Delhi

West Delhi

CC/07/736

DEEPAK RASTOGI - Complainant(s)

Versus

ICICI INSURANCE - Opp.Party(s)

06 Nov 2017

ORDER

CONSUMER DISPUTES REDRESSAL FORUM (WEST)

                            GOVERNMENT OF NCT OF DELHI

  150-151 Community Centre, C-Block, Janak Puri, New Delhi – 110058

                                                                                     Date of institution: 05.09.2007

Complaint Case. No. 736/07                                          Date of order: 06.11.2017

IN  MATTER OF

Shri Deepak Rastogi S/o Sh. R.L. Rastogi R/o A-46, Gujrawala Appartment, J-Block, Vikas Puri, Delhi-110018.

                                                                                                                         Complainant

VERSUS

 

1. ICICI Prudential Life Insurance Co. Ltd.  ICICI Prulife Towers  1089, Appasaheb Marathe  Marg, Prabhadevi, Mumbai-400025.

 

                                                                   Opposite Party No. 1

 

2. ICICI Prudential Life Insurance Co. Ltd. B-26/27, Ist  Floor, DDA Community Centre, Janak Puri, New Delhi-110058.

 

        Opposite Party No. 2

 

ORDER

R.S. BAGRI,PRESIDENT

Sh. Deepak Rastogi named above herein the complainant has filed the present consumer complaint under section 12 of the Consumer Protection Act 1986 against ICICI Prudential  Life Insurance  Co. Ltd.  and another herein  after in short referred  as the opposite parties for directions to the opposite parties to pay  Rs. 3,00,000/- assured sum with interest @ 18% p.a.  with effect from 01.04.2007 and Rs. 2,00,000/-  as compensation  on account  of trauma, harassment  and mental agony suffered by complainant   with interest from 19.03.2007 date of filing  the present complaint. 

 Brief facts of the complaint as  stated  by the complainant  are that  the complainant vide receipts no. 15343547  and 16594715 dated 14.08.2006  paid sum  of Rs. 17,627/- to the opposite party no. 1 as first premium for endowment  insurance policy no. 03302121 for twenty five years from 14.08.2006 to 14.08.2031 .  The opposite parties in first week of September 2006 asked the complainant for report of Bharat x-ray laboratory   Tilak Nagar,  New Delhi for confirmation  of  his weight, height and blood pressure.  The complainant received demand for Rs. 1070/- from the opposite parties.  The complainant vide cheque no. 099016 dated 19.09.2006 paid the amount of Rs. 1070/- to the opposite parties.  The complainant received policy no. 03302121 dated 23.09.2006 from the opposite parties with commencement of policy from 14.08.2006 with maturity /termination  on 14.08.2031.

That on 19.03.2007  the  complainant was diagnosed with AWMI by Maharaja Agrasen Heart Institute and Research Centre Delhi.  The complainant on the basis of the diagnoses and terms of the policy dated 14.08.2006 submitted medical papers to branch office of Janak Puri, New Delhi of the opposite parties.  The opposite parties  vide letter dated 18.04.2007 attempted   to dis-own  from their  liability  to pay against  critical  illness rider  on the ground that commencement  of the policy was taken  23.09.2006  on the policy  document and  not the date mentioned therein  for commencement.  Whereas date of commencement of the policy was retained  14.08.2006  with  termination dated  14.08.2031. So if the commencement of the  policy is taken on 14.08.2006  the complainant  suffered  critical illness only on  19.03.2007  after expiry of six months from commencement  of the  policy on 14.08.2006.  Therefore, the letter dated 18.04.2007 of the opposite parties is without any thought  and non application of mind .

That the opposite parties  unilaterally altered date of commencement of the policy after issuance  of main policy documents.  The complainant  and the opposite parties remained  bound  by  terms of policy  providing  commencement date 14.08.2006 and maturity date 14.08.2031.   Hence the  letter dated 18.04.2007 of the  opposite parties is deficiency in service on the part of the opposite parties.   Therefore, the complainant sent a legal notice to the opposite parties to pay the amount as per the  medical papers dated 27.03.2007 of the complainant.  But to no effect.  Hence the present complaint for directions to the opposite parties to pay Rs. 3,00,000/- assured sum, with interest @ 18% p.a.  with effect from 01.04.2007 and Rs. 2,00,000/-  as compensation  on account  of trauma, harassment  and mental agony suffered by the  complainant   with interest from 19.03.2007 date of filing  the present complaint.

After notice the opposite parties appeared and submitted reply raising preliminary objections of maintainability of the complaint, concealment  and  suppression of material and relevant facts.   The complaint is devoid of any material particulars and has been filed with  ulterior  motive. The complaint is false, frivolous  and  vexatious .  Therefore,  liable to be dismissed with costs.

 On merits the opposite parties asserted that the complainant on   10.08.2006 submitted a proposal form  received by the opposite parties on 14.08.2006 .  The complainant was required to undergo physical and  medical examination.  The complainant completed medical examination on 22.08.2006.  The complainant in the proposal form submitted his  weight 64 kgs.   Whereas  in the medical  examination his actual  weight   was 75 kgs.   The opposite parties on the  basis  of the  medical  examination of the complainant decided  to change  premium  on  critical  illness benefit  rider  on the  ground  the complainant being over weight.  Therefore, letters dated 31.08.2006 and 21.09.2006 were sent to the complainant by the opposite  parties for consent of the  complainant.  The opposite parties on 23.09.2006 issued policy no. 03302121 to the complainant with  risk  commencement  dated 14.08.2006.

The Regulatory and Development Authority (Protection of Policyholders Interests)   Regulations, 2002   provides   that in case  the policy holder is not satisfied with the terms and conditions of the policy he can withdraw/ return the   policy within  fifteen days  of receipt  under “ Free Look” provision.  But the complainant did not return the policy in “Free Look”   period  for cancellation of the policy  thereby implying that he had agreed to all terms and conditions of the policy.    The policy  was issued on 23.09.2006 and six months waiting  period from date of issue of the policy expired on 23.03.2007.  Whereas the  life  assured underwent  Percutaneous  Trans  luminal Coronary Angioplasty(PTCA)  on 19.03.2007.  He was diagnosed CAD AWMI  on 19.03.2007 within  six months waiting period  from the policy  issue date.  The policy document is a contract and binding  on the parties  according to which  no benefit become payable. 

However on merits it is admitted  by the opposite parties that the complainant  was required to undergo physical medical examination .  The complainant completed medical examination on 22.08.2006. The complainant  in the proposal form submitted  weight 64 kgs.   Whereas  in the medical  examination his actual  weight   was 75 kgs.   The opposite parties  on the  basis  of  medical  examination of the complainant  decided  to change  premium  on  critical  illness benefit  rider  on the  ground  the complainant being over weight.  Therefore,  letters dated 31.08.2006 and 21.09.2006 were sent  to the complainant by the opposite  parties  receiving  

the consent of the  complainant.  The opposite parties  23.09.2006 issued policy no. 03302121 to the complainant with the risk commencement  dated 14.08.2006 and prayed for dismissal of the complaint.    

The complainant filed rejoinder to the reply of the opposite  parties  controverting stand of the opposite parties reiterating  his stand  taken in the complaint and once again prayed for directions to the opposite parties.   

 When Sh. Deepak Rastogi  complainant was asked to lead evidence he  tendered in evidence  his affidavit narrating facts  of the complaint  and rejoinder. He also relied upon  Annexure C/1   copy of   cover note acknowledging   concluded contract, Annexure C/2 true copy of first premium of the policy, Annexure C/3 letter dated 31.08.2006, Annexure C/4 copy of insurance policy no. 03302121 dated 23.09.2006, Annexure C/5 copies of medical records, Annexure C/6 letter  dated 18.04.2007, Annexure C/7 letter dated 18.04.2007, Annexure C/8  copy of legal notice  dated 31.07.2007, Annexure C/9 receipt of speed post with A.D, Annexure C/10 receipt of UPC and  Annexure C/11 receipt of Courier.

When the opposite parties were asked to lead evidence they tendered in evidence affidavit of Ms Rashmi  Bahttcharya Legal Manager of ICICI Prudential Life Insurance Co. Ltd.  narrating  facts of their reply. They  also  relied upon Exhibit “ A”  proposal form, Exhibit “B ” letter dated 14.08.2006,

Exhibit “ C ”  Medical Examination Report, Exhibit “ D ” letter dated 31.08.2006 , Exhibit “E ” insurance policy no. 03302121,  Exhibit “ F ” Discharge Summery dated 10.02.2007, Exhibit “G  ”opinion given by Dr. C.H. Ansari, Exhibit “ H ” letter dated  18.04.2007, Exhibit “ I  ” letter dated 31.07.2007 and  Exhibit “ J  ” letter dated 21.08.2007.

The parties have also submitted written arguments in support of their  respective  version.

We have heard learned counsel for the parties.  We have also gone through the material available on record carefully and thoroughly.

After having heard and going though the material on record carefully  and thoroughly it is a common case of the parties  that the complainant took  endowment insurance policy no. 03302121 from the  opposite  parties for twenty five years from 14.08.2006 to 14.08.2031.  The opposite parties in                first week of September 2006 asked the complainant for report  or Bharat X-ray Laboratory, Tilak Nagar, New Delhi for confirmation of weight, height and blood pressure of the complainant.  He received a letter from the opposite parties to pay for Rs. 1070/-  to the opposite parties.  He deposited the sum of Rs.  1070/- on 19.09.2006 with the opposite parties. The complainant   again  received   policy  no. 03302121 dated  23.09.2006  with

 

 

 

commencement of the policy on 14.08.2006  with  maturity/ termination  on

14.08.2031.  The complainant  on 19.03.2007  was diagnosed AWMI by Maharaja Agrasen Heart Institute and Research Centre ,  New Delhi .  He on the basis  of diagnosis  and terms of  the insurance  policy dated 27.03.2007 submitted medical papers to the opposite parties.

The case of the complainant further is that the opposite parties vide letter  dated 18.04.2007 attempted to disown liability  to pay against critical  illness rider on the ground  that  commencement of the policy was taken on 23.09.2006 on  the basis  of policy documents.  Whereas date of commencement of the policy was retained 14.08.2006 with termination dated 14.08.2031.  Therefore, if commencement of the policy is taken on 14.08.2006  the complainant suffered  critical illness on 19.03.2007 after expiry of six months from   commencement of the policy . The complainant is entitled for payment of Rs. 3,00,000/-assured  sum with interest @ 18% p.a. and Rs.  2,00,000/- as compensation on account of trauma, harassment  and mental agony suffered by the complainant.

Whereas the case of the   opposite parties is that on deposit of Rs. 1070/- on 19.09.2016 by the complainant to the opposite parties the policy no. 03302121 dated 23.09.2006 the commencement date of the policy became 23.09.2006 instead of 14.08.2006.  Whereas the complainant suffered critical illness on 19.03.2007 within six months  from  issuance of the policy on 23.09.2006 and as per clause No. “C” of supplementary benefits applicable if opted for all  the general conditions of the policy the complainant  is not  entitled for any amount .

After having heard  learned counsel for the parties and going through the material on the record we are of the opinion that arguments advanced by the learned counsel for the complainant are forceful and the arguments advanced by the learned counsel for the  opposite parties are devoid of merits.  Admittedly the complainant applied for endowment insurance policy with the opposite parties. The opposite parties on 23.09.2006 issued cover note with commencement date 14.08.2006 and maturity date 14.08.2031 of the policy  The opposite parties on 23.09.2006 issued the same insurance policy no. 03302121 with commencement date 14.08.2006 and maturity date 14.08.2031.  Therefore, we have no hesitation in concluding that commencement date of the insurance policy is 14.08.2006.  The complainant on 19.03.2007 was diagnosed with AWMI that is critical illness.  The complainant applied for payment to the opposite parties on 27.03.2007.  But the opposite parties vide letter dated 18.04.2007 disowned the amount on the ground of critical illness rider stating that commencement of the policy is 23.09.2006 within six months from date of issuance of policy   Therefore, the opposite parties are not liable to pay any

compensation. Whereas the complainant succeed to prove that commencement  date of the policy was 14.08.2006.  The complainant suffered  critical  illness  on 19.03.2007  after  six months from  commencement  date 14.08.2006  of the policy.    

Before proceeding further it is worthwhile to reproduce clause “C” critical illness  benefits of the insurance policy  supplementary benefits applicable if opted which reads as under:-

(C )Critical illness Benefit:-

Provided the policy is in force for the full Sum Assured, the Life Assured is diagnosed  to be suffering from a Critical  illness( as defined below ) after six months from the issue  Date of Policy but before the policy anniversary on which he attains age 65 years nearer birthday, or before the expiry of the period for which the premiums are  payable, whichever is earlier, the Sum  Assured under this  Policy shall fall to  be paid together with guaranteed  additions and bonuses vested till then.     

            Hence  we are of the  opinion  that the opposite parties  adopted unfair trade practice and  there is deficiency  in service on the part of the opposite parties by refusing payment of  the insurance amount. Therefore,  we hold  that the opposite parties are bound to pay the amount and  direct the opposite parties  to pay Rs. 3,00,000/-  assured sum  paid by the complainant  with  interest  @ 9%  per  annum from  the  date of filing of the

complaint till actual realization of the amount and pay compensation of              Rs. 1,00,000/- for trauma, harassment  and mental agony suffered by complainant  .

 Order pronounced on : 06.11.2017

• Compliance of the order be made within 30 days after receipt of the order.
• Copy of order be sent to the concerned parties free of cost.
• Thereafter, file be consigned to record.

         

 

                  

(PUNEET LAMBA)                                                              ( R.S.  BAGRI )

             MEMBER                                                                               PRESIDENT