Before the District Consumer Disputes Redressal Forum, Rohtak.
Complaint No. : 53.
Instituted on : 23.01.2009.
Decided on : 01.06.2016.
Narender Singh Saharan, House No.13, near Double Phatak, Old Housing Board Colony, Rohtak.
………..Complainant.
Vs.
- ICICI Prudential Life Insurance Company Ltd. ICICI Prulife Tower, 1089, Appasahab Marathe Marg, Prabha Devi Mumbai-400025 through its President/Principal Officer.
- ICICI Prudential Life Insurance Company Ltd. 3rd Floor, Ashoka Plaza Opposite Myna Tourist Complex, Delhi Road, Rohtak-124001 through its Divisional Manager.
……….Opposite parties.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.JOGINDER KUMAR JAKHAR, PRESIDENT.
MS. KOMAL KHANNA, MEMBER.
SH. VED PAL, MEMBER.
Present: Sh. Satpal Hooda, Advocate for the complainant.
Sh. M.K.Munjal, Advocate for the opposite parties.
ORDER
SH. JOGINDER KUMAR JAKHAR, PRESIDENT :
1. The present complaint has been filed by the complainant with the averments that he had taken a Health Insurance policy from the opposite parties on 14.04.2007 for a sum of Rs.300000/- vide policy No.05210403 and the opposite parties told the complainant that this policy was for six critical illness i.e. Cancer, Heart Attack, Stroke, Coronary artery By-pass graft surgery(CAGB), Kidney failure, major organ transplant. It is averred that opposite parties also told that the total sum assured shall be payable in the event of life assured being diagnosed to be suffering from any one of the critical illness as mentioned above where the diagnose is after six months and within a year from the policy issuance date and the policy will terminate. It is averred that prior to availing the policy, the complainant was physically and mentally fit in all respect. It is averred that in the month of October 2007 the complainant fallen ill and he consulted the doctors of PGIMS, Rohtak who disclosed that the complainant is suffering from Ischemic heart disease and preferred Angioplasty. Accordingly the complainant took treatment from PGIMS, Rohtak and informed the opposite party about the said disease in writing vide letter dated 28.03.2008 and also submitted the documents as required by the opposite parties. It is averred that the opposite parties have illegally repudiated the just and legal claim of the complainant. It is averred that complainant sent a legal notice to the opposite parties but no reply to the same was given by the opposite parties. It is averred that the act of opposite parties of not disbursing the lawful claim of the complainant is unjust and against the natural justice. As such it is prayed that opposite parties may kindly be directed to pay an amount of Rs.300000/- alongwith interest, compensation and litigation expenses to the complainant.
2. On notice opposite parties appeared and filed their written reply submitting therein that the policy bearing no.05210403 was issued on the life of the complainant on 14.05.2007 under the health Asure plan of the company. It is averred that as per clause 1(iv) of the policy, “In the event of the Life assured being diagnosed to be suffering from any of the Critical illnesses as mentioned in Clause(2) where the diagnosis is within six months from the issue of the policy, the premiums(excluding any extra premiums) paid shall be returned and the policy will terminate”. It is averred that the opposite parties on April 09, 2008 received claim intimation form dated nil duly signed by complainant stating the cause of claim as Heart disease Advice of Angioplasty. It is averred that since the complainant was diagnosed of “Ischemic Heat Disease during the waiting period, the claim was assessed in accordance with clause 2.2. &1(iii) of the policy terms and conditions. Hence the policy was terminated and the premium were refunded to the complainant vide cheque no.907494 dated June 20, 2008 for Rs.2806/- and the said cheque was duly encashed by the complainant on August 23, 2008. It is averred that on November 03, 2008 the opposite parties received a legal notice dated September 03, 2008 requesting the company to reconsider its decision on the claim under the subject policy. It is averred that the opposite parties submit that after giving due consideration to the request of the complainant, the company decided to stand by its decision as communicated to the complainant vide letter dated June 09, 2008 and the decision was communicated to the company’s Advocate through letter dated December 02, 2008. It is averred that the claim of the complainant was assessed as per policy terms and conditions and the premiums paid under the policy was refunded to the complainant. As such there is no deficiency in service on the part of opposite parties and dismissal of complaint has been sought.
3. Both the parties led evidence in support of their case.
4. Ld. Counsel for the complainant in his evidence has tendered affidavit Ex.C1, documents Ex.C2 to Ex.C21 and has closed his evidence. On the other hand ld. Counsel for the opposite parties has tendered affidavit Ex.RW1/A, documents Ex.R1 to Ex.R8 and has closed his evidence.
5. We have heard ld. counsel for the parties and have gone through the material aspects of the case carefully.
6. In the present case it is not disputed that as per proposal form dated 14.04.2007 the complainant had taken a policy of Home Asure/Health assured from the opposite party. It is also not disputed that as per terms and conditions of the policy mentioned in the policy document Ex.C3, “The plan provides a long term cover against six critical illnesses by providing with the necessary financial assistance irrespective of the actual medical expenses’ and as per clause 1(ii) of the policy “Half of the Sum assured shall be payable in the event of the Life Assured being diagnosed to be suffering from any one of the Critical illnesses as mentioned in Clause(2) of the policy where the diagnosis is after six months and within a year from the policy issuance date and the policy will terminate”. As per claim intimation letter Ex.C4, the complainant had intimated the opposite parties that he had been advised Angioplasty by the Doctor and also filled the Claim intimation Form Ex.C5. As per letter Ex.C7 all the documents as required by the opposite parties were sent by the complainant and were received by the opposite party on 03.05.2008.
7. The contention of ld. counsel for the complainant is that despite submitting all the required documents, opposite parties have not paid the claim under the policy. On the other hand contention of ld. counsel for the opposite parties is that the policy was issued on 14 May 2007 and as per policy terms and conditions, the 6 months waiting period got over on November 2007. It is further contended that the Life Assured was diagnosed to be suffering from “Ischamic Heart Disease on October 17, 2007 which is within the six months waiting period. Hence clause 1(iv) of the policy terms and conditions becomes applicable and as such the opposite parties opposite parties had dispatched a cheque bearing no.907494 dated June 19, 2008 for an amount of Rs.2568/- (being the premiums paid under the above mentioned policy) and the same was encashed by the complainant on August 23, 2008. It is contended that the company is not liable to make any further payment under the policy.
8. After going through the file and hearing the parties it is observed that the claim of the complainant has been repudiated by the opposite parties on the ground that the policy was issued on 14.05.2007 whereas the life assured was diagnosed to be suffering from Ischamic Heart Disease on October 17, 2007 i.e. within 6 months from the date of issuance of policy and as per terms and condition no.1(iv) of the policy only the premiums paid under the policy were refundable to the complainant. In this regard it is observed that the proposal form Ex.C2/Ex.R1, the date of proposal is 14.04.2007 and the premium was paid through cheque No.075956 dated 17.04.2007 amounting to Rs.60972/- including the Home Assure premium, Health Assure Premium and Health Assure (co applicant) premium. In this regard reliance has been placed upon the law cited in 2008(1)137CCC titled Yellamma Vs. Bhy Sukhadev Singh, whereby Hon’ble Karnataka High Court has held that: “Liability commences from the date of issuance of cheque and not from the date of its encashment-Insurer liable to pay compensation when accident occurs within 15 days from the date of issuance of cover note” and as per 2005(2)CLT 231 titled Express Resorts and Hotels Ltd. Vs. Oriental Insurance Co. Ltd. and others, Hon’ble National Commission, New Delhi has held that: “Insurance contract-Cover note-Insurance policy-Held that till the time the policy is issued, the cover note itself covers the peril”. In view of the aforesaid law which are fully applicable on the facts and circumstances of the case, it is observed that the risk covers from the date of issuance of cheque i.e. 17.04.2007 and as per claim Statement Form Ex.R5 and Treating Doctor’s Certificate Ex.R6, the symptoms of disease first appeared on 17.10.2007 i.e. after 6 months from the date of covering of risk. As such as per clause 1(ii) of the policy terms and conditions “Half of the Sum assured shall be payable in the event of the Life Assured being diagnosed to be suffering from any one of the Critical illnesses as mentioned in Clause(2) of the policy where the diagnosis is after six months and within a year from the policy issuance date. As such complainant is entitled for the claim amount as per policy terms and conditions i.e. half of the sum assured .
9. In view of the facts and circumstances of the case it is observed that opposite party shall pay the amount of Rs.150000/-(Rupees one lac fifty thousand only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e. 23.01.2009 till its actual realization, other benefits under the policy, if any and shall also pay an amount of Rs.3500/-(Rupees three thousand five hundred only) as litigation expenses to the complainant maximum within one month from the date of decision failing which the awarded amount shall carry further interest @ 12% p.a. from the date of decision. Complaint is allowed accordingly.
10. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
01.06.2016.
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Joginder Kumar Jakhar, President
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Komal Khanna, Member.
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Ved Pal, Member.
