Chandigarh

DF-I

CC/541/2014

Gurjeet Kaur - Complainant(s)

Versus

ICICI Prudential Life Insurance Company Limited. - Opp.Party(s)

Upender Prasher & Saurabh Garg

31 Mar 2015

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I,

U.T. CHANDIGARH

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Consumer Complaint No.	:	CC/541/2014
Date of Institution	:	13/08/2014
Date of Decision	:	31/03/2015

 

 

Gurjeet Kaur wife of Sh. Amarjit Singh resident of House No.612, Sector 7-B, Chandigarh

…..Complainant

V E R S U S

1. ICICI Prudential Life Insurance Company Limited Vinod Silk Mill Compound Chakravarthy Ashok Nagar Ashok Road, Kandivali (East) Mumbai 400101 through its Chairperson.
2. ICICI Prudential Life Insurance Company Limited ICICI Pru Life Towers 1089 Appasaheb Marathe Marg Prabhadevi Mumbai 400025 through its Managing Director and Chief Executive Officer.
3. ICICI Prudential Life Insurance Company Limited BSEL Tech C Wing 1 Floor Vashi Navi Mumbai through VP Claims.
4. ICICI Prudential Life Insurance Company Limited 1^st Floor, SCO 134, 135, 136, Sector 8C, Chandigarh, 160009 through its Branch Head.

……Opposite Parties

 

 

 

QUORUM:	P.L.AHUJA	PRESIDENT
	MRS.SURJEET KAUR	MEMBER

                                               

                                               

                       

ARGUED BY	:	Sh. Upender Prashar, Counsel for complainant
	:	Sh. Gaurav Bhardwaj, Counsel for OPs.

                       

                 

PER P.L.AHUJA, PRESIDENT

1.         Smt. Gurjeet Kaur, complainant has filed this consumer complaint under Section 12 of the Consumer Protection Act, 1986, against ICICI Prudential Life Insurance Company Limited and others, Opposite Parties (hereinafter called the OPs), alleging that relying on the advice of the advisor of the OPs, she was lured into purchasing the Save and Protect policy (Annexure C-1) on 30.1.2002 after paying yearly premium of Rs.11,969/-.  The policy was issued for a term of 20 years and she had been regularly paying premium since 2002.

                According to the complainant on 3.6.2014 she suffered from pain in lower abdomen and faced difficulty in walking. The complainant approached the Inderprastha Apollo Hospital, New Delhi and after examination and thorough medical check-up, she was diagnosed with gall bladder stones and was advised Lap Cholocystectomy.  Copies of the medical reports are at Annexure C-2 and C-3 respectively. Thereafter on 19.6.2014 the complainant was admitted in Inderprastha Apollo Hospital, New Delhi for surgery which was performed on 20.6.2014 and she was discharged on 21.6.2014. In view of the policy, the complainant approached the hospital helpdesk and the OPs to provide the cashless facility but the OPs flatly refused and she had no choice but to get the treatment at her own by incurring expenditure of Rs.1,45,886.47. The complainant submitted all the original documents alongwith the claim form (Annexure C-5) to OP-3 but vide reply dated 30.6.2014 (Annexure C-6), the OPs showed their inability to entertain the claim. The complainant on 7.7.2014 (Annexure C-7) again issued a letter and requested the OPs to entertain the claim but vide letter dated 21.7.2014 (Annexure C-8), OP-3 refused to reimburse the amount on the ground that removal of gall bladder is not covered in critical illness benefit rider.  Alleging that the aforesaid acts amount to deficiency in service and unfair trade practice on the part of the OPs, the complainant has filed the instant complaint.

2.         In their joint written reply, OPs have averred that they received a duly filled and signed proposal form from the complainant under the company’s ICICI Pru Save ‘n’ Protect Plan. After necessary verifications of the proposal and considering the information and declaration made in the proposal form to be true and correct in all aspects, the OPs issued policy in question to the complainant which was despatched and admittedly received by the complainant.  It has been contended that the complainant upon receipt of the policy documents had the option to return the policy under the provisions of free look as per the Insurance Regulatory and Development Authority (Protection of Policyholder’s Interests) Regulations, 2002 within 15 days from the receipt of the policy, but she did not submit the free look request.  It has been admitted that OPs received the claim documents and medical records informing that the complainant was hospitalized from 19.6.2014 to 21.6.2014 for removal of gall bladder. After careful evaluation of the records, the claim was rejected vide letter dated 30.6.2014 as the procedure of ‘Removal of Gall Bladder’ was not covered under the Critical Illness Benefit Rider.
3.         The parties led evidence in support of their contentions.
4.         We have appraised the entire evidence, written arguments submitted by both sides and heard the arguments addressed by the learned Counsel for the parties. 
5.         It is admitted case of the parties that the complainant purchased one ICICI Pru Save ‘n’ Protect policy (Annexure C-1) after paying yearly premium of Rs.11,969/- on 30.1.2002. The policy was issued for a term of 20 years and its maturity/termination date was 30.1.2022.  It has also been admitted that the complainant has been regularly paying the premium since 2002 till date. It has not been denied by the OPs that the complainant was hospitalized from June 19, 2014 to June 21, 2014 for the removal of gall bladder as she was advised Lap Cholocystectomy vide medical reports Annexure C-2 and Annexure C-3.  The complainant incurred expenses of Rs.1,45,886.47 vide details (Annexure C-4) and a claim form (Annexure C-5) was  filed with the OPs with original documents.  However, the OPs vide letter dated 30.6.2014 (Annexure C-6) rejected the claim on the ground that the said surgery is not covered under the critical illness benefit rider.  The complainant also made a representation dated 7.7.2014 (Annexure C-7) for reconsideration but the same was also rejected vide letter dated 21.7.2014 (Annexure C-8).  Hence, the most material question for determination in this case is whether the removal of gall bladder is covered under the critical illness benefit rider mentioned in the policy or not?
6.         It has been urged by the learned counsel for the complainant that the insurance advisor of the OPs informed the complainant about the riders and claimed that all health related surgeries including liver, gall bladder etc. were covered under the policy and she was lured into purchasing the said policy on his advice.  The learned counsel for the complainant has argued that now the OPs cannot turn around and wriggle out of the promises made by their agent.  The learned counsel for the complainant has further argued that the liver is the largest organ in the body and carries out many important functions including production of bile. The gall bladder is a small pear shaped sac that stores and concentrates bile and it is connected to the liver which produces the bile by the heptic duct. The learned counsel for the complainant has vehemently argued that the gall bladder is in fact a part of liver and the removal of the gall bladder is certainly connected with the surgery related to the liver and since liver is covered under clause (e) relating to major organ transplant, mentioned under the Critical Illness Benefit in the policy document (at page 23-24 of the paper book), therefore, the rejection of the claim of the reimbursement of the surgery is arbitrary and an act of unfair trade practice on the part of the OPs.  He has also argued that there is no specific exclusion clause regarding removal of gall bladder and further such exclusion was never ever conveyed to the complainant, therefore, the same is not binding on the complainant.  In support of his arguments, he has placed reliance on National Insurance Co. Ltd. Vs. Shri D.P. Jain, Revision Petition No.186 of 2007 decided on 15.5.2007 by the Hon’ble National Commission and National Insurance Co. Ltd. Vs. Radhey Shyam Balwada, Revision Petition No.3528 of 2013 decided on 4.3.2014 by the Hon’ble National Commission.
7.         We have given our thoughtful consideration to the above arguments of the learned counsel for the complainant but we regret our inability to accept the same.  In the first place, it is pertinent to note that the complainant has not impleaded the insurance advisor of the OPs who allegedly lured her into purchasing the policy and allegedly assured her that all sort of surgery pertaining to the major body organs such as liver, kidney, heart etc. would be covered under the same.  In this view of the matter, the complaint is bad for non-joinder of necessary party.
8.         Secondly, the policy commencement date of the complainant was 30.1.2002 and complainant must have received the policy document after a few days thereafter.  Now in the complaint filed in the year 2014, the contention of the complainant that the exclusion clause was not explained to her cannot be accepted. Since the insurance between the insurer and the insured is a contract between the parties, the terms of agreement, including the applicability of the provision and also its exclusion, have to be strictly construed to determine the extent of the liability of the insurer. As it has been rightly contended in the written statement of the OPs, the terms of the policy are in the nature of a contract and their interpretation has to be made in accordance with strict construction of the contract. 
9.         It is no doubt true that under the purchased policy (Annexure C-1), the sum insured for the critical illness rider is Rs.2,00,000/-.  The terms and conditions of the policy document Annexure C-1 mention that critical illness shall mean any one of the following diseases as defined separately hereunder occurring within six months from the date of policy :-

        “(a)   Cancer :   

xxx                    xxx                            xxx

                (b)     Coronary Artery By-Pass Graft Surgery (CABGS) :

xxx                    xxx                            xxx

                (c)     Heart attack :

xxx                    xxx                            xxx

                (d)     Kidney failure :

xxx                    xxx                            xxx

(e)     Major Organ Transplant : The actual undergoing as a recipient of a transplant of heart, liver, lung, pancreas or bone marrow as a result of chronic irreversible failure. Evidence of end stage disease must be provided and the requirement for transplantation must be conformed by a consultant physician.

(f)     Stroke

xxx                    xxx                            xxx

                (g)     Paralysis

xxx                    xxx                            xxx

                (h)     Aorta-surgery

xxx                    xxx                            xxx

(i)      Heart valve replacement/surgery

xxx                    xxx                            xxx”

A perusal of the list of the diseases mentioned above under the critical illness, as per the terms and conditions of the policy, nowhere shows that removal of gall bladder is covered under any of the critical illnesses.  So far as clause (e) of the policy relating to major organ transplant is concerned, it shows that it relates to transplant of heart, liver, lung, pancreas or bone marrow as a result of chronic irreversible failure.  The removal of gall bladder cannot be considered to be a major organ transplant.  Though the treatment involving the removal of gall bladder is connected with the surgery relating to the liver, yet it does not amount to major organ transplant.  We feel that the OPs have rightly interpreted the terms and conditions of the insurance policy and if they informed the complainant that the procedure of removal of gall bladder is not covered under the critical illness benefit rider, no illegality can be found in such an act of the OPs.  We do not find any unfair trade practice or deficiency in service on the part of the OPs if the claim of the complainant for reimbursement of the expenses incurred on removal of gall bladder has been declined by the OPs.  We have gone through the rulings cited by the learned counsel for the complainant, as mentioned above, but we feel that the observations in those rulings were made in a different set of circumstances and the same are not applicable to the facts of the present case.

10.         For the reasons recorded above, the complaint is devoid of any merit and the same is dismissed leaving the parties to bear their own costs.
11.         The certified copies of this order be sent to the parties free of charge. The file be consigned.

	Sd/-	Sd/-
31/03/2015	[Surjeet Kaur]	[P. L. Ahuja]
hg	Member	President