Punjab

Fatehgarh Sahib

CC/26/2014

Hardeep Singh - Complainant(s)

Versus

ICICI Prudential LIC Comp LTD - Opp.Party(s)

Sh Ak Gupta

22 Jan 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FATEHGARH SAHIB.

Consumer Complaint  No. 26 of 2014

                                           Date of institution : 20.02.2014                                                  Date of decision    : 22.01.2016

Hardeep Singh, aged about 48 years, son of Sh. Gurdev Singh, resident of village Naraingarh, Tehsil Amloh, District Fatehgarh Sahib, C/o M/s Hargobind Kheti Store, shop No.1, Nabha Road, Beer Amloh, Tehsil Amloh, District Fatehgarh Sahib.

……..Complainant

Versus

1. ICICI Prudential Life Insurance Company Limited, having its branch at 3^rd Floor, City Tower, G.T.Road, Khanna, Tehsil Khanna, District Ludhiana through its Branch Manager.
2. ICICI Prudential Life Insurance Company Limited, having its branch at Bassi Road, Sirhind, Tehsil and District Fatehgarh Sahib, through its Branch Manager.
3. ICICI Prudential Life Insurance Company Limited, having its registered office at ICICI Prulife Towers, 1089, Appasahed Marathe Marg, Prabhadevi Mumbai-400025 through its MD/Authorized person.
4. Raghuvir Singh Shukla, Agent of ICICI Prudential Life Insurance Company Limited, having his office at Nabha Road, Amloh, Tehsil Amloh, District Fatehgarh Sahib.

…..Opposite Parties

Complaint Under Sections 11 to  14 of the Consumer Protection Act.                                             

Quorum

Sh. Ajit Pal Singh Rajput, President                                       Smt. Veena Chahal, Member                                                       Sh. Amar Bhushan Aggarwal, Member

Present :  Sh.A.K.Gupta, Adv. counsel for the complainant.                                   Sh.M.L.Singhi, Adv.Cl. for OPs No.1 to 3.                                            Sh. R.G.Sharda, Adv.Cl. for OP No.4.

ORDER

 

By Ajit Pal Singh Rajput, President.

                      Complainant, Hardeep Singh, aged about 48 years, son of Sh. Gurdev Singh, resident of village Naraingarh, Tehsil Amloh, District Fatehgarh Sahib, C/o M/s Hargobind Kheti Store, shop No.1, Nabha Road, Beer Amloh, Tehsil Amloh, District Fatehgarh Sahib, has filed this complaint against the Opposite Parties (hereinafter referred to as the OPs) under Sections 11 to  14 of the Consumer Protection Act. The brief facts of the complaint are as under:

2.                   The complainant purchased a Medi Claim Policy bearing No.00980719(UIN No.105N004V02) from the OPs through OP No.4 at Amloh. The said policy is valid from 28.06.2004 to 28.06.2029 and as per policy, the complainant was insured for the purpose of medical treatment in respect of all kinds of diseases, as told by OP No.4 at the time of selling the said policy. The complainant paid a total sum of  Rs.2,14,415/- till date as premium on yearly basis. As per policy, the medical expenses to be incurred by the complainant in future on himself upto the amount of Rs.4,50,000/-, will be paid by the OPs to the complainant. The complainant had to undergo medical treatment in respect of heart attack(Acute Coronary Syndrome) and in this regard he remained admitted in Satguru Partap Singh Apollo Hospital, Ludhiana from 24.09.2013 to 27.09.2013. During his treatment the complainant incurred more than Rs.2,50,000/-, which included attendant expenses, visit expenses, special diet expenses etc including the expenses of his treatment to the tune of Rs.1,98,670/-. During October 2013, the complainant filed his claim for Rs.2,50,000/- with the OPs alongwith all original documents such as case history, treatment given, investigation and original payment receipts etc.  Thereafter, the complainant so many times  requested the OPs and also send reminders to release the claim amount but to no effect. Thereafter, the complainant received letters dated 22.10.2013 and 04.01.2014 from the OPs, vide which the OPs informed the complainant that they are unable to honour his claim as the Coronary Angioplasty Condition  is not covered under the critical illness benefit rider. But neither such condition was ever told to the complainant while issuing the policy nor any such condition has been mentioned therein. The act and conduct of the OPs amounts to gross negligence, deficiency in service, carelessness and unfair trade practice on their part. Hence this complaint for giving directions to the OPs to pay an amount of Rs.2,50,000/- as claim amount, Rs. 1,00,000/- as compensation on account of mental tension, pain, agony, undue and unnecessary harassment suffered by the complainant.

3.                   The complaint is contested by the OPs. OPs No.1 to 3 filed joint written reply.          In reply to the complaint, OPs No.1 to 3 stated that insurance being a contract between the company and the policy holder is strictly governed by the terms and conditions of the said policy. Only those claims are paid which are payable under the terms and conditions of the policy in question. It is further stated that the complainant submitted a claim intimation dated 15.10.2013 and it was mentioned in the same that he was admitted in Apollo Hospital from 24.09.2013 to 27.09.2013 with unstable angina and underwent coronary Angioplasty. As per the terms and conditions, the policy provides life insurance cover and CIBR(Critical Illness Benefit Rider). As coronary angioplasty condition is not covered under the critical illness benefit rider, the claim for hospitalization and operation for Coronary Angioplasty condition is not covered under the terms and conditions of the policy. Hence, the OPs are not contractually bound to honour the claim. It is further stated that on careful evaluation the documents at claim processing stage it was observed that no claim was payable as per the policy terms and conditions and the same was communicated to the complainant, vide letter dated 22.10.2013. The OPs again received a letter from the complainant for reconsidering the claim of the complainant and the same was duly replied vide letter dated 04.01.2014. The claim is rightly repudiated as per the terms and conditions of the policy. Hence, there is no deficiency in service on the part of the OPs. After denying the other averments made in the complaint, it prayed for dismissal of the complaint.

4.                   In reply to the complaint OP No.4 raised certain preliminary objections, inter alia, that the present complaint is not maintainable in the present form; the complainant has not come to this Forum with clean hands and has suppressed the material facts; the complainant has no cause of action to file the present complaint and the complainant is stopped by his own act and conduct from filing the present complaint. As regards the facts of the complaint, OP No.4 stated that he is working as agent of OPs No.1 to 3. The complainant himself approached him to show the policy plans. He explained the plans of policies of OPs No.1 to 3 to the complainant and asked him to contact OPs No.1 to 3. The complainant contacted the OPs No.1 to 3 personally. The complainant after being satisfied with the policy, as per terms and conditions of the OPs No.1 to 3, agreed to purchase the policy in question and the premium amount was paid by the complainant to OPs No.1 to 3. The medical of the complainant was conducted by OPs No. 1 to 3 from the concerned medical examiner of the company. OP No.4 has no concern or connection with the medical of the complainant and premium amount of policy was directly paid to the OPs No.1 to 3 by the complainant. The complainant also received the policy from OPs No.1 to 3. OP No.4 has unnecessarily dragged been by the complainant into uncalled and unwanted litigation. The matter regarding the premium amount, any treatment and validity is between the complainant and OPs No.1 to 3. There is no deficiency in service on his part. After denying the other averments made in the complaint, he prayed for dismissal of the complaint.

5.                   In order to prove his case, the complainant tendered in evidence his affidavit Ex. C-1, true copies of documents i.e. letter dated 04.01.2014 Ex. C-2, letter dated 22.10.2013 Ex. C-3, policy Ex. C-4, certificate dated 24.12.2013 Ex. C-5, coronary angioplasty report Ex. C-6, discharge summary Ex. C-7, advance receipt/bill dated 24.09.13(two pages) Ex. C-8, bills/retail invoice(6 pages) Ex. C-9 and closed the evidence. In rebuttal OPs No. 1 to 3 tendered in evidence affidavit of Swati Singh, Legal Manager, Ex. OP/A, attested copy of proposal form Ex. OP-1, copy of claimant statement form Ex. OP-2,  copy of coronary angioplasty report Ex. OP-3, copy of policy documents Ex. OP-4, copy of letter dated 22.10.2013 Ex. OP-5, copy of letter dated 04.01.2014 Ex. OP-6 and closed the evidence. OP No.4 tendered in evidence affidavit of Raghubir Shukla as Ex. OP4/1 and closed the evidence.

6.                   The ld. counsel for the complainant has submitted that OPs No.1 to 3 had repudiated the claim of the complainant, vide letter dated 04.01.2014 i.e Ex.C-2, in an arbitrary manner. The ld. counsel further submitted that the complainant had purchased a medical policy and the same is valid from 28.06.2004 to 28.06.2029 and as per the policy, the complainant was insured for the purpose of medical treatment for all kinds of diseases. He also stated that despite regular payment of the premiums by the complainant his claim had been rejected. The ld. counsel argued that the OPs are misinterpreting the terms and conditions. He stated that the complainant is entitled to receive the claim, as the complainant was diagnosed to be suffering from the disease after 6 years from the date of the policy. The ld. counsel pleaded that the complainant deserves to be compensated for the act and conduct of the OPs and made a submission that his complaint be accepted against the OPs.

7.                    On the other hand, the ld. counsel for  OPs No. 1 to 3 objected to the submissions made by the ld. counsel for the complainant and submitted that the OPs had rightly repudiated the claim as per the terms and conditions of the Insurance Policy, under critical illness benefit which is binding on the complainant. The ld. counsel further submitted that complainant cannot interpret the terms and conditions of the policy. He stated that if the complainant had any objections with regard to the policy he had the option to return the same within a period of 15 days, which complainant failed to avail. The ld. counsel pleaded that it is well established from the certificate dated 24.12.2013 issued by the Doctor i.e Ex. C-5, coronary angioplasty report i.e Ex. C-6 and discharge summary i.e Ex. C-7 that the complainant had been admitted and treated for Acute coronary syndrome (Heart Attack) and the same is not covered under the Critical Illness Benefit as defined in the terms and conditions of the Policy i.e Ex.OP-4 (colly).The ld. counsel argued that in view of the terms and conditions of the policy  the present complaint deserves to be dismissed with special costs.

8.                   The ld. counsel for OP No.4 submitted that the alleged allegations against the OP are totally wrong and stated that  complainant approached the OP for policy and the OP explained about the policy in detail and thereafter he opted to purchase the same .The ld. counsel further stated that the medical examination was got conducted by  OPs No.1 to 3 and thereafter the payment of the premium was also directly made to  OP No.1 to 3. The ld. counsel pleaded that he had only been dragged into unwanted and uncalled for litigation and the OP deserves to be compensated by this Forum by imposing special cost upon the complainant.

9.                   After hearing the Ld. Counsel for the parties and going through the pleadings, evidence produced by the parties and the oral arguments and written submissions, we have gone through the contents of the Critical Illness Benefit and the same reads as; “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 Date of Policy but before the Policy anniversary on which he attains the 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 Supplementary Benefit shall fall to be paid together with Guaranteed Additions and Bonuses vested on such Sum Assured till then, subject to conditions set out below:

1)  The benefit shall not be payable in respect of any illness other than those defined as Critical Illness nor shall it apply or be payable in respect of any of those said illnesses the symptoms of which have occurred or which has been diagnosed or for which the insured person received treatment during the first 6 months from the date of Policy.”

As per the terms and conditions of policy i.e Ex.OP-4 (Colly), in the present case the complainant was treated for  Acute coronary syndrome, as it is evident from  certificate dated 24.12.2013 issue by the Doctor i.e Ex. C-5, coronary angioplasty report i.e Ex. C-6 and discharge summary i.e Ex. C-7 and the same has also been admitted by the OPs. It is also proved that the complainant had been treated for the disease, which is defined under the Critical illness as defined in Note1:A(b) “Coronary Artery By-Pass Graft Surgery(CABGS)- the undergoing of open heart surgery on the advice of a Consultant Cardiologist to Correct narrowing or blockage of one or more Coronary arteries with bypass grafts” of the terms and conditions of the Policy. In our opinion the complainant was diagnosed to be suffering from the critical illness disease i.e   Acute coronary syndrome after a period of 6 months, before the policy anniversary and before the expiry of the period for which the premiums are payable. Thus the complainant was entitled to the claimed amount.

10.                 Accordingly, in view of the aforesaid discussions and the terms and conditions, we are of the view that the complainant was fully entitled for the reimbursement of his claim, in view of the clauses of critical illness as mentioned above. In our opinion OPs No.1 to 3 have committed deficiency in services by repudiating the claim of the complainant in an arbitrary manner. Hence we direct OPs No.1 to 3 to pay a sum of Rs.2,50,000/- as per the claim submitted alongwith 6% interest per annum from the date of repudiation of the claim i.e 22.10.2013. The complainant is also held entitled for compensation on account of mental agony amounting to Rs.15000/- alongwith litigation cost of Rs. 5000/-. OPs No.1 to 3 are directed to comply with the order of this Forum within 45 days from the date of receipt of this Order. In case OPs No. 1 to 3 fail to comply the same, within the stipulated period, the OPs shall be liable to pay 9 % interest per annum on the aforesaid awarded amount. The present complaint stands accepted.  

11.           The present complaint could not be decided within the stipulated period as parties were interested in out of court settlement and thereafter the complainant had sought time to reconstruct his brief, as he had misplaced the same.        

12.                 The arguments on the complaint were heard on 08.01.2016 and the order was reserved. Now the order be communicated to the parties. Copy of the order be sent to the parties free of cost and thereafter the file be consigned to the record room.

Pronounced

Dated:22.01.2016

(A.P.S.Rajput)                          President

 

(Veena Chahal)                        Member

 

      (A.B.Aggarwal)                       Member