car loan, Beema Kawach Scheme bearing Car No. HR-14L-1246 through respondent No.1. That baljeet Singh suffered all of sudden from serious and major medical illness and got treatment from various hospitals i.e. Advanta Super Speciality Hospital, Silani Gate, Jhajjar and Batra Hospital and Medical Research Centre, New Delhi etc. and expired on 18.10.2015 during the treatment. That the complainants are the parents and only legal heirs of Baljeet Singh and entitled to the insured amount alongwith all benefits. The complainants applied for the disbursement of the insured amount and the information regarding the death of Baljeet Singh with all documents required by respondent company. That respondent company vide their letter dated 12.07.2016 made the claim as inadmissible as per policy. That the act and conduct of respondents is illegal and amounts to deficiency in service. It is, therefore, prayed that the respondent No. 2 may kindly be directed to disburse the claim amount against the insurance policy alongwith other benefits + interest at the rate of 18% per annum from the death of Bijender Singh i.e. 18.10.2015till the date of actual realization. It is further prayed that respondent No. 1 may kindly be also directed to settle the car loan and balance amount of the deceased Baljeet be refunded to the complainant.
2 After registration of complaint, notice was issued to the opposite parties. Opposite party No. 1 in its reply submitted that the complainants have concealed the fact that the loan account No. LAJHJ00031753405 in the name of Baljeet Singh is still active and an amount of Rs.2,86,526.77/- is total outstanding on account of unpaid EMIs and towards further installments. Without payment of the aforesaid amount, the loan account cannot be closed. That the complaint is liable to dismissed on the ground that the complainants have not brought any succession certificate showing them to be the only legal heirs of the deceased Baljeet Singh. It is further submitted that the complainants are not entitled to the insured amount as the said amount is to be released by the respondent No. 2 in favour of the answering respondent being the financer of the car. It is also submitted that the aforesaid communication has been made between the complainant and respondent No. 2. It is respectfully submitted that complaint qua the OP No. 1 may kindly be dismissed and also direct OP No. 2 to make the payment of the awarded amount to OP No. 1.
3 OP No. 2 also submitted in reply that the claim of the complainant has been rightly rejected as the ailments for which Baljeet Singh was treated does not fall within the purview of the nine Major medical illnesses and procedures defined in the insurance policy and its terms and conditions. It is further submitted that the decision of rejection of the claim was taken solely as per said policy terms and conditions and in view of the above, the company vide its letter dated 12.07.2016 has rejected the said claim. That company is not liable to make any payment to the complainant under the policy and lastly prayed for dismissal of the complaint qua the OP No. 2.
4. Ld. counsel for the complainant in his evidence has tendered affidavit Ex.CW1/A, documents Ex.C1 to Ex.C7 and has closed his evidence on dated 05.07.2018. Ld. counsel for the OP No. 1 has tendered affidavit Ex.RW1/A and documents Ex.R1 & Ex.R2 and closed his evidence on dated 08.08.2018. Ld. Counsel for the OP No. 2 has tendered in evidence documents Ex.R-3 to Ex.R-8 & affidavit Ex.RW2/A and closed the evidence on dated 26.10.2018.
5. We have heard learned counsel for the parties and have gone through material aspects of the case very carefully.
6. After going through the file and hearing the parties it is observed that the claim of the complainants has been repudiated by the opposite party No.2 on the ground that the ailments for which life insured Baljeet Singh was treated, does not fall within the purview of the nine Major medical illnesses and procedures defined in the insurance policy and its terms and conditions. As per document Ex.C7/Ex.R5, the deceased LA received treatment of Strangulated Paraesophageal hernia with gastric perforation with gangrene of lower esophagus with perforation peritonitis with Septicemia. From this document, it is proved that the deceased had suffered some major problems and he had different type of ailments at the time of death. Moreover, it cannot be established without the PMR that from which ailment the deceased had died. The respondent has also failed to prove that from which ailment/deceased LA had died. It is also not proved on record that the detailed policy was ever supplied to the LA as no receipt of the same has been placed on record. In support of his contention, ld. counsel for the complainant has placed reliance upon the law 2014(3)CLT 202 titled as The Oriental Insurance Company Ltd. Vs. Vivek Rekhan whereby Hon’ble State Commission, Haryana, Panchkula has held that: “Unless the terms and conditions have been supplied to the complainant before taking the policy, the same cannot be enforced-Exclusion clause not binding”. Reliance is also placed upon 2015(1)CLT 591 titled as Star Health and Allied Vs. Asha.
7. In view of the aforesaid facts and circumstances of the case, we come to the conclusion that complainants are entitled for the insurance claim under the policy. That due to non-payment of claim amount by the opposite party No.2 to the complainant or to the opposite party No.1, so many charges e.g. interest, late payment pentaly etc. have been levied by the opposite party No.1 on the loan amount which amounts to deficiency in service on the part of opposite party No.2. As per respondent No.1 outstanding amount is Rs.342557/- whereas the sum assured is Rs.233226/-. As such opposite party no.2 is liable to pay the whole outstanding amount to the opposite party No.1.
8. Accordingly, we hereby allow the complaint and direct the opposite party No.2 to pay the outstanding amount of Rs.342557/-(Rupees three lac forty two thousand five hundred fifty seven only) to the opposite party no.1 for settlement of loan account of life assured Baljeet Singh. It is made clear that the alleged awarded amounts includes the interest, compensation as well as litigation expenses.
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:
05.12.2018.
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Nagender Singh Kadian, President
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Ved Pal Hooda, Member.
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Saroj Bala Bohra, Member.
