BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.401 of 2019
Date of Instt. 10.09.2019
Date of Decision: 22.12.2020
Kewal Krishan aged about 41 years S/O Sh. Gopal Krishan R/o 167, Makhdoom Pura, Jalandhar.
..........Complainant
Versus
1. ICICI Prudential Life Insurance Co. Ltd. Registered Office, 1089, Appasaheb Marathe Marg, Prabhadevi, Mumbai, through its Chairman/Director/Managing Director/Manager/Representative.
2. ICICI Prudential Life Insurance Co. Ltd., Local Branch Office, Plot No.22-23, 1st Floor, Above Punjab and Sind Bank, G. T. Road, Jalandhar, through its Chairman/Director/Managing Director/Manager/Representative.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Sh. Kuljit Singh (President)
Smt. Jyotsna (Member)
Present: Sh. Amit Beri, Adv. Counsel for the Complainant.
Sh. K. S. Minhas, Adv. Counsel for the OPs No.1 & 2.
Order
Kuljit Singh (President)
1. The instant complaint has been filed by the complainant, wherein alleged that the complainant has purchased an insurance policy plan name ICICI PRU HEALTH SAVER bearing Policy No.15045206in the year 2011 for his and his family. Under this policy the OPs covered/insured the health of the whole family of the complainant upto Rs.5,00,000/- (annual limit). As per highlights of the policy, a health check up shall be provided by the insurance company once after every 2 years, to all insured person subject to a limit of Rs.5000/- or 1% of the annual limit, whichever is lower. Copy of the health policy is attached. That till date the complainant has regularly paid all the premiums to the OPs regarding above said policy and till date he has never filed any medical/illness claim to the OPs. That in the month of January, 2017, the representative of the OPs visited the office of the complainant and informed that the complainant has not filed any health check up claim in last 6 policy years. When the complainant told that he is now aware about it, then the representative of the OPs informed the complainant that insured person under the aboe said health saver policy can claim Health Check Up. He further informed that as per above said policy highlights “a health check up shall be provided by the insurance company once after every 2 years, to all insured person subject to a limit of Rs.5000/- or 1% of the annual limit, whichever is lower”. After few days the representative collected all the medical test reports (health check up reports) alongwith original payment receipts from the complainant and taken signatures on Health Check Up claim form for filing the claims for last six policy years. After that the complainant received Rs.4630/-, Rs.2530/- and Rs.1150/- on 22.01.2017 through NEFT as health check up claims for present as well as previous policy terms because he was never applied for the same in the previous policy years. That on 10.07.2019 the complainant again filed/applied for health check up claim because the earlier health check up claim was availed in January, 2017 and now, as per policy highlights the complainant is eligible to apply for the same. As per demand of the OPs all the original bills of Rs.5430/- and health check up reports were handed over to the official of the OPs in their local branch office. That on 12.07.2019 the complainant received Rs.2900/- in his bank account through NEFT from the OPs. The complainant immediately made a phone call to the official of OPs and asked about the reason of transfer of Rs.2900/- instead of Rs.5000/-. Then the official of the OP showed her inability to clarify the reason for the same. In the month of August, 2019, the complainant received an intimation letter dated 12.07.2019 regarding above said health check claim sent by the OPs. Through the said intimation letter the OPs have informed the complainant as After careful evaluation of the records received by us during the claim processing, it is noted that you have already taken the benefit of health check up claim in this policy year and next claim will be payable after the completion of 2 years of slab of health check up claim. Hence no benefit is payable under the given medical check up.
2. That on 17.08.2019, the complainant sent an complaint cum legal notice through email to the OPs and informed that he have not taken any claim in last two policy years and also wrote in his email that if he have already availed the health check up claim in last two policy years, then provide the details of the same. After that the complainant received another intimation letter dated 19.08.2019 and the OPs informed that after careful evaluation of records it is noted that you have already taken benefit for this policy years. Hence the next benefit will be payable in the next slab. In view of the above, we stand by our decision to reject the claim as already conveyed to you. No other reason was assigned in the intimation letter. The complaint cum legal notice dated 17.08.2019 and intimation letter dated 19.08.2019 is attached. That on receiving of intimation letter dated 19.08.2019, the complainant again requested the OPs to give him details of claims pass in the whole previous policy years, then they provided detail in their email dated 02.09.2019. As per their email in the whole previous policy years they had made only 3 payments of Rs.4630/-, Rs.2530/- and Rs.1150/- on 22.01.2017 and after that they have not made any payment till 11.07.2019. It is pertinent to mention here that on the filing of fresh claim on 10.07.2019 the OPs transferred only Rs.2900/- in the bank account of complainant. That in the above said replies of emails, the OPs admitted a fact i.e. complainant have not taken any single penny as claim in last two and half policy years from the OPs. The OPs have rejected the claim of the complainant wrongly and without any genuine reason. The OPs have not legal right to do the same. That the OPs have paid only Rs.2900/- instead of Rs.5000/- only for their own benefit. The difference of both the amount i.e. Rs.2100/- is illegally retained by the OPs. The act and conduct of both the OPs amounts to unfair trade practice and the OPs are providing deficient and negligent services to the complainant as well as general public for their own benefit. The complainant has suffered a lot financially, physically and mentally on account of deficiency of service and unfair trade practice on the part of the OPs and as such, the present complaint filed with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay Rs.2100/- as balance of health check up claim amount and further be directed to pay Rs.2,00,000/- for harassment, mental tension, agony and inconvenience and also directed to pay Rs.15,000/- as litigation expenses alongwith interest @ 18% per annum from the date of filing of medical claim to the complainant.
3. Notice of the complaint was given to the OPs, but after availing so many dates with cost, the OPs failed to file written reply and as such, the defence of OPs struck off on 19.11.2019.
4. In order to prove his case, the counsel for the complainant produced on the file affidavit of the complainant Ex.CA alongwith some documents Ex.C-1 to Ex.C-6 at the time of filing the complaint.
5. We have heard the learned counsel for the respective parties and also gone through the case file very carefully.
6. The case of the complainant is that he has purchased an insurance policy plan name ICICI PRU HEALTH SAVER bearing Policy No.15045206 in the year 2011 for his and his family. In this policy, the OPs covered/insured the health of the whole family of the complainant upto Rs.5,00,000/-. As per the policy, a health check up shall be provided by the insurance company once after every 2 years, to all insured persons subject to a limit of Rs.5000/- or 1% of the annual limit, whichever is lower. Copy of the health policy is attached as Ex.C-1 and copy of Policy Highlights is Ex.C-2. Till date the complainant has regularly paid all the premiums to the OP and till date he has never file any medical/illness claim to the OPs. As per the information of the OPs, complainant can claim Health Check Up and this facility is provided by the insurance company once after every 2 years to all insured person subject to a limit of Rs.5000/- or 1% of the annual limit, whichever is lower and the representative collected all the medical test reports alongwith original payment receipts from the complainant and taken signatures on Health Check up claim form for filing the claims for last six policy years. After that the complainant received Rs.4630/-, Rs.2530/- and Rs.1150/- on 22.01.2017 through NEFT. On 10.07.2019 the complainant again filed for health check up claim because the earlier health check up claim was availed in January 2017 and as per policy highlights the complainant is eligible to apply for the same. The complainant provided all the original bills of Rs.5430/- to the OPs. On 12.07.2019 the complainant received Rs.2900/- in his bank account through NEFT from the OPs. The complainant immediately made a phone call to the official of OPs and asked about the reason of transfer of Rs.2900/- instead of Rs.5000/-. Then the official of the OP showed her inability to clarify the reason for the same and then complainant received intimation letter in which mentioned that complainant had already taken the benefit of health check up claim in this policy year and next claim will be payable after the completion of 2 years of slab of health check up claim. Regarding this complainant produced on the file complaint legal notice dated 17.08.2019 and intimation letter dated 19.08.2019 Ex.C-4 and Ex.C-5, Copy of the email dated 02.09.2019 in which the OPs provided detail of payments made to the complainant Ex.C-6.
7. On the other hand, the OPs failed to file written reply and as such, the defence of OPs struck off.
8. After considering over all facts, it is proved that the OPs have paid only Rs.2900/- instead of Rs.5000/- only for their own benefit. The balance amount Rs.2100/- is illegally retained by the OPs. As per document Ex.C-2 Customer Information Sheet Sr. No.2 under the heading Health Check, it is mentioned that After the first policy year, a health check up shall be provided, once after every two years, to all insured person (s) subject to a limit of Rs.5000/- or 1% of the annual limit, whichever is lower. So, after going through the all facts and circumstances, we reached to the conclusion that complainant is entitled for the relief as claimed.
9. In the light of above detailed discussion, the complaint of the complainant is partly accepted and OPs No.1 and 2 are directed to pay Rs.2100/- as balance of health check up claim amount to the complainant and further, OPs No.1 and 2 are directed to pay compensation to the complainant, to the tune of Rs.2500/- and litigation expenses of Rs.500/-. The entire compliance be made within one month from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.
10. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jyotsna Kuljit Singh
22.12.2020 Member President
