ORDER

23.10.2024

Sh. Sanjay Kumar, President

1. The factual matrix of the present case is that in India after the enactment of Life Insurance Corporation Act, 1956, business of life cover was nationalized and a virtual system of social security developed, that laid provisions for financial indemnity on sudden and unforeseen loss of life, loss of earning to the surviving family members and immediate respite from depravity that ensued.
2. It is stated that, therefore, the ‘life insurance’ did not merely remain a state managed business under the Ministry of Finance, Government of India, but it became a household necessity since the framers of the country’s solemn Constitution did not have enough corpus of funds in hand to have Fundamental Rights or Directive Principles aimed at providing for death or disablement, unemployment allowance on becoming invalid, or other reliefs to all its citizens in times of contingencies of providence.
3. It is stated that over the  years life insurance policies became a sole and default avenue that covered both future mishaps as well as present savings. It is stated that to put it more clearly, when one spoke about LIC, “life” was paramount in it, and “insurance” was sequel and “corporation” was the governance model that statutory body was to operate within. It is further stated that global dimension of economic developments led to privatization of various sectors of goods and services and in the year 1999 life insurance segments were also privatized. The Insurance Regulatory & Development Authority Act was promulgated and the IRDA took over the entire regulation of both general as well as life insurance domains.
4. It is stated that appropriate amendments were made in the Insurance Act, 1938 and the Life Insurance Corporation Act, 1956 to regulate life insurance products, as well as the General Insurance Business (Nationalization) Act, 1972 to cover the non-life based coverage under the erstwhile GIC. It is further stated that one such company known as the ICICI Prudential Life Insurance Company Limited, hereafter called the OP, also functions, inter alia, within the statutory domain of the Insurance Act, 1938, The Insurance Regulatory and Development Authority Act, 1999 and The Insurance Regulatory and Development Authority (Protection of Policy Holders’ Interest) Regulations, 2002, thus, and ostensibly, renders the services envisaged therein to public at large, prospecting business for profit.
5. It is stated that in the realm of its product range the OP in the public domain canvassed for its “Crisis Cover Policy” and the complainant was also attracted towards its features. Accordingly, a general Proposal form bearing no.12374064 was got filled on 23.02.2008, the simplicity of the said proposal form was self explanatory as it did not reflect any limitations, exclusions or exceptions to the scope of the “crisis that was covered’ as against the crisis that was not covered. It is stated that complainant filled the said proposal form under the impression that the product gave comprehensive coverage to health crisis.
6. It is stated that the complainant’s said Proposal Form dated 23.02.2008 was considered by the OP after thorough scrutiny and risk was underwritten by the OP and for valuable consideration of premium in the sum of Rs.525.00 per month and issued to the complainant an annual cover under its Policy No.08056204 w.e.f. 03.03.2008 for a period of twenty years ending on 03.03.2028. It is further stated that the sum insured is Rs.3,00,000/- for death benefit (monthly premium Rs.194.00) premium and Rs.3,00,000/- for total and permanent disability (monthly premium Rs.331.00) aggregating to total monthly premium of Rs.525.00. It is stated that in its product paper book the OP claimed that “By choosing the ICICI Prudential Crisis Cover, you have opted for the services from India’s No.1 Private life insurance company, known for its pioneering services”.
7. It is stated that it was in the policy document that complainant was revealed that the “CRISIS COVER” was in fact “Critical Illness” cover confined to 35 categories of illness and the policy was to be services by the OP as per its own set of definitions, terms and conditions as stated in the policy. It is further stated that although “crisis cover” became “critical illness” the complainant did not return the policy during the free look period as there was no apprehension of any imminent health issues and all the major vital organs were even otherwise ostensibly covered in the spirit of the proposal form. It is further stated that to the understanding of the complainant he had proposed for CRISIS COVER which could not be abridged by the glossary of the critical illness by the OP.
8. It is stated that conversely speaking, every illness suffered by the complainant is a “crisis” for the complainant, though the OP may agree it to be “crisis” but paradoxically test it with their own self-styled definitions of critical illness, irrespective of the pathology, prognosis, morbidity and mortality of disease as per universal standard protocols of medical sciences, therefore, ironically enough, virtually breaching the “crisis cover” to Crisis Uncovered!. It is further stated that interestingly, born on 16.01.1964 the complainant about 44 years of age at the time of issuance of the policy, had disclosed correctly his state of health in the said proposal form and the OP and its team of medical/non-medical underwriters were well aware of the risks or crisis that a person of that age may be prone to without having any prehistory of ailments.
9. It is stated that primary object of the OP is “life insurance”, and when “life” is insured with support of a “crisis cover” at an additional charge, it is the mandate of the underwriters that they will not give up or abandon the insured and would rather help save his life if afflicted with serious diseases, and in turn, the policy holder continues to pay the premium till its full term by maintaining good health and getting treatment, if required on the way to maturity of the policy. It is further stated that perversely or conversely, if a young healthy individual is trapped into multiple disease symptoms at random, in such an event, denial of treatment claim on hyper technical grounds rather deprives him of the medical care and he may even die.
10. It is stated that such an insurer acquiesced death of an insured was never contemplated in law, contract, social or commercial parlance. It is further stated that direct and inevitable paradoxical sequel of such a situation would be that death claims may rise on account of denial of the claims under crisis cover, thus defeating the very purpose of life insurance. It is stated that the aforesaid “life and crisis” cover are unique and integral to each other as compared or in contrast to the other regular mediclaim policies which are issued on acceptance of risk related only to diseases, and treatment of such listed diseases, and with approved list of hospitals to treat the same, and provision for cashless benefits at the admission stage of hospitalization or reimbursement after treatment.
11. It is stated that such customized mediclaim policies could be envisaged to have stricter interpretation of disease process as typically defined or excluded, covered or subjected to conditions or completely barred on the test of pre-existence. It is further stated that Risk Commencement Date is 03.03.2008 and Cover Cessation Date is 03.03.2008, a full term of twenty years of “life”, unlike the annually renewable mediclaim policies grounded solely on disease. It is stated that welcome letter dated 04.03.2008 placed as first page the policy booklet.
12. It is stated that at the time of filling up of the proposal form, no such details of 35 diseases or their narrowest terminal stage for admission of claim was stated anywhere in the proposal form. It is further stated that at the time of filling up of the proposal form, there was no medical man available to explain the nature of partitioned coverage to the complainant. It is stated that at the time of filling up of the proposal form, no literature or prospectus was provided to the complainant showing the scheme of the product. It is further stated that at the time of filling up of the proposal form, the complainant was not even asked if he was aware about the 35 diseases allegedly covered therein.
13. It is stated that ironically, para 23 of the proposal form is a verification questionnaire about various adverse medical conditions covering about more than 50 sub-categories of diseases, which are mentioned by title only, and austerely only covering half page space of the proposal form, whereas, while actually translating the 35 diseases in the policy document as Critical Illness Benefit Clause 3 thereof, it surprisingly covers 12 pages out of the 21 paged policy booklet. It is stated that it rather reads more like a medical document, which could not have been understood by the policy holder without aid of a doctor. It is stated that the reason for such concealment of actual and complete product detail from the policy holder complainant is best known to the OP, and therefore, the burden is also upon the OP to explain its liability. It is stated that in the absence of a clear, full, unambiguous knowledge, notice or virtual understanding of the policy terms and conditions, it is a case of mis-selling.
14. It is stated that after 6 years of uneventful term of the said policy the complainant was admitted on 26 June, 2014 to the Indraprastha Appollo Hospital, New Delhi and diagnosed with Systemic Hypertension, Diabetes Mellitus Type II, Acute Lower Respiratory Tract Infection (Right Side Pneumonitis), Toxic Myocarditis (CHF), Seizure Disorder, Dyslipidemia, Borderline hypothyroidism. It is further stated that complainant remained inpatient and was discharged after 9 days on 05 July, 2014 emergency management with medicines, life support systems and follow up regimen.
15. It is stated that the in-patient records of the complainant reveal that the course of treatment that was adopted at the said hospital was in accordance with “crisis” management and critical care. It is stated that the discharge summary issued by the Department of Cardiology in the said hospital is a compilation of the regimen followed during 9 days. It is stated that at the time of discharge on 05 July 2014 the complainant was billed by the said hospital in the sum of Rs.292997.00. It is further stated that the complainant submitted to the OP claim as per the terms and conditions of the said policy for a sum of Rs.292997 supported by all the medical records and bills. It is stated that vide claim rejection letter dated 10.02.2015 the OP illegally an unilaterally repudiated the claim merely on the basis of Evaluation of Medical records that the medical conditions were not covered under the critical illnesses mentioned in the policy.
16. It is stated that in the said repudiation letter the OP has not even specified under which category the medical conditions diagnosed with the complainant fall, if not under their self-styled “critical illnesses” definition. It is further stated that in the said repudiation letter the OP has not even clarified that how since the medical conditions diagnosed with the complainant did not fall under their self-styled “critical illnesses” definition of the OP, the same were not a “CRISIS COVER” episode as envisaged in their own format of the general proposal form. It is further stated that the OP had not signed from the complainant any customized “CRITICAL ILLNESS PROPOSAL FORM” to put to notice the complainant about the hyper-technical, all exclusive and narrow definitions of the coverage under the said product. It is stated that the said policy starts with Clause 1, the Definitions. “Critical Illness” is nowhere defined in the definition clause of the policy. However, in Clause 3 containing the 35 medical conditions the OP has narrowed down the various stages of the disease process, thereby converting its  initial proposal of “Crisis Cover” to “Critical Illness” and finally to “Critical Stages” policy creating an unfair advantage in its favour, the last medical condition sub-clause 35 being Terminal Illness.
17. Para 40.
18. It is stated that the intention of the OP seems to be collecting premiums and denying claims, blindly, without going through the facts of the case. The complainant reserves the right to take appropriate action with the IRDA also as the OP does not wish to discharge its contractual and legal obligations despite the fact that the case of the complainant falls within the scope of liability under the policy. It is further stated that the Insurance Regulatory and Development Authority (Protection of Policy Holders Interests) Regulations, 2002, framed by the Insurance Regulatory and Development Authority (IRDA) in exercise of the powers, vested in it, under Section 114(A) of the Insurance Act, 1938 read with Sections 14 and 26 of the Insurance Regulatory and Development Authority Act, 1999, came into effect from the year 2002. It is further stated that therefore, the policies, which were issued after 2002, were covered under the said Regulations. It is stated that the insurance companies are bound by the aforesaid Regulations, which are mandatory in nature. It is stated that these Regulations were framed by IRDA to protect the interests of the policyholders.
19. It is stated that the aforesaid Regulation 3 clearly reveals that it is the duty of the insurer to supply the entire information by issuance of prospectus of any insurance product stating therein the scope of benefits, the extent of insurance cover, in an explicit manner explaining the warranties, exceptions and conditions of the insurance cover. The complainant has referred to the judgment of M/s Modern Insulators Ltd. Vs. Oriental Insurance Co. Ltd. I (2000) CPJ 1 (SC) and  United India Insurance Co. Ltd. & Anr. Vs. S.M.S Tele Communications & Anr. III (2009) CPJ 246 (NC).
20. It is stated that further vide IRDA/HLT/CIR/036/02/2013 dated 20.02.2013 the guidelines  on Standardization in Health Insurance were issued by the IRDA. It is further stated that as per its section 2 Standard Nomenclature and Procedures for Critical Illnesses were provided in view of resolving the differences in the definitions of terms on Critical Illnesses adopted by the different insurers which were creating confusion in the minds of consumers and the industry especially at the time when insurers and re-insurers had to arrive at a point where lump sum payment is to be made. It is stated that 11 Critical Illness terms have been standardized to be adopted uniformly across industry, if offered under the product. It is further stated that all products offering the 11 critical illness coverage shall ensure that definitions of the stated 11 terms were in line with the stipulated definitions.
21. It is stated that in the policy in question the OP has made additional 24 illness conditions under its crisis cover and aggregated it to 35 diseases. It is further stated that disease no. (5) Heart Attack does not match the definition as required by the said corresponding clause 2 of the said Guidelines dated 20.02.2013 issued by the IRDA and the OP has made this clause onerous and unfair for the policy holder. It is stated that complainant’s case falls under the definitions of critical illness of First Heart Attack as laid down by the IRDA. It is stated that similarly disease no. (32) stroke does not match the definition as required by the corresponding clause 7 of the said guidelines dated 20.02.2013 issued by the IRDA and the OP has made this clause onerous and unfair for the policy holder. It is further stated that the complainant’s case falls under the definition of Stroke having suffered from seizures, as laid down by the IRDA. It is stated that complainant’s case is also covered under disease no.10, Chronic Lung Disease, as per the said policy terms and conditions, i.e Pneumonitis.
22. It is stated that inter alia the medical records maintained by the Department of Cardiology, Indraprastha Appollo Hospitals, New Delhi clearly shows that on 26.06.2014 the complainant was admitted in acute, systemic and toxic conditions of all the three most important regulatory vitals of human anatomy, the heart, lungs and the brain. It is stated that repudiation letter dated 10.02.2015 based only on the opening sheet of the Discharge summary dated 05.07.2014 is non-speaking, mechanical, meaningless and totally out of context as it has glaringly missed and grossly not considered that the complainant was actually, inter alia, treated for acture and chronic CHF, moderate LVF and LVEF-60% and significant diastolic dysfunction, managed with life support systems throughout. It is stated that the complainant was inpatient in the said hospital.
23. It is stated that it is not the case of the OP that all their critical illnesses in the policy terms and conditions are not be treated as critical unless becoming terminal. It is stated that it is also not the case of the OP that all such claims for reimbursement must  be supported a “grave prognosis” note by the treating establishments. It is further stated that another paradox of this policy seems that no claim is likely to be allowed unless the insured is crippled or invalidated for life. It is stated that medicine is an inexact science. It is further stated that a highly polarized patient may be saved and even in the OPD a patient may die. It is stated that a patient cannot be imagined to wait in his hospital room for the disease to aggravate to a point where it matched the entry-level self contradictory definitions in the policy under reference.
24. It is stated that every acute condition is virtually a threat to life if not treated in time, each chronic attack has impact on the vital organs involved to calibrate into mortality unless controlled by protocol, and all anomalies involving the emergent situations of the heart, brain or lungs are, indeed, critical. It is further stated that the policy relates to diseases those are critical, not that the patient must be critical after getting afflicted with those diseases. It is stated that it is crisis-cover cum critical illness product, not “critical patients cover”. It is stated that the complainant is a consumer having paid the premium to the OP under the valid and legally enforcible policy contract with the OP is guilty of deficiency in service and unfair trade practice within the meaning of the Consumer Protection Act, 1986 and violation of its statutory obligations under the Insurance Act, 1938, the Contract Act and IRDA protocols.
25. Complainant is seeking direction against OP for reimbursement of Rs.292997 only under the aforesaid policy valid between 03.03.2008 to 03.03.2028 with interest @ 12% p.a from 26.06.2014 till realization, to pay Rs.50,000/- compensation for mental agony and harassment, to pay Rs.22,000/- cost of the proceedings and any other order in view of facts and circumstances of present case in favour of complainant.
26. OP filed detailed WS and taken preliminary objections that the OP acted as per the mandate given to the complainant in proposal form and issued the insurance policy and took all decision in conformity of insurance terms and conditions which is concluded contract between the insurance company and life assured. It is further stated that it is well settled law that the insurance terms have to construe strictly and no relief which travels beyond the terms of the insurance policy can be granted, hence no case for deficiency in services is made out in this case as there is no breach on the part of the insurance company accordingly the present complaint is liable to be dismissed on this ground alone.
27. It is stated that an insurance policy is to be construed strictly as per the terms and conditions of the policy document and no deviation from the same is permissible. The OP referred the judgments of Export Credit Guarantee Corporation of India Ltd. Vs. Garg Sons International 2013 (1) Scale 410, Suraj Mal Ram Niwas Oil Mills (P) Ltd. Vs. United India Insurance Co. Ltd. (2010) 10 SCC 567, Reliance Life Insurance Co. Ltd. Vs. Madhavacharya Revision Petition No.211 of 2009, General Assurance Society Limited Vs. Chandumull Jain & Anr. (1966) 3 SCR 500 and United India Insurance Co. Ltd. Vs. Harchand Rai Chand Rai Chandanlal I (2003) CPJ 393 & Vikram Greentech (i) Ltd. & Anr. Vs. New India Assurance Co. Ltd. II (2009) CPJ 34.
28. It is stated that the present complaint is time barred and liable to be dismissed. It is further stated that in present complaint the complainant is allegedly raising objection as to insurance policy bearing no.08056204 applied by proposer hence the cause of action in this case, can only arise at the time of selling insurance product i.e at proposal stage and at last on issuance of policy and at no latter stage. It is stated that the present complaint is filed in respect of insurance policy issued on 03.03.2008 and same was received on 12.03.2008. Hence, the Free Look Period of 15 days had expired on 27.03.2008 whereas present complaint is filed in 2015 which is after expiry of 7 years of applicable free look period as per Insurance Act 1938.
29. It is stated that the complainant was duly informed that in case he is not satisfied with the features or the terms and conditions of the policy he can withdraw/cancel the policy under the “Free Look Period” provision that is within 15 days from the date of receipt of policy document. It is further stated that the complainant retained the policy document and did not raise any objection towards the policy during the said “Free Look Period” with any grievance regarding the policy or its terms and conditions, meaning thereby that the complainant agreed to the policy and its terms and conditions and the policy was to the agreement and satisfaction of the complainant. It is stated that the complainant must produce documentary evidence in support of his false and concocted story.
30. It is stated that the proposer of the policy is an educated person and has signed the proposal form with his free will and released the premium amount hence it is stated that no prudent individual would simply sign on a form without being aware of and satisfied with the contents of the same. OP has relied on the judgment of Hon’ble National Commission Kishor Chandrakant Rathod Vs. The Managing Director, ICICI Prudential Life Insurance Co. Ltd. & Anr. On 21.05.2014 in Revision Petition No.3390 of 2013, Prema & Ors. Vs. Life Insurance Corporation of India Ltd. IV (2006) CPJ 239 (NC) and M/s Grasim Industries Ltd. & Anr. Vs. M/s Aggarwal Steel 2010 (1) SC 33 of Hon’ble Supreme Court.
31. It is stated that the complaint is devoid of any material particulars and has been filed merely to harass and gain undue advantage and unjustified monies from the OP and hence complaint deserves to be dismissed in limine.  It is further stated that the complaint has been filed with ulterior motive and malafide intention to cause harassment and prejudice to the OP, which a company of high repute; hence the complaint being malafide is liabe to be dismissed. It is stated that the ct has failed to set up a nexus between the damages claimed in the present complaint and the damage suffered by them. It is stated that the damages claimed are arbitrary, without basis is an abuse of process of law. It is further stated that damages not being debt are liable to proved by cogent and reliable evidence by the complainant, hence the damages in shape of mental harassment, agony or for legal expenses etc cannot be granted merely on asking of the complainant, hence the prayer clause of the complainant for damages etc being not supported by any cogent is liable to be dismissed.
32. It is stated that complaint being frivolous and vexatious is liable to be dismissed under section 26 of Consumer Protection Act as the ct has failed to make out a case of “Deficiency of Service” as alleged or otherwise, within the meaning of The Consumer Protection Act 1986, hence the present complaint is not maintainable. OP has referred the judgment of Ravneet Singh Bagga Vs. KLM Royal Dutch Airlines (2000) 1 SCC 66 of Hon’ble Supreme Court and Reliance Life Insurance Co. Ltd. Vs. Madhavacharya (Revision Petition No.211 of 2009) of Hon’ble National Commission.
33. It is stated that preliminary objections raised herein above with regard to maintainability of the complaint, go to very root of matter and as such these objections need to be considered at the outset as preliminary issue and the OP most humbly pray that this Hon’ble Forum may be pleased to dismiss the complaint summarily without going into the merits thereof.
34. OP has stated the facts that the OP was in receipt duly signed and filled in Proposal form from the complainant for issuance of crisis cover policy on his own life where the wife of the complainant was made the nominee as per details contained in said form. It is further stated that the OP on believing the information given by the Life Assured in the proposal form to be true and correct in all aspects and as per underwriting norms of the OP issued the policy in favor of the complainant.  It is stated that the details of policy as issued by the OP is application no. CR12374064, policy no.08056204, policy plan ICICI Pru Crisis Cover (T16), Policy status in force, Life assured Amit Aggarwal, Proposer Amit Aggarwal, Servicing Agent Mona Sharma, Sum Assured Rs.3,00,000/-, Prop Recd Date February 29, 2008, Risk Commencement Date March 03, 2008, Paid TO Date January 03, 2016, Premium Frequency Monthly, Premium Amount Rs.525/- and Total Premium of Rs.49,350/-. Copy of the proposal form for policy no.08056204 is filed on record.
35. It is stated that the complainant applied for the Crisis Over (T16). It is further stated that based on the duty filled in and signed application form no. CR12374064, the company issued a policy bearing no.08056204 and 03.03.2008 and dispatched the policy document to the address mentioned by the complainant on the proposal form via First Flight Couriers vide Air Way bill no. D991Z2122331 which was duly received at the communication address of the complainant on 12.03.2008.
36. It is stated that on the basis  of policy proposal form received from the complainant, OP had sent the policy documents to the communication address mentioned in the proposal form of Life Assured, stating the policy terms and conditions and a forwarding letter stating the “Free Look Period” provision of cancellation of policy within 15 days time along with a copy of proposal form. It is stated that the policy documents along with the Welcome Kit were duly dispatched by OP and the same was received at the communication address mentioned in the proposal form for insurance. It is further stated that the  in accordance to clause 6 (2) of the Insurance Regulatory and Development Authority (Protection of Policyholder’s Interests) Regulations, 2002 every policy document sent by it is accompanied by a forwarding letter which clearly mentions that in case policyholder is not satisfied with the features or the terms and condition of the policy he can withdraw/return the policy within 15 days i.e under the “Free Look Period” provision.
37. It is stated that the Life Assured retained the policy document and did not approach the company with any discrepancies regarding the details mentioned in the proposal form and the policy terms and conditions, neither did complainant approach the company for cancellation of the said policy during the free look period thereby implying that the had agreed to all the terms and conditions of the subject policy. Hence by not availing free look period option, the complainant has forfeited his rights to cancel the policy and accordingly the subject policy continued. It is stated that OP company had received claimant stated dated 03.02.2015 and medical records informing them that the complainant was hospitalized in Indrapratha Apollo Hospital on March 14, 2014 and was diagnosed with Systemic Hypertension, Diabetes Mellitus Type-II, Acute Lower Respriatory Tract Infections, Toxix Myocarditis, CHF, History of Seizure Disorder, Dyslipidemia & Borderline Hypothyroidism.
38. It is stated that OP company after careful examination of the medical documents submitted by the complainant it was found that all the illness suffered by the complainant are not covered under the subject policy and the same was conveyed to the complainant vide letter dated 10.02.2015. It is further stated that the OP company is not averse to settling claims. It is further stated that all the claims received by the company are investigated and only genuine claims are honored b y the OP company. It is further stated that the policy of the complainant is still in force and lA is still covered by the same. It is stated that if the condition suffered by the complainant can match any of the criterions mentioned under the captioned policy then the benefit shall be paid to the Life Assured. It is stated that the contract of insurance is a contract of good faith and OP is willing to honor the same only if the same is covered under the policy.
39. It is stated that the OP claim is paid by any Insurance OP out of the common pool of funds belonging to all policyholders of the OP and Insurance Company has to check the genuineness of a claim before honoring it. It is further stated that the insurance company cannot do injustice to genuine policyholders by allowing ingenious claims.
40. On merit all the allegations made in the complaint are denied by OP and reiterated contents of preliminary objections.
41. Complainant filed rejoinder to the WS of OP and denied all the allegations and reiterated contents of the complaint. 
42. Complainant filed evidence by way of his affidavit and reiterated contents of the complaint.
43. OP filed evidence by  way of affidavit of Karanvir Singh Senior Manager Legal and reiterated contents of WS.
44. Written arguments filed by complainant as well as by OP.
45. We have heard Sh. Anup Kaushal counsel for complainant and Sh. Yash Nirwan proxy for Sh. Praveen Mahajan counsel for OP and perused the record.  
46. The complainant alleged that he got issued insurance policy plan ICICI PRU CRISIS COVER (T 16) for a sum assured of Rs.3,00,000/- on 03.03.2008 and premium paid upto 03.01.2016. It is admitted case of the parties that a claim filed by complainant dated 03.02.2015 alongwith medical record that complainant was hospitalized in Indrapratha Apollo Hospital on 14.03.2014 and was diagnosed with Systemetic Hypertension, Diabetes Mellitus Type II, Acute Lower Respiratory Tract Infection, Toxic Myocarditis, CHF, history of Seizure Disorder, Dyslipidemia and Borderline Hypothyroidism. It is admitted case of the parties that OP Insurance Co. conveyed to the complainant vide letter dated 10.02.2015 that all the illness suffered by complainant were not covered under the subject policy plan. The complainant admitted the fact that he had received the policy documents filed on record alongwith welcome letter dated 04.03.2008. The policy document has heading “Crisis Cover”. The key features are defined in detail under the column “The benefits under Crisis Cover and payable benefits also explained in detailed”.
47. The relevant portion of the benefits under crisis cover are reproduced hereunder:-

2. The benefits under Crisis Cover are as follows:

I. Critical Illness Benefit:

The benefit will be payable provided that the Critical Illness has first occurred or first maintained and diagnosed after the waiting period as stated in Clause 1.

The payouts (benefits) payable on the occurrence of any of the Critical Illness shall be as stated in the table below:

48. We have gone through the discharge summary filed on record, according to which complainant was admitted at Indrapratha Apollo Hospital on 26.06.2014 and discharged on 05.07.2014. The complainant was diagnosed for Systemic Hypertension, Diabetes Mellitus Type II, Acute Lower Respiratory Tract Infection, Toxic Myocarditis CHF, history of Seizure disorder, Dyslipidemia and Border line Hypothroidism. As per OP letter dated 10.02.2015 the OP Insurance Co. categorically stated that the diagnosed diseases are not covered under “Crisis Cover Policy” although it provide cover against 35 Critical Illness, Death and TPD. We have considered the detail oral and written submission of counsel of complainant and as per material on record the impugned letter of OP Insurance Co. whereby rejecting the claim is inconsonance with the terms and conditions of the policy and in accordance with justification which is fair and legal in the present circumstances. The complainant failed to establish deficiency of service on the part of OP Insurance Co.
49. On the basis of above observation and discussion present complaint is dismissed. No order as to cost. File be consigned to record room.
50. Copy of the order be given to the parties free of cost as per order dated 04.04.2022 of Hon’ble State Commission after receiving an application from the parties in the registry. The orders be uploaded on www.confonet.nic.in.

Announced in open Commission on  23.10.2024.

      SANJAY KUMAR                                                                     RAJESH  

       PRESIDENT                                                                              MEMBER