DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I, U.T. CHANDIGARH

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Dr.Barinder Singh, resident of House No.3168, Sector 50-D, Paradise Enclave, Chandigarh-160047.

…..Complainant

                 V E R S U S

1]  ICICI Lombard General Insurance Company Limited, Corporation Office : Zenith House, Keshavrao Khadye Marg, Mahalaxmi, Mumbai-400034.

2]  ICICI Lombard General Insurance Company Limited, Branch Office: SCO 24-25, 1^st Floor, Sector 8-C, Madhya Marg, Chandigarh.

                      ……Opposite Parties

CORAM:   SH.P.D.GOEL                   PRESIDENT

         SH.RAJINDER SINGH GILL       MEMBER

         DR.(MRS) MADANJIT KAUR SAHOTA  MEMBER

Argued by: Sh.Sandeep Bhardwaj, Counsel for the Complainant.

          Sh.Nitin Kant Setia, Counsel for OPs.

PER DR.[MRS.]MADANJIT KAUR SAHOTA,MEMBER

        It is case of the complainant that his wife Dr. Gurpreet Kaur had taken Critical Illness Insurance Policy from the OP bearing No.4026/0000013/ICICIHL/0006141 on payment of Rs.6734/- as premium. The policy was valid from 10.6.2006 to 10.7.2011 and the sum assured was Rs.5 lacs.

        It is further case of the complainant that on the unlucky day of 28.5.2010, son of the complainant, who was away to Manali alongwith his school teachers and class-fellows, called his mother that he was beaten by the teachers and they had left him in the campus. Hearing these words from her son, she immediately ran to the School. When she reached school premises, she started feeling difficulty in breathing. She was immediately taken to Fortis Hospital by the complainant, where she was declared dead. The cause of death in the Post Mortem Report dated 29.5.2010 has been given as ‘Cardiogenic Shock (Vasovagel Shock) leading to Sudden Cardiac Arrest.  

        It is further case of the complainant that he filed the claim with the OP with the requisite documents but the OP vide its letter dated 20.9.2010 rejected the claim on the ground that it did not fall under the policy terms. According to the complainant, the OP has illegally repudiated the claim which amounts to deficiency in service on the part of OP, hence this complaint.

2.       OP filed reply and stated that under the terms and conditions of the policy, the claim of the complainant could not be allowed because “the company will pay the sum insured if during the policy period the insured is found to have Critical Illness contracted during the policy period and survives such critical illness for at least 30 days”. It is further stated that the insured lost her life within 30 days after contracting serious illness i.e. Cardiogenic Shock (Vasovagal Shock), hence the claim is not payable. In view of this, it is submitted that the complaint is not maintainable and is liable to be dismissed with costs. 

3.       Parties led evidence in support of their contentions.

4.       We have heard the learned counsel for the parties and have also perused the record.

5.       Admittedly, the Complainant’s deceased wife (Dr. Gurpreet Kaur), has taken Critical Illness Insurance Policy [Annexure C-1] from the OPs, which was valid from 10.6.2006 to 10.7.2001 for a sum insured of Rs.5 lacs. As per the said Critical Illness Policy, in the event of death of Policy holder due to any of the eventualities mentioned in the policy itself under heading “Operative Event”, the nominee/ legal heir were to be paid the sum insured.

6.       The death of the wife of the Complainant on 28.05.2010 is also not disputed [Annexure C-3]. The Death Summary [Annexure C-4], as well as Post-Mortem Examination and Chemical Examination [Annexure C-6] has determined the cause of death as Cardiogenic Shock (Vasovagel Shock), leading to sudden cardiac arrest [Annexure C-7]. The report of Medical Board [Annexure C-8] also proves that death in the present case is due to Cardiogenic Shock (Vasovagel Shock) sudden cardiac arrest.

7.       The grouse of the Complainant is that the OP has wrongly and illegally rejected his well founded claim qua Annexure C-11, on the ground that it did not fall under the policy terms and conditions.

8.       Per contra, while clarifying the terms & conditions of the policy [Annexure R-1], the OP contended that the claim of the Complainant could not be allowed, because as per the terms & conditions of the policy, the sum assured would be payable only if during the currency of policy, the insured is found to have critical illness, contracted during the policy period, and survives such critical illness for atleast 30 days from the date of discovery of the ailment.

9.       A close scrutiny of the terms & conditions of the policy shows that in order to fall under the policy terms, the insured should have survived the illness for atleast 30 days. It is the case of the Complainant that the action of the OP in repudiating his claim, on aforesaid account, is wholly unjustified, as the deceased was never pre-occupied by any illness. In support of his case, he placed reliance on the definition of “Myocardial Infraction” given in medical dictionary, as well as in the medical jurisprudence, which limb is not available to him, for the reason that the insured lost her life within 30 days after contracting serious illness i.e. Cardiogenic Shock (Vasovagal Shock).  

10.      Going minutely into the facts & circumstances of the case & perusing the entire documents placed on record by the respective parties, it is crystal clear that as per Clause A of the Part-II of the Schedule, annexed with the policy terms & conditions, claim is payable only if the insured survives critical illness for atleast 30 days. The said clause is reproduced below for the sake of convenience: -

         “Part II of the Schedule

          A.   Insuring Clause

The company will pay the sum insured if during the policy period the insured is found to have a critical illness contracted during the policy period and survives such critical illness for at least 30 days from the date of its discovery.”

A perusal of above made it amply clear that the OP company will pay the sum insured only if during the policy period, the insured is found to have a critical illness contracted during the policy period and survives such critical illness for at least 30 days from the date of its discovery. Undoubtedly, the insured, in the instant case, lost her life shortly after contracting serious illness i.e. Cardiogenic Shock (Vasovagal Shock). Furthermore,   Clause B of Part-II of the Schedule, defines “Critical Illness”, for the purpose of the policy in question and the determination of the Company’s liability under it, which duly covers the Myocardial Infarction (Heart Attack) under point no.3. 

11.      Now, it can safely be concluded that insuring clause A of Part II of the Schedule, which has been reproduced in para supra, is a condition precedent, which paves the way for the rejection of the insurance claim in question. Resultantly, it is held that the action of the OP in rejecting the claim of the Complainant is certainly a part of the agreement between the parties and is a condition precedent as per the terms and conditions of the said Critical Illness Policy purchased by the deceased Dr. Gurpreet Kaur, wife of the Complainant.

12.      The Learned counsel for the Complainant has placed reliance on SBI Life Insurance Company Ltd. Versus Y.Dayamani, III (2010) CPJ 1 (NC), ICICI Prudential Life Insurance Company Ltd. Versus Anil Kumar Jain, I (2010) CPJ 514, National Insurance Co Ltd. Versus Mona Ohri & Anr., First Appeal No. 1583 of 2005, decided on 25.3.2011 by the Hon’ble Punjab State Consumer Commission. In our considered opinion, the said authorities find no favour to this case, as the facts and circumstances of these cases were entirely distinct from that of the present case in hand. It is not the case of the Complainant that the terms and conditions of the Policy were not in the knowledge of the policy holder or the same were not disclosed to her; so much so, it is the Complainant who has annexed the relevant extract of the terms and conditions of the policy at Page 12 [Annexure C-1] with the complaint.

13.      In view of the above discussion, in our opinion, there is no merit, weight or substance in the present complaint and, therefore, the same cannot be accepted in favour of the Complainant and against the OP. There is neither any deficiency of service, nor indulgence in any unfair trade practice on the part of the OP. As such, we dismiss the complaint. However, the respective parties shall bear their own costs.

14.      Certified copies of this order be sent to the parties free of charge. The file be consigned.