BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, JALANDHAR.
Complaint No.210 of 2018 Date of Instt. 14.05.2018 Date of Decision:20.04.2021
1. Sh. Shivender Sehgal S/o Sh. Varinder Sehgal R/o 410, New Jawahar Nagar, Jalandhar.
2. Smt. Bindu Sehgal wife of Sh. Shivender Sehgal S/o Sh. Varinder Sehgal R/o 410, New Jawahar Nagar, Jalandhar.
….. Complainants
Versus
ICICI Prudential Life Insurance Company Limited, 22-23, 1st Floor, P. S. Jain Commercial Centre, G. T. Road, Jalandhar through its Branch Manager.
..…Opposite party
Complaint under the Provisions of Consumer Protection Act.
QUORUM:
SH. KULJIT SINGH, PRESIDENT
MRS. JYOTSNA, MEMBER
ARGUED BY:
For Complainants : Sh. A. K. Arora, Advocate.
For OP : Sh. R. S. Rayat, Advocate.
ORDER:-
KULJIT SINGH, PRESIDENT
The present complaint has been filed by complainants against the OP on the averments that the complainant had purchased policy of insurance from the OP bearing No.12098131 with date of commencement 18.07.2009. At the time of issuing the policy of insurance by the OP, the complainants were told by the OP that only Rs.1,25,000/- was to be given by the complainants in five annual installments and from the said amount of Rs.1,25,000/-, the health insurance risk of the complainant No.1 as well as his wife namely Bindhu Sehgal complainant No.2 and Daughter Sonia Sehgal shall be covered upto 18.07.2040 for reimbursement of medical expenses upto Rs.3,00,000/- annually. That the wife of the complainant No.2 namely Smt. Bindu Sehgal fell ill and she has taken treatment from M/s Bhargava Advanced Gyane Surgery Cancer Centre, Jalandhar. Thereafter the wife of the complainant No.1 also remained admitted in Premier Gastroenterology Institute, Jalandhar, where she was treated for Gall Bladder Stone on 24.01.2018. Further the wife of the complainant was taken to SPS Hospital i.e. SJS Health Care Limited, Sherpur Chowk, Ludhiana where she was operated for Gall Bladder Stone. That the complainant No.1 incurred a sum of Rs.1,26,463/- on the treatment of his wife Smt. Bindu Sehgal complainant No.2 covered under the aforesaid policy of insurance. That the complainant No.1 went to the office of OP at Jalandhar for lodging of claim in respect of the reimbursement of expenses regarding the treatment of Smt. Bindu Sehgal complainant No.2 but the official of the OP refused to take the documents for lodging of claim under the aforesaid policy of insurance stating that the policy in question has elapsed. That the policy of insurance issued to the complainant is very much in existence and cannot lapse, since the complainants have already paid full and final premium of the said policy of insurance to the OP at the time of issuance of policy of insurance and thereafter. That the complainants have never received any notice from the OP for making any payment due and payable under the aforesaid policy of insurance and as such, the OP is legally bound to make payment of the expenses of Rs.1,26,463/- to the complainants being the reimbursement of the medical expenses incurred on the treatment of Smt. Bindu Sehgal, the wife of the complainant No.1. That the OP has no right or authority to allege that the policy of insurance bearing No.12098131 issued to the complainants have lapsed, especially in view of the fact that the due premium due and payable under the aforesaid policy of insurance has already been paid to the OP, especially in view of the fact that no further demand whatsoever was ever raised by the OP from the complainants on account of any premium due and payable by the complainants to the OP. That since the OP has refused to entertain the claim of reimbursement of medical expenses of Rs.1,26,463/- incurred on the treatment of Smt. Bindu Sehgal complainant No.2 and as such, the complainant No.1 sent the documents i.e. bills, discharge summary etc. to the OP vide registered post vide letter dated 13.03.2018 for lodging of claim regarding the reimbursement of medical expenses of Rs.1,26,463/-. That ever since the sending of letter dated 13.03.2018 to the OP for reimbursement of medical expenses of Rs.1,26,463/-, the complainant No.1 has approached the OP twice regarding the action taken by the OP on the claim of the complainant under the aforesaid policy of insurance. That the complainant No.1 has received letter dated 05.04.2018 from the OP, but no such letter has been written by the OP to the complainants informing the option to reduce the Health Service Benefit claim. As per the letter dated 05.04.2018 the OP was supposed to send letter to the complainants giving option to reduce the Health Service Benefit claim or in the alternative have asked the complainants to deposit the particular amount with the OP so that the fund value does not fall below 110%. The OP is indulging in unfair trade practice and the services provided by the OPs are deficient and defective in nature 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 make payment of Rs.2,26,463 alongwith interest @ 12% per annum to the complainants from the date of lodging of claim i.e. 13.03.2018 till the date of payment on account of medical expenses incurred by the complainant No.1 for the treatment of his wife complainant No.2 and further the OP be directed to disclose the status of the aforesaid policy of insurance bearing No.12098131 and OP be directed to continue the policy of insurance upto 18.07.2040 and further OPs be directed to pay Rs.1,00,000/- on account of mental stress, strain and tension and Rs.15,000/- as litigation expenses.
Notice of the complaint was given to the OPs, who filed reply and contested the complaint of the complainant by raising preliminary objections that the OP most humbly and respectfully submits that the present complaint filed by the complainant in its entirely is vague, false, vexatious and frivolous and is required to be dismissed in limine. It is further alleged that the present complaint has been filed by the complainant only to cause harassment and prejudice to the OP, which is a company of long standing and high repute, and to extract unnecessary monies from it without just cause or valid reason. The complainant has with malafide and dishonest intention not only concealed the material facts but has also twisted and distorted the same to suit his convenience and to mislead this Commission. The allegations of the complainant that he was required to pay the annual premiums for five years only and thereafter the policy will continue till 18.07.2040 are false frivolous and concocted. The OP never informed the complainant that he was required to pay the premium for a period of five years only. It is submitted that it is not the case of the complainant that the complainant has not filled or singed the proposal form or have not received the policy terms and conditions. It is submitted that the complainant is an educated person and is a graduate as stated by him in the proposal form wherein the complainant himself opted for annual premium of Rs.25,000/- which was required to be paid by him for the full policy term of 56 years. Thus the allegations of the complaint from the face of it appears to be false and concocted therefore the present complaint deserves outright dismissal. It is further alleged that the present complaint does not disclose any cause of action against the OP. The OP has performed all its actions strictly according to the policy terms and conditions. Thus, in absence of any cause of action against the OP, the present complaint is liable to be dismissed. It is further alleged that as per terms and conditions of the policy the complainant was provided a freelook period of 15 days from the date of receipt of the policy to cancel the same in case there is any discrepancies in the policy. On merits, the factum in regard to purchase of the policy from the OP is 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.
3. In order to prove his case, the counsel for the complainant tendered into evidence affidavit of the complainant Ex.CA and affidavit of the complainant’s wife Ex.CB alongwith some documents Ex.C-1 to Ex.C-58 and closed the evidence.
4. In order to rebut the evidence of the complainant, the counsel for the OP tendered into evidence affidavit as Ex.OP1 alongwith some documents Ex.OP1/A to Ex.OP1/J and then closed the evidence.
5. We have heard the learned counsel for the respective parties and have also gone through the record as well as written arguments submitted by counsel for the OP, very carefully.
6. The glance of evidence is required by us for settlement of the case in hand. The complainant has tendered in evidence his affidavit Ex.C-A in support of his case. He alleged that he had purchased the insurance policy from OPs bearing no. 12098131 with date of commencement 18.07.2009. At the time of issuing the policy, he was told by OPs that only Rs.1,25,000/- was to be given by him in five installments and from said amount Rs.1,25,000/- his health insurance risk as well as his wife Bindu and daughter Sonia shall be covered up to 18.07.2040 for reimbursement of medical expenses up to Rs.3 lakh. The wife of the complainant fell ill and she has taken treatment from M/s Bhargava Advanced Gyane Surgery Cancer Centre Jalandhar where she was treated for Gall Bladder Stone on 24.01.2018 and further taken to SPS Hospital i.e. SJS Health Care Limited Sherpur Chowk, Ludhiana where she was operated for Gall Bladder. The complainant incurred Rs.126463/- on the treatment of his wife. He lodged the claim with OPs for reimbursement of the expenses, but OPs refuted to take the documents and stated that policy in question has elapsed. The complainant has paid full premium amount of the said policy and he has never received any notice from OPs for making any payment due and payable under the policy, as such OPs legally bound to make the payment of expenses. Ex.C-B is joint affidavit of complainant and his wife on the record. Ex.C-1 is copy of insurance policy. Ex.C-2 is copy of customer information sheet. Ex.C-4 is copy policy certificate. In this document, the name of nominee has been mentioned as Bindu Sehgal. The date of commencement mentioned as 18.07.2009 and cover cersation date is 18.07.2040. Ex.C-5 is letter addressed to Branch Manager ICICI Prudential Life Insurance Company Limited from complainant regarding reimbursement of medical expenses for treatment taken by Mr. Bindu Sehgal his wife during the policy period. Ex.C-5-A is postal receipt thereof. Ex.C-6 is letter written to complainant Shivender Sehgal from ICICI Prudential/OPs regarding norms of the policy. In this letter, it has been specifically mentioned that the fund value so calculated can be withdrawn by you within 5 years for health expenses upon submission of original bills for expenses incurred. This withdrawal will be subject to a maximum of 50% per annum of the fund value as on date of foreclosure. This condition will also apply during the cover continuance stage, if opted for. Ex.C-8 to Ex.C-10 are copies of receipts for payments of different dates. Ex.C-11 is copy of tests conducted by Bhargava Advanced Gyne Surgery Cancer Centre. Ex.C-12, Ex.C-13 is prescription slip prepared by concerned doctor. Ex.C-14 is copy of discharge summary prepared by PGI Premier Gastroenterology Institute inside Dr. Shingara Singh Hospital, Near Nakodar Chowk, Jalandhar. In this document, date of admission of the patient Bindu Sehgal is mentioned as 23.01.2018 and date of discharge is mentioned as 24.01.2018. This document proves that the wife of the complainant taken treatment as indoor patient not as outdoor patient. to Ex.C-15 is copy of details of receipts. C-16 to Ex.C-19 are tax invoices/bills-receipts of different dates. Ex.C-20 to Ex.C-58 are copies of payment receipts/bills of different dates.
7. To refute this evidence of the complainant, OPs tendered in evidence affidavit of Thejus Joseph Manager Legal ICICI Prudential Life Insurance as Ex.OP-1 on the record. This witness stated that the complainant is an educated person and he opted for an annual premium of Rs.25,000/- which was required to be paid by him for the full policy terms of 56 years. As per Clause 4(1) and 6(2) of the IRDA Regulations 2002, policy along with proposal form sent to the complainant with giving him an opportunity to review/cancel the policy within free-look period. Ex.OP-1/A is copy of insurance application form. Ex.OP-1/B is copy of details of the policy. Ex.OP-1/C is copy of policy document. Ex.OP-1/D is copy of letter addressed to OPs from complainant regarding correction of name. Ex.OP/F is copy of repudiation letter addressed to the complainant by OPs dated 30.11.2011. Vide this letter OPs repudiated the claim of the complainant on the ground that “you had diabetes and you had taken the treatment on OPD basis for same, hence no benefit is payable for the claim intimated by you under the policy.” Ex.OP-1/H is copy of letter dated 20.08.2014 addressed to Fortis Healthcare Limited from Gayatri Nathan Vice President Claims. Ex.OP-1/I is copy of indemnity bond, which was signed by complainant. Ex.OP-1/J is copy of letter dated 05.04.2018 addressed to complainant by OPs. In this letter, in para no.2 it has been specifically mentioned that on payment of at least five years premium, the policy will continue subject to all applicable charges and foreclosure condition for arevival period of two years.
8. It is as admitted fact that complainant purchased the insurance policy bearing no. 12098131 from the OPs with the date of commencement 18.07.2009. The complainant alleged that OPs told him that only Rs.1,25,000/- was to be given in five annual installments but OPs denied this allegation of the complainant. But from perusal of document of Ops Ex.OP-1/J this fact is clear because in para no.2 of this document, it has been specifically mentioned that on payment of at least five years premium, policy will continue subject to all applicable charges. Secondly, OPs repudiated the claim of the complainant vide letter dated 30.11.2011 Ex.OP-1/F on the ground that wife of the complainant suffering from diabetes and treatment taken on OPD basis hence no benefit is payable for the claim. The OPs taken plea in repudiation letter Ex.OP-1/F that patient (wife of the complainant) taken treatment on OPD basis, hence no benefit is payable for the claim intimated by her. But we do not agree with this submission of OPs because from perusal of discharge summary Ex.C-14, it is clear that patient taken the treatment from Premier Gastroenterology Institute inside Dr. Shingara Singh Hospital, Link Road, Near Nakodar Chowk, Jalandhar as indoor patient. In this document Ex.C-14 discharge summary the date of admission is mentioned as 23.01.2018 and date of discharge is mentioned as 24.01.2018. From perusal of these dates, it is clear that the patient admitted in the hospital for one day. So, it is clear that the patient had taken the treatment as indoor patient not a OPD patient. The second objection raised by OPs in repudiation letter is that the patient is a diabetic patient. The diabetes is not a disease, it can be controlled by medication. With the medicine, it can be increase or decrease. In simple words, blood sugar levels are controlled by a hormone called insulin, and reduced levels of insulin cause increased sugar levels. The first one is insulin-dependent diabetes mellitus (IDDM) and is related to the hormone insulin. This is a hereditary condition. Diabetes should not be classed as a disease — it is a condition that can be controlled. As a matter of fact, type 2 diabetes, which accounts for 90 per cent of patients, may also be put in remission quite quickly without any medication but only through lifestyle changes. The insurance companies collect the premiums from the insured and find ways to decline the claims without any valid reasons. This fact is settled by Hon’ble Punjab and Haryana High Court at Chandigarh in case titled as New India Assurance Company Limited versus Smt. Usha Yadav and others reported in 2008(3) RCR (Civil) Page 111 held as under:-
“It seems that the insurance companies are only interested in earning the premiums and find ways and means to decline the claims. All conditions which generally are easily understood by a person at the time of buying any policy. The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy.
9. In view of our above discussion, we find that rejection of insurance claim of the complainant by OP is not valid or genuine. Therefore, we allow the complaint of the complainant and OP is directed to pay Rs.1,26,463/-which as incurred by the complainant on the treatment of his wife with interest @ 6% per annum from lodging the claim till its realization. The complainant is also entitled Rs.7000/- as compensation for mental harassment as well as costs of litigation. The opposite party is also directed to deposit Rs.3000/- as costs in the Consumer legal Aid Account maintained by this Commission.
9. The compliance of the order be made within 45 days from receipt of copy of this order.
10. The complaint could not be decided within the stipulated timeframe, due to heavy pendency of the court cases and spread of Covid-19.
11. Copies of the order be sent to the parties, as permissible, under the rules.
12. File be indexed and consigned to the record room after due compliance.
Announced in open Commission
20th day of April 2021
Kuljit Singh
(President)
(Jyotsna)
Member
