District Consumer Disputes Redressal Commission ,Faridabad.

Consumer Complaint  No. 546/2019.

 Date of Institution:14.11.2019.

Date of Order:.08.08.2023.

Vipin Sharma Son of Shri Hetram Sharma Age 35 years Resident of  Palwal, Tehsil and District Faridabad, Haryana, Adhar card No. 75624072 2969.

                                                          …….Complainant……..

                                                Versus

1.                ICICI Prudential Life Insurance Company Limited, 1049, Apasahab Marathe Marg, Prabhadevi, Mumbau – 400 025, Maharashtra through Managing Diector.

2.                ICICI Prudential Life Insurance Company Limited, Plot NO. 55, Ist floor, B.P. Neelam Bata road, Near Milniyam Hotal, NIT, Faridabad through Branch Manager.

                                                                              …Opposite parties

BEFORE:            Amit Arora……………..President

Mukesh Sharma…………Member.

Indira Bhadana………….Member.

PRESENT:                   Sh. Anil Parashar,   counsel for the complainant.

                             Sh. R.K.Bhati, counsel for opposite party.

ORDER:             

                             The facts in brief of the complaint are that the complainant had take life  insurance policy NO. 20755946 for 30 years from the defendant on

 23.2.2017.   The complainant had paid the premium amount of Rs. 20,005/- through cheque No. 16780 of State Bank of India dated 23.02.2017 for the above policy,, the receipt of which receipt number was provided.  He has  also paid the installment of Feb, 2018 and Feb. 2019.  The complainant was absolutely healthy at the time of the policy was taken and at that time he was not suffering from any kind of disease and  their  doctor had also done a complete  medical examination of him at that time.  In February 2019, suddenly, the complainant started feeling breathless, When he started  having chest pain,  he got his checkup done at J.P. Hospital and after the checkup, the doctor told that his heart valve was defective and his valve would have to be replaced, the complainant was not aware of this disease before, nor was he undergoing treatment for heart disease in any hospital.  After that he went to the Fortis Escorts Heart institute and Research Center Okhla Road, New Delhi for his treatment.  There also the doctors declared the heat valve defective and admitted him to the hospital on 26.03.2019 and the heart valve of the complainant was  replaced and the hole in the heart was filled.  The complainant was admitted to Fortis Escorts Heart Institute Hospital, Delhi from 26.3.2019 to 3.4.2019. His treatment cost of Rs.6,10,175/- which the complainant had paid the amount to the hospital in cash.  The complainant had presented a claim to them in July 2019 for payment of Rs.20 lakhs due to serious illness as per the policy alongwith all the necessary documents for the  hospital bill, but on 5.8.2019 he wrongly unlawfully refused to pay the amount on the ground that his illness did not fulfil the conditions of critical.   Illness that the policy in the above policy issued by him the terms conditions shown in Part B include heart valve replacement and heart valve surgery in severe disease .The aforesaid act of opposite party amounts to deficiency of service and hence the complaint.  The complainant has prayed for directions to the opposite party to:

a)                 pay Rs. 20,00,000/- as compensation for causing mental agony and harassment .

c)                 pay  litigation expenses.

2.                 Opposite party put in appearance through counsel and filed written statement wherein Opposite party refuted claim of the complainant and submitted that  the opposite  parties had  received an online sell proposal form bearing NO. OS06936555 alongwith with a duly filled and signed Customer Declaration form by the complainant for ICICI Pru Protect Smart T47 Plan of the company for annual premium of Rs.17,395/-.  In the proposal form, the complainant did not disclose any prior ailment or any congenital diseases for which specific questions were raised by the company.  Based on the information provided in the
Application  form and the declaration in the CDF to be true and correct, the policy bearing No. 20755946 was issue don 24.02.2017 under standard category without any medicals to the complainant.   The salient features of the policy were as stated below:

In the present case, the policy was dispatched on 01.03.2017 via Bluedart Courier bearing airway bill Number 34032947815 which was duly received by the complainant.  After receipt of the policy documents the complainant/Life assured did not approach the opposite parties with any discrepancies regarding the benefits payable or any of the terms and conditions of the subject policy, neither did he approach the company for cancellation of the subject policy during the free look period thereby implying that he had agreed to all the terms and conditions of the policy.  The life assured had ample opportunity to go through and understand the terms and conditions of the policy after receipt of the same and also had ample opportunity to approach the opposite parties in case of any discrepancy, but the life assured failed to do so.  Hence the subject policy continued as per its terms and conditions.  The opposite party company was in receipt of a CI claim from the complainant receive don 14.05.2019 regarding his treatment and surgery of Redostemotomy – pulmonary valve replacement on March 28,2019.  On the perusal of the medical document submitted by the complainant himself it was noted by the opposite parties that the complainant was:

• Diagnosed with Arterial Septal Defect for the first time in 2016 from Fortis Escorts heart Institute; and

• Diagnosed with a congenital heart disease – Tetralogy of fallot and underwent total corrective surgery of the same in AIIMS in 1993.

 The following medical documents submitted by the complainant/LA himself was relied upon by the company for arriving at the above mentioned conclusion:

2.                                             Indoor case papers          Date: 17.03.2019

                                                Of Vipin Sharma            Nme: Vipin Sharma

                                                From Fortis Escorts        Reg, No. 1843743

NotingL Operated for TOF at AIIMS in 1993

Defected to have ASD in 2016 during check for ear surgery.

From the above mentioned medical documents and brief of the ailment suffered by the complainant it becomes clear that the complainant was diagnosed with atrial spetal defect in 2016 and that he was a patient of Tetralogy of Fallot which was a congenital heart disease.  It was also safe to conclude that the Atrial septal defect diagnosed in 2016 was directly related to the TOF suffered by the complainant/Life assured since birth. The opposite party company in the proposal form had sought specific questions regards congenital diseases and prior ailment which was replied by the complainant in Negative.  Had he LA honestly disclosed in the proposal form that he was suffering from TOF and ASD prior to the issuance of the policy then the company would not have given the CI benefit to the LA as the same comes within the exclusion in policy T&C.  The relevant part of the proposal form was reproduced above in the preliminary objections and to repeated for the sake of brevity. The terms and conditions of the policy in Clause 4.3: Exclusion for CI benefit, clearly states that (a) pre-existing condition or (b) in case of congenital defects were excepted form CI benefit.  In view of the above mentioned pre-existing conditions which was not disclosed by the complainant in the proposal from the claim of the complainant was rejected by the opposite parties as per Clause 4.3 of the policy terms and conditions vide letter dated 07.06.2019 and communicated the same to the complainant. Opposite party denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.

3.                The parties led evidence in support of their respective versions.

4.                We have heard learned counsel for the parties and have gone through the record on the file.

5.                In this case the complaint was filed by the complainant against opposite party–ICICI Prudential Life Insurance with the prayer to: a)       pay Rs. 20,00,000/- as compensation for causing mental agony and harassment .b)      pay  litigation expenses.

                    To establish his case the complainant  has led in his evidence,  

Ex.CW1/B – affidavit of Vipin Sharma,, Ex.C-1 – affidavit of  Vipin Sharma, Ex.C-2 – legal notice,, Ex.C-3 – letter dated June 7, 2019, Ex.C-4 – reply to legal notice, Ex.C-5 -  Postal receipts,, Ex.C-6 – email, Ex.C-7 – Discharge medication, Ex.C-8 – Discharge summary,, Ex.C-9  - investigation, Ex.C-10 – receipt, Ex.C-11 – bill, Ex.C-12 – Final Bill-cum- receipt, Ex.C-13 – payment details, Ex.C-14 to 16 – premium paid certificates, Ex.C-17 -  letter dated march 30,2019,

                    On the other hand counsel for the opposite party strongly agitated and opposed.  As per the evidence of the opposite party  Ex.RW1/1 – affidavit of Gopi Retnakar, sEnior Manager, Legal of ICICI Prudential Life Insurance company Ltd. Having its at unit No.1A, & 2A, Raheja Tipco Plaza, Rani Sti Marg, Malad (East), Mumbai, Maharashtra, Ex.RW1/A – application,, Ex.RW1/B – Policy documents – Terms and condition of policy, Ex.RW1/C – IS Claimant Statement Form (Health Claims) Ex.RW1/D – discharge summary, Ex.RW1/E -  letter dated June 7,2019., Ex.RW1/F –  repudiation letter dated 27.09.2019 ,Ex.RW1/G -  letter.

6.                In this case, the complainant has taken life  insurance policy No. 20755946 for 30 years from the defendant on 23.2.2017.   The complainant had paid the premium amount of Rs. 20,005/- through cheque No. 16780 of State Bank of India dated 23.02.2017 for the above policy. He has  also paid the installment of Feb, 2018 and Feb. 2019.   In February 2019, suddenly, the complainant started feeling breathless, When he started  having chest pain,  he got his checkup done at J.P. Hospital and after the checkup, the doctor told that his heart valve was defective and his valve would have to be replaced, the complainant was not aware of this disease before, nor was he undergoing treatment for heart disease in any hospital.  After that he went to the Fortis Escorts Heart institute and Research Center Okhla Road, New Delhi for his treatment.  There also the doctors declared the heat valve defective and admitted him to the hospital on 26.03.2019 and the heart valve of the complainant was  replaced and the hole in the heart was filled.  The complainant was admitted to Fortis Escorts Heart Institute Hospital, Delhi from 26.3.2019 to 3.4.2019. His treatment cost of Rs.6,10,175/- which the complainant had paid the amount to the hospital in cash. Opposite party repudiated the claim of the complainant vide letter dated 27.09.2019 (Ex.RW1/F) on the ground of  :Since the said medical condition was pre-existing to the policy and was not disclosed in the proposalform by him, the company rejected the said hospitalizaiton claim as per exclusion clause 4.3 of the policy terms and conditions.

7.                During the course of arguments, the counsel for the complainant has placed on reliance Medical Insurance – Once Insurer Accepts that concealment of disease was not material, reimbursement & renewal can’t be refused  passed by the Hon’ble Supreme Court of India on 6^th July 2023.

Ratio of this authority is applicable to the facts of the present case

8.                After going through the evidence led by the parties,  the Commission is of the opinion that the complaint is allowed. Opposite parties, jointly & sevrally, are directed to process the claim of the complainant within 30 days from the date of receipt of the copy of order and pay the due amount to the complainant

alongwith interest @ 6% p.a. from the date of filing of complaint  till its realization.    Opposite parties are also directed to pay Rs.2200/- as compensation for causing mental agony  & harassment alognwith  Rs.2200/- as litigation expenses to the complainant.  Compliance of this order  be made within 30 days from the date of receipt of copy of this order.   Copy of this order be sent to the parties concerned free of costs.  File be consigned to the record room.

Announced on: 08.08.2023                                  (Amit Arora)

                                                                                  President

                     District Consumer Disputes

           Redressal  Commission, Faridabad.

                                                            (Mukesh Sharma)

                Member

          District Consumer Disputes

                                                                                 Redressal Commission, Faridabad.

                                                              (Indira Bhadana)

                Member

          District Consumer Disputes

                                                                                   Redressal Commission, Faridabad.