DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BATHINDA

C.C.No. 226 of 04-04-2014

Decided on 16-09-2014

Kanchan Singla aged about 54 years W/o Jawahar Lal Singla R/o H. No.877-A, Shakti Nagar, Bathinda.

........Complainant

Versus

ICICI Prudential Life Insurance Company Limited, The Mall, Opp. Dr. Mohan Lal, Bathinda, through its Branch/Divisional Manager.

ICICI Prudential Life Insurance Company Limited, SCO No.70, 1st & 2nd Floor, Phase-9, Mohali, through its Branch Manager.

.......Opposite parties

Complaint under Section 12 of the Consumer Protection Act, 1986.

QUORUM

Smt. Vikramjit Kaur Soni, President.

Smt. Sukhwinder Kaur, Member.

Sh. Jarnail Singh, Member.

For the Complainant: Sh.Naresh Garg, counsel for the complainant.

For Opposite parties: Sh.Ashok Bharti, counsel for the opposite parties.

O R D E R

VIKRAMJIT KAUR SONI, PRESIDENT

The instant complaint has been filed by the complainant under section 12 of the Consumer Protection Act, 1986 as amended upto date (here-in-after referred to as an 'Act'). Briefly stated the case of the complainant is that she and her husband have purchased one insurance policy bearing No.11168101 for a sum assured of Rs. 3 lacs from the opposite parties on 19-2-2019 for death benefit and critical illness/TPD benefit and paid the annual premium of Rs.7265/- to them. The said policy covers 10 years cessation date i.e. up to 19-2-2019. In the year 2013, the opposite parties approached the complainant with the new insurance product i.e. ICICI Pru Health Saver UIN 105L087V01 and told them that the previous policy was for just 10 years and this new policy covers her up to 75 years of the age i.e. next 22 years and stated that it is continuous policy, as she was already insured with them vide policy bearing No.11168101. On the assurance of the opposite parties the complainant discontinued the previous policy and purchased the new policy bearing No.17505601 w.e.f. 20-3-2013 as continuous of insurance (Medical) and paid the premium of Rs.22,000/- for the sum assured of Rs. 3.00 lacs. The opposite parties sent the insurance policy to the complainant, it covers her risk and major medical illness including the claim up to one knee or one HIP treatment. In the month of November, 2013 the complainant was having swear pain in the Lt. Knee and immediately approached Max Hospital, Bathinda, its doctors suggested her that there is Osteoarthritis in Lt. Knee that is required to be replaced. On 3-12-2013, the complainant admitted in Max Hospital, Bathinda for Lt. knee transplant and doctor wrote in the history that the Pt. Started having pain in both knees for 5-6 years back. The complainant is an old aged, as such she stated the doctor that there was pain in her both knees due to old age for 5 years back, but there was no serious problem but for the last 6 months she had swear pain and could not walk properly. There was no previous history or admission in any hospital for the treatment of the knees of the complainant except this treatment with Max Hospital, Bathinda, where she admitted on 3-12-2013 and discharged on 10-12-2013 after replacement of the Lt. Knee. The complainant lodged the claim with the opposite parties on 17-12-2013 alongwith complete original medical file (Including X-ray and lab reports etc.), original medical bills for the amount of Rs.1,59,733.56, claim form, photocopy of policy certificate, ID proof and cancelled cheque etc. Thereafter the complainant through her husband received letter dated 25-1-2014, vide which the opposite parties rejected her claim with the remarks that the 'Claim is not payable'. After that the complainant and her husband took the matter with the opposite parties, they again sent letter with the same date i.e. 25-1-2014 by adding new clauses 8.5 and 8.8.19 mentioning therein that the claim is not payable as per these clauses, although the insurance policy is continuous and as per Clause 8.8.19 the claim of one knee replacement is payable whereas the opposite parties have denied her claim. Hence the complainant has filed the present complaint seeking the directions to the opposite parties to pay her claim with interest alongwith cost and compensation.

The opposite parties filed their joint written statement and took preliminary objection that the complainant under the policy in question is only a life assured, not the owner or the proposer. The proposer i.e. consumer under the policy is Jawahar Lal Singla and not the complainant, as such she is not competent entity to file the present complaint. On merits, the opposite parties have pleaded that they have received the claim documents and medical record informing that the life assured was hospitalized on 3-12-2013 and diagnosis stated was Osteoarthritis left knee. After evaluation of the records received by the company, it was found that the claim under the policy is not payable as per clause 8.5 and 8.8.19 of the policy. The opposite parties have further pleaded that in the light of the said clauses of the terms and conditions of the contract, the claim has been rejected by the company on the ground that the present ailment is not covered under the policy terms and conditions as the expenses incurred during the first 2 years shall not be payable. From the discharge summary of max hospital, it is clear from the history of the life assured that she was having pain in both knees for the last 5-6 years and there was difficulty in walking, but this fact was concealed by the life assured at the time of taking the policy. The decision of the company was conveyed to the complainant vide letter dated 25-01-2014. Since the claim of the complainant was not lawful, hence the same was rejected by the opposite parties.

The parties have led their evidence in support of their respective pleadings.

Arguments heard. The record alongwith written submissions submitted by the parties perused.

The submission of the complainant is that the complainant and her husband purchased one insurance policy from the opposite parties on 19-2-2009 for Rs. 3,00,000/- for death and critical illness/TPD benefit and the policy cover 10 years cessation date i.e. upto 19-2-2019. In the year 2013, the opposite parties approached the complainant with new insurance policy product and told her that new policy cover upto 75 years of age and stated that this is continuous policy as the complainant was already insured with the opposite parties. On the assurance of the opposite parties, the complainant discontinued the previous policy and purchased the said new policy. In the month of November, 2013, the complainant had swear pain in her left knee. She approached Max Hospital, Bathinda, where the doctors suggested that there is Osteoarthritis in left knee and the same is required to be replaced. On 3-12-2013, the complainant was admitted in Max Hospital, Bathinda and was discharged on 10-12-2013 after replacement of left knee. The complainant filed claim to the tune of Rs. 1,59,733.56 and submitted all the required documents with the opposite parties, but her claim was rejected by them vide letter dated 25-1-2014 by mentioning the clauses 8.5 and 8.8.19 on the ground that the expenses incurred during the first 2 years shall not be payable. The learned counsel for the complainant submitted that the complainant is old aged, as such she stated to the doctor in general way that there was pain in her both knees due to old age for about five years and the doctor wrote the same in the history. The learned counsel for the complainant further submitted that the opposite parties did not disclose regarding previous policy of the complaint. The policy in question is the continuous second policy. The complainant was insured w.e.f. 19-2-2009 and she was hospitalized on 3-12-2013 after four years.

On the other hand, the submission of the learned counsel for the opposite parties is that the claim under the policy is not payable as per clauses 8.5 and 8.8.19 of the policy. The opposite parties have further pleaded that in the light of the said clauses of the terms and conditions of the contract, the claim has been rejected by the company on the ground that the present ailment is not covered under the policy terms and conditions as the expenses incurred during the first 2 years shall not be payable. From the discharge summary of Max hospital, it is clear from the history of the life assured that she was having pain in both knees for the last 5-6 years and there was difficulty in walking, but this fact was concealed by the life assured at the time of taking the policy.

The opposite parties have rejected the claim of the complainant vide letter Ex. C-6 dated 25-1-2014, the relevant portion of which reads as under :-

:...After careful evaluation of the records received by us during the claim processing, we regret to inform you that no benefit is payable for the claim intimated by you under the above mentioned policy.

The relevant policy clause 8.5 and 8.8.19 is reproduced below for your reference -

8. Exclusions for Hospitalisation Insurance Benefit :

The Company shall not be liable to make any payments under this Policy in respect of any expenses whatsoever incurred by any insured person(s) in connection with or in respect of any of the following :

5. Pre-existing condition unless stated in the proposal form and specifically accepted by the company and endorsed thereon. “Pre-existing condition” means a condition for which, prior to the policy commencement date or policy revival date, the insured person(s) had signs or symptoms of disease or injury which would have caused any ordinarily prudent person to seek treatment, diagnosis or care, or medical advice, or treatment was recommended by or received from a medical practitioner, or the insured person(s) has undergone medical tests or investigations. Any investigation or treatment for any disease, disorder, complication or ailment arising out of or connected with the pre-existing disease shall be considered part of that pre-existing condition.

8. Any expenses incurred during the first 2 years from Policy commencement date or revival date in case the revival is after 60 days from the date of first unpaid premium shall not be payable for the following diseases or surgeries & any complications arising out of them.

19. Osteoarthrosis leading to Total Knee Replacement or Total Hip Replacement (claim for upto one knee or one hip treatment will be covered in a policy year ).

A perusal of discharge summary Ex. OP-1/6 of Max Hospital, Bathinda, reveals that no doubt in brief history of complainant it has been mentioned that “History dates back to 5-6 years back when pt. Started having pain in both knees” but it has also been mentioned in the history that “More on left side : progressively increased …...now from last six months, patient had marked difficulty in doing activities of daily living.” meaning thereby that the version of the complainant found correct that due to age factor she was having pain in both her knees. The pain in her left knee progressively increased, due to which complainant visited Max Hospital for further management and only her left knee was operated. The opposite parties have not placed any document on file to prove that prior to visiting Max Hospital, Bathinda, complainant ever took treatment for her knees from any doctor or hospital. Hence, it cannot be said that the complainant has not disclosed her pre-existing condition in her proposal form.

So far as the plea of the opposite parties that expenses incurred during the first two years from the policy commencement date is concerned, the record placed on file by the complainant proves that prior to policy in question the complainant was insured vide insurance policy Ex. C-2 bearing No. 11168101 for the sum assured - Death Benefit Rs. 3,00,000/- : Critical illness/TPD benefit Rs. 3,00,000/-, date of commencement of policy 19-02-2009 and cover cessation date 19-02-2019. Thereafter the said policy was cancelled and policy in question Ex. C-3 bearing No. 17505601 for the same sum assured i.e. Rs. 3,00,000/- : policy commencement date 30-03-2013, cover cessation dated 20-03-2035 was issued to the complainant. A perusal of First Premium Receipt attached with policy Ex. C-3 reveals that receipt No. C7464826 was issued to the complainant on 18-02-2013, cheque transaction No. 000262 and date of cheque/transaction is 18-02-2013 meaning thereby that on the day of due date of premium of previous policy i.e. 18-02-2013, it was cancelled and after receiving the proposal and premium, the policy in question was issued to the complainant. Thus, the version of the complainant that it was conveyed to the complainant by the opposite parties that this is continuous policy as the complainant was already insured with them, seems to be correct in view the record placed on file by the complainant.

The legal objection taken by the opposite parties that Jawhar Lal Singla, husband of the complainant is the proposer of the policy in question, so she is not eligible to file the present complaint is not tenable as being insured, the complainant is the consumer and is competent to file complaint against the insurer/opposite parties.

Keeping in view the facts, circumstances and the evidence placed on file by the parties, this Forum is of the considered opinion that there is deficiency in service on the part of the opposite parties in repudiating the claim of the complainant on flimsy grounds whereas claim for , upto one knee or one hip treatment is covered in a policy year, and thus she is entitled for the same.

With utmost regard and humility to the authorities cited by the learned counsel for the opposite parties, they are distinguishable on facts.

In view of what has been discussed above, this complaint is accepted with Rs.15,000/- as compensation and cost against the opposite parties. The opposite parties are directed to pay the claim amount Rs. 1,59,734/- to the complainant.

The compliance of this order be made within 45 days from the date of receipt of copy of this order failing which an amount of Rs. 1,59,734/- will carry interest @ 9% p.a. till realization.

A copy of this order be sent to the parties concerned free of cost and the file be consigned to record.

Pronounced in open Forum

16-09-2014

(Vikramjit Kaur Soni)

President

(Sukhwinder Kaur)

Member

(Jarnail Singh)

Member