BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.324 of 2017
Date of Instt. 04.09.2017
Date of Decision: 12.06.2019
Rajni Sharma aged about 42 years W/o Neeraj Sharma R/o BB 34-A, Shiv Vihar Lane No.1, Jalandhar.
..........Complainant
Versus
1. ICICI Prudential Life Insurance Co. Ltd. ICICI Pru Life Tower, 1089, Appasaheb Marathe Marg, Prabhadevi, Mumbai-400025 through Dinaz Maria, Associate Vice President (Claim).
2. ICICI Prudential Life Insurance Co. Ltd. 1st Floor, Plot No.22- 23, PS Jain Commercial Centre, Above Punjab and Sind Bank, GT Road, Jalandhar Through its Manager/Authorized Signatory.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Sh. Karnail Singh (President)
Smt. Jyotsna (Member)
Present: Sh. Darshan Singh, Adv Counsel for the Complainant.
Sh. K. S. Minhas, Adv Counsel for the OPs No.1 & 2.
Order
Karnail Singh (President)
1. The instant complaint has been filed by the complainant, wherein alleged that the complainant believed in the version of representative of ICICI Prudential Insurance and complainant got a policy No.20273844 after making payment of premium Rs.17,197/- on 12.09.2016 and next premium was due on 16.09.2017.
2. That on 03.10.2016, the complainant was not feeling well and she was feeling some uneasiness and approached Dr. Naveen Khanna, MD (Medicine), Department of Cardiology, Patel Hospital, Jalandhar. The complainant was examined and tests were conducted at Patel Hospital, Jalandhar and thereafter, the complainant was again went to the hospital and admitted on 12.11.2016 by Dr. Naveen Khanna, MD (Medicine) because the complainant was feeling heart problem and treating doctor Naveen Khanna provided her medicines and also stated that the complainant was suffering from heart problem and copy of the discharge slip as well as bill supplied by the hospital and whereby the total cost of her treatment is mentioned Rs.4,39,882/-. Thereafter, the complainant submitted the required claim form along with all documents to OP through their local office at Jalandhar, but the claim of the complainant has not been settled by OP, rather the complainant received claim intimation, vide letter dated 31.12.2016, wherein stated that the disease of the complainant is not covered under Critical Illness Benefit Rider as well as terms and conditions of the policy and accordingly, the claim of the complainant was repudiated, which is exactly against the natural justice as well as illegally rejected the claim of the complainant, which is tantamount to deficiency in service on the part of the OPs and accordingly, the complainant served a legal notice dated 29.07.2017, but all in vain and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay medical claim of the complainant of Rs.4,39,882/- along with interest @ 9% per annum and further OPs be directed to pay compensation of Rs.45,000/- for causing mental tension and agony to the complainant and further OPs be directed to pay litigation expenses of Rs.11,000/-.
3. Notice of the complaint was given to the OPs, who appeared through its counsel and filed joint written reply, whereby contested the complaint by taking preliminary objections that the complainant has tried to challenge the veracity of the decision taken by the OPs on the basis of medical records submitted by the complainant and after invoking the terms and conditions governing the policy. The claim of the complainant has been rejected and as such, there is no deficiency in service on the part of the OPs and therefore, complaint deserves to be dismissed. It is further averred that the complainant has admittedly submitted a claim intimation and it was mentioned in the same that she was hospitalized for acute Pancreatitis and Cholesystitis with Cholelithiasis and acute coronary syndrome. As per the terms and conditions, the policy provides life insurance cover and CIBR (Critical Illness Benefit Rider). Complainant was availed the Critical Illness Rider, but from a mere perusal of the policy terms and conditions titled supplementary benefits applicable if opted for Clause (c) titled Critical Illness Benefit, procedure undergone by complainant is not covered under the captioned policy. A letter of rejection of the claim was sent to the complainant on 30.11.2016. The claim of the complainant has been rejected on the ground that the medical conditions opted by the complainant, acute pancreatitis with cholecystitis, cholelithiasis, other forms of acute ischaemic heart disease and laparoscopic cholecystectomy were not covered under the Critical Illness Benefit Rider Part C, Clause 1 {1.4 (a)}, of the terms and conditions of the policy, is not covered under the Critical Illness Rider as per policy terms and conditions. It is further averred that the OP had sent the policy documents to the communication address mentioned in the proposal form, including the policy terms and conditions and a forwarding letter stating the Free Look Provision alongwith the copy of proposal form to the complainant on 17.09.2016 and the same was duly received by the complainant, but the complainant is trying to mislead this Forum. The allegations made by the complainant are totally false and with malafide intention. It is clear that the allegations are merely an afterthought to take advantage of the complainants own willful neglect and failure to approach the OP company during the Free Look Period. Despite receipt of the policy and policy documents, the policy holder failed to approach the OP within free look period making any grievance with respect to the policy or its terms and conditions implying the policy and its terms and conditions were duly accepted by the policy holder and were in order and as such, the complainant is not entitled to the relief claimed. It is further alleged that the complaint of the complainant is frivolous and vexatious and the same is liable to be dismissed. On merits, the factum in regard to getting insurance policy by the complainant after paying premium as well as submitting insurance claim are admitted, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
4. In order to prove the case of the complainant, the attorney of the complainant namely Sh. Neeraj Sharma along with counsel tendered into evidence affidavit Ex.CA alongwith some documents Ex.C-1 to Ex.C-30 and closed the evidence.
5. Similarly, counsel for the OPs tendered into evidence affidavit Ex.OP1/A alongwith some documents Ex.OP-1/1 to Ex.OP-1/6 and closed the evidence.
6. We have heard the argument from learned counsel for the respective parties and also gone through the written arguments submitted by learned counsel for the complainant as well as case file very minutely.
7. After hearing argument and from scrutiny of the case file, it has become clear that the case of the complainant to the extent that he obtained insurance policy from the OP after making a payment of premium and thereafter, the complainant remained admitted in the hospital from 05.10.2016 to 23.10.2016 i.e. Patel Hospital, Jalandhar and where-from he got treatment and bill was issued by the doctor along with discharge slip, the amount paid by the complainant was Rs.4,39,882/- and accordingly, for recovery of that amount, the complainant submitted an insurance claim, but the same was considered and repudiated by the OP, vide letter dated 30.11.2016 on the ground that the treatment got by the complainant does not cover under the terms and conditions of the policy and the said repudiation letter is challenged by the complainant through this complaint, which required deep scrutiny for reaching a right conclusion.
8. We have gone through the repudiation letter Ex.OP-1/4 dated 30.11.2016, wherein described as under:-
“We have received your claim intimation dated 11.11.2016 informing us about your illness.
On detailed examination of the medical records we noted that you had been diagnosed of Acute pancreatitis with Acute cholecystitis, cholelithiasis, choledocholithiasis and underwent ERCP & CBD stenting for it. The above stated condition is not covered under the Critical Illness Benefit Rider terms of this policy. We regret to inform you that no benefit is payable. Also noted that the policy continues, in line with the policy terms and conditions.” From the above repudiation letter, it has become clear that the insurance claim of the complainant has been repudiated by the OP simply on the ground that there is a rider in the shape of terms and conditions of the policy that the treatment got by the complainant regarding disease, which is not covered under the Critical Illness Benefit Rider. No doubt, the OP has also brought on the file copy of the terms and conditions of the policy, which contains 6/7 leaves, the same is Ex.OP-1/5. But now question remains to be adjudicated whether these terms and conditions were ever supplied to the complainant or not, if not supplied, then these terms and conditions will not create any hurdle in payment of the insurance claim to the complainant. As per version of the complainant, he never received the terms and conditions of the insurance policy and these facts have been categorically mentioned by the complainant in his complaint and its reply has been also given by the OP in the Preliminary Objections that the insurance policy along with the terms and conditions were supplied to the complainant on his address given in the Proposal Form and further complainant made reliance upon a judgment of Delhi State Commission, cited in 2015 (4) CPJ 13, titled as “New India Assurance Co. Ltd. Vs. Mr. Deepak Gupta” and further, referred an other pronouncement of Hon'ble National Commission, cited in 2007(3), CPJ 34, tiled as “National Insurance Co. Ltd. and Anr. Vs. D. P. Jain and Ors.”, and on the basis of said judgments, the counsel for the complainant make a request that when the terms and conditions of the policy or exclusion clause was never made understand or copy of its supplied to the complainant, then the same are not binding upon the complainant and therefore, the repudiation of the insurance claim on the basis of said terms and conditions is totally illegal, null and void, the same is liable to be set-aside and insurance claim of the complainant may be allowed.
9. We have considered the argument of the learned counsel for the complainant and find that the complainant alleged that he never received the copy of the terms and conditions of the policy, whereas in its reply, the OP alleged that same were supplied along with insurance policy, no doubt, the OP has not brought on the file any other documentary evidence to prove that the terms and conditions were sent to the complainant by registered post or any other mode, but from the scrutiny of the insurance policy produced by the complainant Ex.C-1 itself established that the document of the policy along with the terms and conditions were supplied to the complainant at the first instance i.e. on 12.09.2016, when first premium was paid by the complainant. If we go through the contents of the insurance policy Ex.C-1, the same was addressed to the insured/complainant at her address, where in the opening line, it is categorically mentioned as under:-
“We hope you have received the policy document for your above mentioned policy. It has been emailed to Again in the footing of this document, the OP has again mentioned a very relevant wording, which we like to reproduce as under:-
“If you have not received your policy document, please contact us at any of our service centres mentioned below or to get in touch with Lalit K Upadhay (00733066) on 9803024151. We will be happy to assist you”
10. It is very much clear from the above insurance policy that the insurance policy document alongwith terms and conditions were sent by the OP to the complainant alongwith insurance policy, the copy of the insurance policy Ex.C-1 came from the possession of the complainant on the file, which is Ex.C-1, if this document received, then how we can accept that the other document i.e. terms and conditions of the policy were not received by the complainant rather we find that the complainant has made an excuse that she has not received the terms and conditions, just to make a ground to file the instant complaint, whereas the terms and conditions were also received by the complainant at the time of receiving the copy of insurance policy. Suppose, if the complainant had not received the terms and conditions, then why the complainant did not make any complaint to the insurance company as mentioned in the footing of the aforesaid document Ex.C-1. Non making of any complaint to the OP that the terms and conditions of the policy were not received by the complainant itself established that the complainant has received a copy of terms and conditions of the policy, if so, then the terms and conditions adhered upon both the parties, who entered into contract like this case. Accordingly, we find that the said terms and conditions are binding upon the complainant and complainant is entitled for insurance claim according to the said terms and conditions and further, we hold that the judgments referred by counsel for the complainant (Supra) 2015 (4) CPJ 13, titled as “New India Assurance Co. Ltd. Vs. Mr. Deepak Gupta” and 2007(3), CPJ 34, tiled as “National Insurance Co. Ltd. and Anr. Vs. D. P. Jain and Ors.”, are not helpful to the complainant in any manner being reason the facts of these judgments are not identical to the facts of the case in hand.
11. As an upshot of our above detailed discussion, we do not find any solid substances in the argument put forth by the learned counsel for the complainant, therefore, we hold that the complaint of the complainant is without merits and the same is dismissed with no order of cost. Parties will bear their own costs. This complaint could not be decided within stipulated time frame due to rush of work.
12. 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 Karnail Singh
12.06.2019 Member President
