Chandigarh

DF-II

CC/154/2017

Kulwant Singh - Complainant(s)

Versus

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

Pradeep Panwar Adv.

04 Sep 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Consumer Complaint  No	:	154 of 2017
Date  of  Institution	:	14.02.2017
Date   of   Decision	:	04.09.2017

 

 

 

 

Kulwant Singh son of Sh.Dev Singh, R/o H.No.18, Kharar Takipur, Kharar, Punjab     

             …..Complainant

Versus

1]  ICICI Prudential Life Insurance Company Limited, Unit No.1A & 2A, Raheja Tipco Plaza, Rani Sati Marg, Malad (East), Mumbai 400097 through its Managing Director.

2]  Registered Office: ICICI Prolife Towers, 1089, Appasaheb Marathe Marg, Prabhadevi, Mumbai 400025, through its Manager.

3]  Branch Office : SCO No.134-135-136, First Floor, Madhya Marg, Sector 8-C, Chandigarh 160009 through its Branch Manager.  

                          ….. Opposite Parties

 

BEFORE:  SH.RAJAN DEWAN            PRESIDENT

                                MRS.PRITI MALHOTRA        MEMBER

                                SH.RAVINDER SINGH         MEMBER 

 

 

Argued by: Sh.Pradeep Panwar, Adv. for complainant.

 Sh.Gaurav Bhardwaj, Adv. for OPs

 

 

PER RAVINDER SINGH, MEMBER

 

 

          The facts in issue are that the complainant purchased a policy from OPs bearing NO.16252040 – ICICI Pru Whole Life covering accident & disability benefit rider (sum assured Rs.1,00,000/-) commencing from 29.12.2011 till late premium on 29.6.2022.  It is averred as per the said policy, it also have Accidental & Disability Benefit Rider (in case of total and permanent disability due to an accident, 10% of the rider sum assured shall be paid out every year, for 10 years) (Ann.C-1).  It is also averred that the complainant paid regular premiums of said policy without any default or delay (Annexure C-2 to C-9 colly.). It is submitted that unfortunately the complainant met with an accident near PGI on 16.4.2016 and remained admitted in PGI, Chandigarh from 16.4.2016 to 22.4.2016.  It is also submitted that in the said accident the complainant lost his left eye and declared 30% permanent disabled by doctors of PGI (Ann.C-10). Thereafter, the complainant lodged claim with OPs and submitted all requisite documents, as demanded, but the same was refused/denied vide letter dated 13.9.2016 (Ann.C-11).  A legal notice was also sent to the OPs, but to no avail.  Hence, this complaint has been filed alleging deficiency in service on the part of the Opposite Parties.

 

2]       The OPs have filed joint reply and while admitting the factual matrix of the case, stated that there is only 30% disability in the present case and the same is evident from the Disability Certificate issued on 19.8.2016 by PGIMER, Chandigarh.  It is stated that the disability suffered by the Life Assured does not qualify to be total and permanent in nature, as per the conditions mentioned in the policy document, hence no benefit becomes payable under the same. It is also stated  that after careful revaluation of the record received by the company during the claim processing, the company noted that injury/ailment suffered by the complainant was diagnosed as Bilateral open globe with Lt. Phthiscal eye and that the said medical condition/surgery is not covered under Accident & Disability Benefit Rider terms of the policy as the medical certificate was showing the percentage of disability as 30%, whereas as per the terms & conditions of the policy, there should be complete and irremediable loss of sight in both eyes.  Therefore, the claim was rightly rejected. Pleading no deficiency in service and denying rest of the allegations, the OPs have prayed for dismissal of the complaint.

 

3]       Parties led evidence in support of their contentions.

 

4]       We have heard the ld.Counsel for the parties and have carefully examined the facts and pleadings along with entire evidence on record.

 

5]       After careful examination of complete evidence on record, especially Ann.C-11, it has been found that ICICI Prudential Life Insurance Company has declined the claim of the complainant under policy Plan ICICI Pru Whole Life bearing No.16252040 (Ann.C-11), stating that the injury/ailment was diagnosed as Bilateral open globe injury with Lt. Phthiscal Eye and that the medical certificate shows percentage of disability only 30 percent.    

 

6]       The Postgraduate Institute of Medical Education and Research, Chandigarh in its Disability Certificate (Ann.C-10), which was issued by a Board of Senior Medical Officers on 19.8.2016, the overall permanent/physical/mental impairment as per guidelines, was assessed to be 30% and the complainant was found/diagnosed as “B/L Open Globe Injury Lt.Phthiscal Eye” and he was also found to be a case of Multiple Disability and extent of his impairment of eye was found to be permanent.  One eye of the complainant has been damaged permanently and his overall physical disability has been assessed as of 30%. 

 

7]       The OPs wrongly just to circumvent the genuine claim of the complainant, have treated the 30% disability only of damaged eye of the complainant.  The OPs have erred in treating the total impairment/damage of one eye of the complainant not as permanent disability.

 

8]       The OPs in the given facts & circumstances due to their deficiency of service, have caused injustice to the complainant denying his right for accidental claim under the policy, which lead to this complaint before this Forum. The complainant has paid Rs.80,334/- as premium till 29.6.2017 and there is no lapse on his part in payment of premiums.

 

9]       After consideration of complete facts and evidence produced by the parties, this Forum have held the complainant to be entitled for Accidental & Disability claim under the insurance policy.  The complaint, as such, is allowed with directions to the Opposite Parties to process the claim of the complainant and pay him the amount of claim within a period of 30 days from the date of receipt of certified copy of this order.

         In case the OPs failed to comply with the order within the stipulated period, then they shall also be liable to pay compensatory cost of Rs.20,000/-.

         The certified copy of this order be forwarded to the parties, free of cost, and file be consigned to record room.

Announced

4^th September, 2017                         

                                       Sd/-

(RAJAN DEWAN)

PRESIDENT

 

 

Sd/-

 (PRITI MALHOTRA)

MEMBER

 

Sd/-

(RAVINDER SINGH)

MEMBER