CONSUMER DISPUTES REDRESSAL FOR`UM, BATHINDA.

CC.No.325 of 12-07-2012

Decided on 10-12-2012

Rachna Grover aged about 40 years w/o Arun Kumar Grover r/o H.No.1349, Ward No.3, Near Petrol Pump, Gidderbaha, District Mukatsar.

........Complainant

Versus

1.ICICI Bank Ltd., Bibiwala Road, Near Clock Tower Chowk, Bathinda, through its Branch Manager.

2.ICICI Prudential Life Insurance Co.Ltd., Branch Office: The Mall, Bathinda, through its Branch Manager/Branch Head.

.......Opposite parties

Complaint under Section 12 of the Consumer Protection Act, 1986.

QUORUM

Smt. Vikramjit Kaur Soni, President.

Sh.Amarjeet Paul, Member.

Smt. Sukhwinder Kaur, Member.

Present:-

For the Complainant: Ms.Gurleen Kaur, counsel for complainant.

For Opposite parties: Sh.Sanjay Goyal, counsel for opposite party No.1.

Sh.Ashok Bharti, counsel for opposite party No.2.

ORDER

VIKRAMJIT KAUR SONI, PRESIDENT:-

1. The complainant has filed the present complaint under section 12 of the Consumer Protection Act, 1986 as amended upto date (Here-in-after referred to as an 'Act'). The brief facts of the complaint are that the complainant is having her bank account with the opposite party No.1 and the opposite party No.2 is the sister concern of the opposite party No.1, having joint venture with it and the officials of the opposite party No.1 used to provide the details of its customers to the opposite party No.2 to promote the business of the opposite party No.2 also. The officials of the opposite party No.2 after collecting the details of the complainant from the opposite party No.1, approached her and her husband at Gidderbaha and allured them to purchase the different type of policies of the opposite party No.2 and assured them to provide good services. The complainant and her husband showed their inability to visit time & again to deposit the premium by visiting their Bathinda office to which the officials of the opposite party No.2 assured them that they shall send their representative to collect the premium from them at Gidderbaha and they need not to visit Bathinda to deposit the due premium. The officials of the opposite party No.2 obtained the signatures of the complainant and her husband on the various blank printed forms/blank papers (alleged proposal forms), but they never disclosed the terms & conditions of the said policy nor they sent any detailed policy terms & conditions to her or her husband. In the month of January 2009, the officials of the opposite party No.2 visited the complainant at Gidderbaha and allured her to purchase Health Insurance Policy known as 'ICICI Pru Health Saver' and assured that in case of any health disorder or any minor/major operation, the opposite party No.2 shall indemnify the insured for the total expenses incurred thereon by the insured. The complainant has purchased the mediclaim/Health Saver Policy No.11057185 effective from 22.1.2009 and paid requisite premium to the opposite parties. The complainant has been regularly paying the due premium to the opposite party No.2, but as per the assurance given by their officials, they have not been regularly visiting her place to collect the due premium. Sometimes, they visited to collect the premium and sometimes, the complainant has to deposit the premium herself with the opposite party No.2 at Bathinda and various other places as there was/is no branch office of opposite party No.2 at Gidderbaha and all the times, she protested about the same with Branch Office Bathinda and all the times, the officials of the opposite party No.2 gave assurance that next time, she need not to visit as they shall arrange their representative to collect the premium from her at Gidderbaha, but to no effect. In the first week of December 2011, the complainant was not feeling well and there was some health disorder and accordingly she was taken to 'Siraram Bhartia Institute of Science & Research, New Delhi' on 4.12.2011 itself for check up and further management. After examining her, the attending doctor of the aforesaid hospital diagnosed it to be 'P2 L2 A1 with Menorrhagia with fibroid uterus' and had admitted the complainant then and there on the same day and she remained admitted there upto 8.12.2011 and during her stay, the doctor conducted the various tests and operations and remained under observation as indoor patient. The abovesaid Institute issued bill/receipts for Rs.95,169/-, which includes room rent, admission fee, room charges, doctor visiting charges, nursing charges, test charges etc. and apart from it, the complainant spent the amount on the transportation and the special diet and in this way, she spent Rs.1,50,000/- in total on her treatment. The abovesaid bills & receipts were duly submitted by the complainant with the opposite party No.2 for the reimbursement and they after getting all the formalities completed assured her that the abovesaid amount of Rs.1,50,000/- incurred by her on the treatment shall be paid to her within few days. The opposite party No.2 has repudiated the lawful claim of the complainant on following grounds:-

'8) Any expenses incurred during the first 2 years from Policy Commencement Date or revival date in case the revival is after 60 days from the date of first unpaid premium shall not be payable for the following Diseases or surgeries & any complications arising out of them.

9) Hysterectomy for Fibroids, menorrhagia, Dysfunctional Uterine Bleeding, Uterine Prolapse'.

The complainant has been regularly paying the due premium and the delay, if any, in depositing the premium was/is on the part of the opposite party No.2 as they did not send their representative to collect the premium as assured by them at the time of selling the said policy. The complainant further alleged that as per the settled law consumer cannot be left to bear the loss on account of the negligence on the part of agent/insurance company itself and non-payment of the premium within time/late payment of the premium, is no ground to repudiate the claim. Moreover the complainant has never been hospitalized for the aforesaid disease before obtaining the said policy or even thereafter except in the month of December 2011. Hence the present complaint.

2. Notice was sent to the opposite parties. The opposite party No.1 after appearing before this Forum has filed its separate written statement and pleaded that the present complaint is not maintainable as neither the insurance premium was received by it nor it has repudiated the claim of the complainant. The dispute is regarding the repudiation of the claim as such it is between the complainant and the opposite party No.2, the opposite party No.2 is to decide whether her claim is genuine or not as such the present complaint qua the opposite party No.1 is not maintainable and liable to be dismissed with this special costs. The opposite party No.1 has admitted that the complainant has her bank account with them.

3. The opposite party No.2 after appearing before this Forum has filed its separate written statement and pleaded that as per the policy terms & conditions no benefit is payable for the claim as the complainant was hospitalized on 4 December, 2011 for Menorrhagia with Fibroid Uterus. After careful evaluation of the records received by them during the claim processing, it was noted that the complainant had undergone Hysterectomy, but the said policy was lapsed from February 14, 2011 to May 24, 2011 i.e. for a period of more than 60 days. In the communication letter it was erroneously mentioned as May 24, 2011 to August 14, 2011. Since the said policy was lapsed for more than 60 days hence waiting period is re-applicable from May 24, 2011, hence no benefit is payable for the claim intimated by the complainant under the abovementioned policy. For this the opposite party No.2 has referred the relevant policy clause 8;8;9. The complainant has not acted in good faith with respect to the subject of this complaint and has approached this Forum with unclean hands. The complainant is guilty of 'suppressio vari and suggestio falsi', which means he has suppressed the relevant facts from this Forum. The opposite party No.2 further pleaded that in the Policy document the mode of premium payment is properly explained. The relevant extracts are mentioned below:-

“Clause 11: Premium:

(a)Premiums are payable on the due dates and at the amount mentioned in the policy certificate at time of commencement of the policy. A grace period of not more than 30 days, where the mode of payment of premium is other monthly, and not more than 15 days in the case of monthly frequency is allowed.

(b)Premiums are payable without any obligation on the Company to issue a notice for the same.

(c )...........................

(d) If the policyholder suspends payment of premium for any reason whatsoever, the Company shall not be held liable and the benefits, if any will be available only in accordance to the Policy conditions.

(e)............................

(f)............................”

The complainant if she had any intentions of paying the renewal premiums could have paid the same by various other means like online payment, cheque, cash, DD, ECS debit etc. The complainant has failed to prove that she had opted for any of these means in order to deposit the renewal premium. The claim is rejected by the opposite party No.2 as the same is beyond the terms & conditions of the policy in question. The opposite party No.2 further pleaded that the words in an insurance contract must be given paramount importance and interpreted as expressed without any addition, deletion or substitution and referred the law laid down by the Hon'ble Apex Court in case titled Suraj Mal Ram Niwas Oil Mills (P) Ltd. Vs. United India Insurance Co. Ltd. (2010) 10 SCC 567.

ICICI Prudential Life Insurance Company is a separate entity legally as well as otherwise and has nothing to do with the business conducted by the other institutions or agents including the ICICI Bank Ltd. ICICI Prudential Life Insurance Company Ltd. has a separate legal, financial and administrative set up from that of ICICI Bank Ltd. No prudent person will ever sign on blank documents or printed documents without knowing the contents of the same. The terms and conditions of the said policy were clearly explained to the complainant in detail and only after understanding the terms of the same she opted for the plan. The opposite party No.2 had sent the said policy document of the subject policy to the complainant on 19.2.2009 only and the same must have been duly received by her as she has never approached the opposite party No.2 for non receipt of the policy document. The complainant is herself admitting that she has not been paying the premiums regularly and the contentions are clearly an afterthought in order to make up a false story to cover her own wrongs and neglect.

4. The parties have led their evidence in support of their respective pleadings.

5. Arguments heard. The record alongwith written submissions submitted by the parties perused.

6. The claim of the complainant was repudiated vide Ex.R5, letter dated 26.12.2011. The relevant portion of this repudiation letter is reproduced as under:-

“We are in receipt of the claim documents and medical records informing us that you were hospitalized on December 4,2011 for Mennorrhagia with Fibroid Uterus.

After careful evaluation of the records received by us during the claim processing, it is noted that you had undergone for Hysterectomy, but policy was lapsed from May 24, 2011 to August 14, 2011, since the policy was lapsed more than 60 days hence waiting period is re-applicable from May 24, 2011, hence no benefit is payable for the claim intimated by you under the abovementioned policy.

The relevant policy clause 8.8.9 is reproduced below for your reference:-

8) Exclusion: Exclusions for Hospitalization Insurance Benefit The Company shall not be liable to make any payments under this Policy in respect of any expenses whatsoever incurred by any Insured Person (s) in Connection with or in respect of any of the following.

8) Any expenses incurred during the first 2 years from Policy Commencement Date or revival date in case the revival is after 60 days from the date of first unpaid premium shall not be payable for the following Diseases or surgeries & any complications arising out of them.

9) Hysterectomy for Fibroids, menorrhagia, Dysfunctional Uterine Bleeding, Uterine Prolapse.

However, your policy shall continue to be inforce and the future premiums will be payable as per the terms and conditions of the contract.”

The complainant alleged that at the time of selling the abovesaid Health Insurance Policy known as 'ICICI Pru Health Saver', the officials of the opposite party No.1 assured her and her husband that in case of any health disorder or any minor/major operation, the opposite party No.2 shall indemnify the insured for the total expenses incurred thereon by the insured and they also assured that they shall send their representative to collect the premium from them at Gidderbaha and she need not to visit Bathinda to deposit the due premium. In para No.8 of the complaint, the complainant has specifically mentioned that

“She has been regularly paying the due premium to the opposite party No.2, but as per the assurance given by their officials, they have not been regularly visiting her to collect the due premium. Sometimes, they visited to collect the premium and sometimes, the complainant has to deposit the premium with the opposite party No.2 at Bathinda and various other placed as there was/is no their branch office at Gidderbaha and all the times, she even protested about the same with Branch Office Bathinda and all the times, the officials of the opposite party No.2 gave assurance that next time, she need not to visit as they shall arrange their representative to collect the premium from her at Gidderbaha, but to no effect.”

In the first week of December 2011, the complainant has suffered from 'P2 L2 A1 with Menorrhagia with fibroid uterus' and had admitted at Siraram Bhartia Institute of Science & Research, New Delhi' on 4.12.2011, various tests and operations were conducted and she remained admitted there upto 8.12.2011 and the doctors put her under their observation as indoor patient and treated her as indoor patient and they issued bill/receipts for Rs.95,169/- and in total she spent the amount of Rs.1,50,000/- including the transportation and the special diet.

7. The claim of the complainant was repudiated on the abovementioned grounds, whereas she has no fault of her own as the opposite party No.2 has failed to sent their representative to collect the premium amount as assured by them at the time of selling the said policy. The complainant has not placed on file any document to prove her this version that she was assured by the opposite party No.2 that premium be collected from her by representative of the officials of the opposite party No.2 from her house.

Moreover as per Clause 11 of the policy:-

“Clause 11: Premium:

(a)Premiums are payable on the due dates and at the amount mentioned in the policy certificate at time of commencement of the policy. A grace period of not more than 30 days, where the mode of payment of premium is other monthly, and not more than 15 days in the case of monthly frequency is allowed.

(b)Premiums are payable without any obligation on the Company to issue a notice for the same.

(c )...........................

(d) If the policyholder suspends payment of premium for any

reason whatsoever, the Company shall not be held liable and the benefits, if any will be available only in accordance to the Policy conditions.

(e)............................

(f)............................”

The policy of the complainant remained lapse from February 14, 2011 to May 24, 2011, meaning thereby it remained lapse for a period of more than 60 days. Hence the claim of the complainant was repudiated as per Clause 8;8;9. It is clear from Clause 8.8.9 that 'Any expense incurred during the first 2 years from Policy Commencement Date or revival date in case the revival is after 60 days from the date of first unpaid premium shall not be payable for the following Diseases or surgeries & any complications arising out of them. Hysterectomy for Fibroids, menorrhagia, Dysfunctional Uterine Bleeding, Uterine Prolapse'.

8. As discussed above the said policy of the complainant remained lapsed from February 14, 2011 to May 24, 2011 for a period of more than 60 days. As per exclusion 8;8;9, the claim of the complainant is rightly done, 'not claim' by the opposite party No.2. The support can be sought by the precedent laid down by Hon'ble National Consumer Disputes Redressal Commission in case titled Divisional Manager, LIC of India Vs. Haribandhu Setha & Others, 1995 (2) CLT, 621, where it has been held:-

“Consumer Protection Act, 1986, Section 2 (1) (o)-Deficiency in service-Salary saving scheme-Scheme introduced by State Government-Lapse of policy due to non-receipt of monthly premium-Insurance company not liable to pay the insured amount in view of non-payment of monthly premium-Employer liable to pay compensation.”

9. Therefore in view of what has been discussed above there is no deficiency in service on the part of the opposite parties. Hence this complaint fails and dismissed without any order as to cost.

10. A copy of this order be sent to the parties concerned free of cost and file be consigned to the record room.

Pronounced in open Forum:- Vikramjit Kaur Soni

10-12-2012 President

Amarjeet Paul

Member

Sukhwinder Kaur

Member