Tamil Nadu

North Chennai

CC/25/2021

V.Saravana Karthikeyan,son of - Complainant(s)

Versus

ICICI Prudential Life Insurance Company Ltd.,Rep by its General Manager - Opp.Party(s)

K.R.Neelambar

26 Apr 2023

ORDER

Complaint presented on :03.02.2021

Date of disposal            :26.04.2023

                                                                                  

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,

CHENNAI (NORTH)

@ 2^ND Floor, T.N.P.S.C. Road, V.O.C. Nagar, Park Town, Chennai – 600 003.

 

                PRESENT : THIRU. G. VINOBHA, M.A., B.L.,                          :PRESIDENT

                                      TMT. KAVITHA KANNAN, M.E.,                         : MEMBER-I

                              THIRU.V.RAMAMURTHY,B.A.,B.L.,PGDLA.,   :MEMBER-II

 

C.C. No.25/2021

 

DATED WEDNESDAY THE 26^th  DAY OF APRIL 2023

 

V.Saravana Karthikeyan,

Son of Mr.L.S.Velusamy,

No.29,32 Rajalakshmi Illam,

Krishnappa Street West,

Mambalam Mettupalalayam Road,

Chennai-600 033, Tamil Nadu

                                                                  …..Complainant

 ..Vs..

1. ICICI Prudential Life Insurance Company Limited (Regd. Office),

Represented by its General Manager,

ICICI Prulife Towers,

No.1089, Appasaheb Marathe Marg,

Prabhadevi, Mumbai-400 025.

 

2. ICICI Prudential Life Insurance Company Limited,

Represented by its Manager,

No.82,84 and 86, 2^nd Floor,

Bascon Maeru,

Kodambakkam High Road,

Nungambakkam, Chennai-600 034.

                                                                             …..Opposite Parties

Counsel for Complainant                          : M/s.K.R.Neelambar, B.Parimala &

          T.V.Pandiaraj

 

Counsel for  opposite parties                      : Ex-parte

 

ORDER

 

THIRU. V. RAMAMURTHY, B.A., B.L., PGDLA, MEMBER-II:

This complaint has been filed by the complainant against the 1^st and 2^nd opposite parties under section 35 of the Consumer Protection Act, 2019 prays to direct the opposite parties to reimburse the medical bills Rs.1405865/- which was paid by the complainant to the MIOT hospitals, Chennai along with interest at the rate of 18% per annum from 28.10.2010 till date of payment and to pay a sum of Rs.300000/- towards compensation for deficiency in service and to pay a sum of Rs.200000/- towards compensation for mental agony caused to the complainant and costs.

1.THE COMPLAINT IN BRIEF:

          The complainant submits that that he had taken a Life Insurance policy named “ICICI Pru iProtect Smart UIN 105N151V01 Policy No.20522335 for a period of 28 years commencing from 29.01.2017 with benefit option of All in One and the sum assured is for Rs.50 Lakhs and Critical Illness Benefit for Rs.10 Lakhs with an annual premium of Rs.34,521/- from the opposite party.  The complainant was admitted in MIOT Hospitals on 16.07.2020 due to fever and later diagnosed as Covid-19 positive and Diabetes Mellitus and discharged on 14.08.2020.  The complainant on insistence of the hospital authorities had paid a sum of Rs.14,05,865/- and submitted the claims to opposite party to reimburse the medical bills.  The opposite parties had received the claims but remained silent and hence the complainant had sent a reminder on 28.10.2020 to both the opposite parties which was also received by both.  After some time on 01.11.2020 the opposite parties sent an email stating “We hereby inform you that as per our record death due to Covid-19/Corona Virus is covered under all our life insurance policies.  Any death or hospitalization claim raised in relation to Covid-19 will be covered across all our products subject to policy terms and conditions” but the opposite parties did not honour the claim.    The complainant had sent a legal notice on 24.11.2020 and the opposite parties had sent a reply on 30.12.2020 admitting that “Any death or hospitalization claim raised in relation to Covid-19 will be covered across all our products subject to policy terms and conditions” but the 1^st opposite party has declined to honour the genuine claim of the complainant stating that Covid-19 is not covered under the policy and the same amounted to negligence and deficiency in service.  The acts of the opposite parties caused untold mental agony and monetary loss to the complainant and hence prayed for reimbursement of Rs.14,05,865/- towards medical reimbursement, Rs.3 Lakhs towards compensation for deficiency in service, Rs.2,00,000/- for mental agony caused to complainant and cost of proceedings.  Hence this complaint.

2. POINTS FOR CONSIDERATION:

1. Whether there is any deficiency in service and unfair trade practice on the part opposite parties 1 and 2 as alleged in the complaint?

2. Whether the complainant is entitled for the reliefs prayed in the

    complaint.  If, so to what extent?

 

The complainant had filed proof affidavit, written arguments and documents Ex.A1 to A11are marked on his side. Oral argument of the complainant counsel heard.  The opposite parties set exparte.

 

3. POINT NO :1 :-

          The complainant alleged that he had taken a Life Insurance policy named “ICICI Pru iProtect Smart UIN 105N151V01 Policy No.20522335 for a period of 28 years commencing from 29.01.2017 with benefit option of All in One and the sum assured is for Rs.50 Lakhs and Critical Illness Benefit for Rs.10 Lakhs with an annual premium of Rs.34,521/- from the opposite party.  The complainant was admitted in MIOT Hospitals on 16.07.2020 due to fever and later diagnosed as Covid-19 positive and Diabetes Mellitus and discharged on 14.08.2020.  The complainant on insistence of the hospital authorities had paid a sum of Rs.14,05,865/- and submitted the claims to opposite party to reimburse the medical bills.  The opposite parties had received the claims but remained silent and hence the complainant had sent a reminder on 28.10.2020 to both the opposite parties which was also received by both.  After some time on 01.11.2020 the opposite parties sent an email stating “We hereby inform you that as per our record death due to Covid-19/Corona Virus is covered under all our life insurance policies.  Any death or hospitalization claim raised in relation to Covid-19 will be covered across all our products subject to policy terms and conditions” but the opposite parties did not honour the claim.   The complainant had sent a legal notice on 24.11.2020 and the opposite parties had sent a reply on 30.12.2020 admitting that “Any death or hospitalization claim raised in relation to Covid-19 will be covered across all our products subject to policy terms and conditions” but the 1^st opposite party has declined to honour the genuine claim of the complainant stating that Covid-19 is not covered under the policy and the same amounted to negligence and deficiency in service.

          4. On careful consideration of the averment of the complainant, on perusal of documents filed by complainant and oral argument of learned counsel for complainant, it is observed from Ex. A1, that complainant had taken Life Insurance policy named “ICICI Pru iProtect Smart UIN 105N151V01 Policy No.20522335 for a period of 28 years commencing from 29.01.2017 with benefit option of All in One and the sum assured is for Rs.50 Lakhs and Critical Illness Benefit for Rs.10 Lakhs with an annual premium of Rs.34,521/- from the opposite parties.  It is observed from Ex. A2, the complainant had fever and later diagnosed as Covid-19 positive and Diabetes Mellitus and admitted for treatment at MIOT Hospital, Chennai on 16.07.2020 and discharged on 14.08.2020.  As seen from Ex.A3, the complainant had paid a sum of Rs.14,05,865/- towards medical expenses to MIOT Hospital, Chennai.  The complainant had submitted the claim to opposite party on 24.09.2020 as per Ex.A5.  It is observed from Ex.A7, the opposite parties have replied that: a) Death due to Covid-19/Corona Virus is covered under all our life insurance policies. (b) Any death or hospitalization claim raised in relation to Covid-19, will be covered* across all our products subject to policy terms and conditions. The opposite parties in their reply notice, which is marked as Ex. A10, stated that payment of claim will be made only in case of life assured is contracted with 34 Critical Illness categorically defined in policy terms and conditions and not otherwise.  In this instant case, Covid 19 is not covered under the list of 34 critical illnesses and hence no claim is admissible for the same and hence claim is declined.

          5. It is observed from Ex. A1, the policy document that complainant policy covers five benefit options i.e. Death, Terminal illness, Waiver of Premium on disability due to accident, Accidental death and Critical Illness.  It is inferred from the reply notice by opposite parties that hospitalization expenses covered only for the 34 critical illnesses listed in the policy document and Covid-19 is not listed in that and hence the claim was declined

          6. The Ministry of Home Affairs, Govt. of India vide its order No.40-3/2020-dm-1(A) dated 24^th March 2020 wherein it is stated that National Disaster Management Authority (NDMA) is satisfied that the country is threatened with the spread of COVID-19 epidemic, which has been already been declared as a pandemic by the World Health Organization, and has considered it necessary to take effective measures to prevent spread across the country.   The NDMA has issued an Order No. 1-29/2020-PP (Pt.II) dated 24.03.2020 directing the Ministries/Departments of Government of India, States/Union Territory Governments and State/Union Territory Authorities to take effective measures so as prevent the spread of Covid19 in the country.

          7. In view of the seriousness of this Covid-19, the Insurance Regulatory and Development Authority of India had issued guidelines on 04.03.2020 which is marked as Ex. A11.  In these guidelines it is categorically mentioned that where hospitalization is covered in a product, insurers shall ensure that the cases related to Corona Virus Disease (COVID19) shall be expeditiously handled.  It is also mentioned that in order to provide need-based health insurance coverage, insurers are introducing products for various specific diseases including vector borne diseases.  For the purpose of meeting health insurance requirements of various sections, insurers are advised to design products covering the costs of treatment for Corona Virus

          8. Having gone through the record, it is very clear that insurance company has declined the claim of the complainant on the ground that Covid-19 is not covered under the list of 34 critical illnesses defined in the policy.  Though the complainant counsel contended that corona virus is also a critical disease and hence claimed that the repudiation of the claim by the insurance company is not valid but on perusal of Ex.A1 it is found that the Covid-19 disease is not specifically mentioned as a critical illness disease in the list of 34 diseases covered under the policy therefore, the complainant is not entitled for the reimbursement of the amounts spend by him for the said disease from the insurance company and the repudiation of the claim by the opposite parties based on terms and conditions of the policy it is found to be a valid one and which cannot be alleged as deficiency in service or unfair trade practice on the part of opposite parties.  Point No.1 is answered accordingly.

9. POINT NO :2 :-

          Based on findings given in Point No.1 there is no deficiency of service or unfair trade practice on the part of opposite parties. Hence, the complainant is not entitled for reimbursement of medical bills for Rs.1405865/- and compensation towards deficiency in service and mental agony as claimed in the complaint. Point No.2 is answered accordingly.

In the result, the complaint is dismissed.  No costs.

Dictated by the Member II to the Steno Typist taken down, transcribed and computerized by him, corrected by the President and pronounced by us in the open Commission on this the 26^th day of April 2023.

 

MEMBER – I                MEMBER – II                                 PRESIDENT

 

LIST OF DOCUMENTS FILED BY THE COMPLAINANT:

Ex.A1	29.01.2017	ICICI Pru iProtect Smart UIN 105N151V01’ bearing policy No.20522335 with policy term of 28 years. Risk commencement date is 29.01.2017.
Ex.A2	14.08.2020	Discharge summary of the complainant.
Ex.A3	14.08.2020	Medical bills.
Ex.A4	14.08.2020	Breakup details of the medical bills.
Ex.A5	24.09.2020	Request letter for reimbursement sent by the complainant to the opposite parties with ack due.
Ex.A6	28.10.2020	Reminder letter sent by the complainant to the opposite parties with ack due.
Ex.A7		Email conversation between the complainant and opposite parties.
Ex.A8	24.11.2020	Legal notice by the complainant.
Ex.A9		Acknowledgement cards.
Ex.A10	30.12.2020	Reply notice by the 1st opposite party to the complainant.
Ex.A11	04.03.2020	Guidelines of IRDAI to honour the insurance claims during Covid-19.

 

 

 

MEMBER  I                MEMBER  II                                 PRESIDENT