IN THE CONSUMER DISPUTES REDRESSAL FORUM KOTTAYAM
Present:
Hon’ble Mr. Bose Augustine, President
Hon’ble Mr. K.N. Radhakrishnan, Member
Hon’ble Mrs. Renu.P. Gopalan, Member
C.C. No. 350/2012
Tuesday, the 3rd day of November, 2015
Petitioner : Sebastian Joseph,
S/o. Joseph,
Kailath House,
Mallappally East P.O.
Pathanamthitta.
(Adv. Sunny George Chathukulam)
Vs
Opposite parties : 1) ICICI Prudential Life Insurance Co. Ltd.
Vinod Silk Mills Compound,
Chakaravarthy Ashok Nagar,
Ashok Road, Kandivali (E),
Mumbai – 4000101.
2) The Operation Manager,
ICICI Prudential Life Insurance
Co. Ltd Vettiyil House,
Kanjikuzhy, Kottayam.
(Adv. Lakshminarayanan & Adv.
Anil Nambudiri for Op 1 and 2)
ORDER
Hon’ble Mrs. Renu P. Gopalan, Member
- The complaint filed by the complainant on 28/11/2012. The averments in brief are as follows;
The complainant’s wife Leelamma Sebastian was a subscriber of the opposite parties’ Life Insurance Policy Vide No.06736788 and the sum assured is Rs.20,00,000/- (Rupees Twenty lakhs only). The yearly premium was Rs,10,714/-. The plan of the policy is hospital care. Before joining the policy, she was subjected through medical check-up and has complied with all the formalities required under the terms and conditions of ICICI Prudential Co. Ltd. The first premium was paid in the year 2007-2008. The policy was renewed in the year 2008 for the period of 2008-09. In the meantime, the said Leelamma had under gone a major surgery in the year 2008 in Lake Shore Hospital. It was diagnosed that she was suffering from carcinova cervix. For the refund of the hospital expenses, she had filed a claim. Though, it had been filed in the year 2008, it was allotted only in the year 2010. Leelamma Sebastian issued a cheque for the third renewal during the first week of Nov.2009 to the opposite parties. But the Associate Business Manager of the 2nd opposite party retained the cheque with him for 3 months and returned to her stating that the system was not accepting the renewal premium. After that, the opposite parties issued a notice seeking a consent letter for increasing the premium amount for the 3rrd renewal due on November 10, 2010. It is specifically stated that, the revised premium would be applicable with effect from November 24, 2010. Thereupon the insured issued her consent on 08/02/2010 for increasing premium amount and issued a cheque for an amount of Rs.18,214/- through the 2nd opposite party. But the Associate Business Manager of the 2nd opposite party directed the insured to pay cheque for Rs.11,113/-. But on, May 12, 2010, the opposite party issued a letter to Leelamma Sebastian stating that, the payment of Rs.11,113/- is kept on hold as the last premium paid by her hand not realized them. On 14th May, 2010, the opposite party issued a letter stating that the refund cheque for the excess amount of Rs.11,113/- was issued to the insured and if no cheque was received, the opposite parties would issue another cheque.
The complainant alleged that, when the opposite parties came to know that the complainant’s wife was suffering from carcinova cervix, the opposite parties raised the premium amount and had not accepted the cheque given by her. The opposite parties were intentionally returned the premium amount of Rs.11,113/- and denied the revival of the policy only for the purpose of refunding the treatment expenses.
The complainant alleged that, the opposite parties had no right to refund the premium amount and reject the renewal of the policy. At the time of joining the policy, the complainant’s wife was not aware that she was suffering from cancer. The wife of the complainant died on 29/09/2010. During the period 2008-2010, she had undergone treatment at Amrutha Hospital, Ernakulam, Lakeshore Hospital, Erankulam and G.M.M. Hospital, Mallappally and spent an amount of Rs.3,92,099.78/- Returning the premium amount received by the opposite parties and repudiating the policy is an unfair trade practice and there is deficiency in service on the part of the opposite parties. Therefore, the complainant filed the complaint for refunding the entire medical bills incurred and also a compensation of Rs.50,000/-(Rupees Fifty thousand only) alongwith the costs of litigation.
- The opposite parties 1 and 2 filed a joint version on 27/0/2013. The facts in brief are as follows;
The complaint filed by the complainant is false, frivolous, vexatious and abuse of the process of Law and is liable to be dismissed. The complaint is not maintainable before the Forum as it is barred by limitation. The complainant does not disclose any consumer dispute as defined under the Consumer Protection Act, therefore, it is liable to be dismissed. There is no deficiency in service on the part of the opposite parties. The complaint is not maintainable under Section 24 A of the Consumer Protection Act, being barred by limitation. The complaint is filed after the lapse of around 5 years from the date of alleged cause of action.
As per the Insurance Regulatory and Development Authority (Protection of policy holders interest) Regulations 2002, and in order to ensure transparency that the policy is issued as the customer’s choice, the opposite party sent the policy and policy document alongiwth the copy of the proposal form to the policy holder giving option to cancel / review the policy within free look period. Free look period is a period of 15 days available to the policy holder during which the policy can be reviewed. If the policy is not suitable, the booklet (policy, policy certificate alongwith proposal form and covering letter) should be returned within 15 days from the day the policy holder received the policy. Here in this case also, the opposite parties sent the booklet to the complainant giving him an option to review / cancel the policy within the free look period. But the complainant made any grievance relating to the policy or its terms and conditions within free look period. It implied that, the complainant has accepted the policy and it’s terms and conditions. The complainant joined the policy only after perusing the brochure of the policy and understanding the terms and conditions of the policy in question. The opposite parties received 2 premiums of Rs.10,714/- in the year 2007 and 2008. The complainant did not pay the subsequent renewal premiums under the policy. As such the policy got lapsed on 24/11/2009. The said policy was foreclosed on 24/11/2011.
On 30/09/2008, the complainant submitted a health claim request for carcinova cervix. The complainant submitted the relevant documents only on 04/08/2009. On perusal of the medical records, it was revealed that the insured was suffering from hypertension and was under treatment for 5 years before taking the policy. The said ailment was not disclosed in the proposal form. But the 1st opposite party decided to pay the claim and paid an amount of Rs.87,000/- to the complainant. But, after coming to know of the suppression of illness, the company as a gesture of goodwill offered to reinstate the policy at a revised rate of premium. The consent letter received from the complainant on 11/02/2010. The 1st opposite party sent an extra premium request for Rs.18,215/-, which was required for reinstatement of the policy. The premium was not paid till the end of April 2010. On 05/05/2010, the opposite parties received only an amount of Rs.11,113/-, which was insufficient to re-instate the policy, thus the policy remained in a lapse status. Thereof, the policy got foreclosed on 24/11/2011 due to non-payment of the required premium amount. There is no deficiency in service or unfair trade practice on the side of the opposite parties. Therefore, the complaint is to be dismissed with cost of the opposite parties. The complainant is not entitled for any relief as prayed for in the complaint. The complainant is not entitled for any compensation or interest as prayed for in the complaint.
- We perused the documents on record carefully and heard the matter in detail.
- From the pleadings of the parties, the following pints arise for consideration are;
- Whether the complaint is maintainable before the Forum?
- Whether the complaint is barred by limitation?
- Whether there is any deficiency in service on the part of the opposite parties?
- As to relief and costs?
- The evidence consists of the Chief and Proof affidavit of the complainant and documents marked as Ext.A1 to A24 and the Chief and Proof affidavit of the opposite parties and 2 documents marked on their side as Ext.B1 and B2.
Points 1 and 2 are considered together.
- Points No.1 and 2
Though, the opposite parties in their version challenged the maintainability of the complaint, they have not advanced any reason or ground to prove that the complaint is not maintainable. The complainant has paid for the service of the opposite parties, but according to the complainant, he did not get the services as expected by him. Hence, there is a prima facie case for the complainant to file the above complaint.
As per Ext.A15, issued by the opposite parties, the Insurance policy was foreclosed. On 24/11/2011, as the complainant’s wife did not pay the premium amount for 2009-2010 within the last date 24/11/2009. The cause of action arose for the complaint on 30/11/2011, the date on which the complaint received Ext.A15. The complaint was filed on 28/11/2012. It is well within 2 years as per Section 24 A of the Consumer Protection Act. The complaint is filed within the limitation period. Hence, Point Nos.1 and 2 are found in favour of the complainant.
VII) Point No.3
On perusal of the documents on records, it is seen that, the wife of the complainant had subscribed for Hospital care policy with a premium of 10,714/- per year. The policy was issued on 26/11/07. The insured remitted 2 premiums in the year 2007 and 2008. She had undergone a surgery. The claim was lodged before the opposite parties. They paid Rs.87,500/- to the insured. The insurance benefit is given to the parties only if the insured complies with the contractual and legal formalities of the Insurer. Here it can be seen that, the 3rd insurance premium for the period of 2009-2010 was not paid in time. The last date of the 3rd premium is 2009-2010 was on 24/11/2009. This premium is not seen to have paid within the stipulated time. The opposite parties raised the premium amount when they came to know that the wife of the complaint was suffering from carcinova cervix, the opposite parties raised the premium amount. In Para 5 of the complaint, it can be seen that, the enhanced premium of Rs.18,214/- was paid by a cheque with the consent of enhanced premium to the opposite parties only on 08/02/2010. On a perusal of Ext.A4 dtd.30/01/2009, it is seen that, the opposite parties demanded a consent letter from the wife of the complainant regarding hike of insurance premium. The complainant’s wife complied with Ext.A4, the request for enhancement of premium only on 08/02/2010. Since, the premium was paid after almost 1 year 1 month. The opposite parties held the cheque with them and informed the complainant that it was not accepted and it was returned to the complainant as it was paid as the last date of the payment of premium. When there is no valid policy existing, the insured cannot claim the benefit of insurance policy. Here, the records speak Res-lapsa-loquitor. The complainant cannot claim any benefit of the insurance policy as there was no valid insurance policy at the time of the claim. Hence, the complainant is not entitled to get any benefit out of the lapsed / foreclosed policy. We can’t find any negligence or deficiency in service on the part of the opposite parties. Hence Point No.3 is found in favour of the opposite parties.
- Point No.4
In the result, the complaint fails and it is dismissed accordingly. There is no Order as to costs.
Pronounced in the Open Forum on this the 3rd day of November, 2015.
Hon’ble Mrs. Renu.P. Gopalan, Member Sd/- Hon’ble Mr. Bose Augustine, President Sd/-
Hon’ble Mr. K.N. Radhakrishnan, Member Sd/-
Appendix
Documents of petitioner
Ext.A1 : Copy of premium paid certificate for the year 2007-2008 dtd.17/08/11
Ext.A2 : Copy of premium paid certificate for the year 2008-2009 dtd.17/08/11
Ext.A3 : Copy of letter dtd.15/02/2010 issued by opposite party
Ext.A4 : Copy of letter dtd.30/01/2009 issued by opposite party
Ext.A5 : Copy of consent slip 08/02/2010 given by Leelamma Sebastian
Ext.A6 : Copy of premium (s) deposit receipt dtd.06/05/2010.
Ext.A7 : Copy of letter dtd.12/05/10 issued by opposite party to Leelamma Sebastian
Ext.A8 : Copy of letter dtd.14/05/2010 opposite party to Leelamma Sebastian
Ext.A9 : Copy of letter dtd.15/06/2010 opposite party to Leelamma Sebastian
Ext.A10 : Copy of letter dtd.15/07/2010 opposite party to Leelamma Sebastian
Ext.A11 : Copy of letter dtd.30/08/2010 opposite party to Leelamma Sebastian
Ext.A12 : Copy of letter dtd.11/02/2011 issued by petitioner to op.
Ext.A13 : Copy of lawyers notice issued by Sunny George Chathukulam.
Ext.A14 : Copy of letter dtd.01/07/2011 issued by Op.
Ext.A15 : Copy of letter dtd30/11/2011
Ext.A16 Series : Copy of bills issued by AIMS (68 Nos.)
Ext.A17 Series : Copy of bills issued by Lakeshore Hospital (26 Nos.)
Ext.A18 series: Copy of bills issued by GMM Hospital (3 Nos.)
Ext.A19 series :Copy of bills issued by Doctors diagnostic Centre International
(6 nos.)
ExtA20 series : Copy of bills issued by Mar Gregarious Memorial Muthoot Med.
Centre (4ns )
Ext.A21 : Copy of bill issued by Tidewater MRI scan and research centre (2 nos.)
Ext.A22 : Copy of bill issued by Nithin Medical (3 Nos.)
Ext.A23 : Copy of bill issued by Warba Poly Clinic
Ext.A24 : Copy of bill issued by Caritas Hospital.
Documents of opposite party
Ext.B1 : Copy of proposal form issued by ICICI Prudential Life Insurance.
Ext.B2 : Copy of policy document and terms and conditions
By Order
Senior Superintendent
