Haryana

Yamunanagar

CC/691/2010

Desh Raj Sharma S/O Kanshi Ram Sharma - Complainant(s)

Versus

ICICI Prudential Life INsurance Company. - Opp.Party(s)

Anil Kamboj

21 Jun 2016

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, YAMUNA NAGAR

 

                                                                                         Complaint No..691 of 2010

                                                                                         Date of institution: 28.07.2010.

                                                                                         Date of decision: 21.06.2016

Desh Raj Sharma aged about 62 years son of Shri Kanshi Ram Sharma, resident of Plot No. 20, Jammu Colony-B, Camp, Yamuna Nagar.                                                                       

                                                                                                                …Complainant.

                                    Versus            

 

1. ICICI Prudential Life Insurance Company, Mall Road, Karnal, through its Branch Manager.
2. ICICI Prudential Life Insurance Company through Local Office, Madhu Hotel Road, near J.K. Residency, Yamuna Nagar.
3. ICICI Prudential Life Insurance Company Ltd. Opp. 66 KV, Sub Station HVPN, 3^rd Floor, Prem Nagar, near Model Town, Ambala City through its Branch Manager.
4. ICICI Prudential Life Insurance Company Ltd, True Life Tower 109=89 Allasaheb, Marathe Marg, Prabha Devi Mumbai.

                                                                                                               …Respondents 

 

BEFORE:         SH. ASHOK KUMAR GARG, PRESIDENT.

                        SH. S.C.SHARMA, MEMBER.

 

Present:  Sh. Anil Kamboj, Advocate, counsel for complainant.  

                Sh. Subhash Chand, Advocate, counsel for respondents.                

             

 

ORDER

 

1.                     Complainant Desh Raj filed the present complaint under section 12 of the Consumer Protection Act to pay the sum insured of R.3,00,000/- on account of expenses of medical treatment and also to pay compensation as well as litigation expenses etc. 

2.                     Brief facts of the present case, as alleged by the complainant,  are that  complainant got himself insured through policy bearing No. 09955097 dated 06.10.2008 by getting a mediclaim policy for 10 years and paid Rs. 25905/- to the OPs Insurance Company vide receipt dated 17.09.2008. The complainant has suffered heart problem Coronary Artery Disease and angina on exertion.  Accordingly, the complainant informed the OPs Insurance Company and completed all the formalities as required by the Ops Insurance Company, on receiving the letter dated 10.07.2009 but the OPs did not bother to accept the claim of the complainant, so, the complainant to save his life approached to PGI for treatment, because the complainant was not having sufficient amount to get his treatment from private hospital. The complainant got angiography on 11.05.2010 from the PGI Chandigarh in which the Doctors suggested the complainant to operate himself and get installed stunt in his heart. Accordingly, the complainant approached the OPs Insurance Company but the OPs Insurance Company did not bother to accept the claim of the complainant.

3.                     However, during the pendency of the complaint, complainant moved an application for amendment of complaint which was allowed by our predecessors   vide order dated 19.07.2013 and a new para was added as para No.2 A mentioning therein that complainant getting angiography on 11.05.2010 in which Doctor of PGI Chandigarh suggested the complainant to operate himself and get install stunt in his heart. Accordingly, the complainant approached the OPs but the Ops did not bother to accept the claim of complainant at least the complainant got himself operated from PGI Chandigarh on 05.10.2010 and spent Rs. 7514/- on angiography as well as Rs. 1,47,948/- installing of stunts in his heart. It has been further stated by the complainant that the complainant approached the OPs so many times to pay the insured amount to him as early as possible but the OPs put off the matter on one pretext or the other due to which the disease of the complainant was increased day by day and now the complainant has come to the door of death due to deficiency in service the part of OPs and lastly prayed for directing the OPs to pay insured amount of Rs. 3,00,000/- alongwith compensation as well as litigation expenses.

4.                     Upon notice, OPs appeared and filed its written statement by taking some preliminary objections such as complaint is false, frivolous and the same is liable to be dismissed; the present complaint does not raise any consumer dispute; Forum has no jurisdiction to entertain the present complaint; there is no deficiency in service or negligence on the part of OPs; the complaint is not maintainable in the present Forum as it has been filed with ulterior motive just to extract the money from the OPs Insurance Company. The facts are that the complainant had submitted proposal form duly filled with the OPs Insurance Company for issuance of policy for crises cover on his life on 17.09.2008 and after completion of medical requirements, the above policy was issued on 07.10.2008 for a sum of Rs. 3,00,000/-. The ailment of the complainant was not covered under the critical illness mentioned in the crises cover policy which is providing cover under 35 critical illness, death and TPD. The benefits shall be to the extent and subject to the fulfillment of the condition specified for each critical illness and further subject to terms and conditions of the Insurance policy being enforced on the date of diagnosis. Therefore, as per the terms and conditions of the policy, no benefits were payable to the complainant. The decision of the OPs insurance company was duly communicated to the complainant vide letter dated 03.03.2010. Even otherwise also, in the documents submitted by the complainant, it is nowhere noted/mentioned that complainant had undergone angioplasty surgery. The OPs insurance company received the claim intimation from the complainant on 21.05.2009 stating therein that the complainant was diagnosed of coronary Artery Disease and Angina on exertion and underwent angioplasty on 06.05.2009 at Santosh Hospital, Yamuna Nagar. The documents submitted by the complainant of Santosh Hospital Annexure R-2 clearly states that complainant was advised angioplasty. However, the complainant failed to submit any documents to the company with the claim documents to show that he had underwent angioplasty. On the basis of documents submitted by the complainant, the complainant was not entitled to any benefits under the terms and conditions of the insurance policy, so vide letter dated 03.03.2010 the complainant was duly informed; complainant had paid inly single premium on 06.10.2008 and due to non-payment of premium amount, the policy of the complainant got foreclosed on 6.10.2011 and on merit reiterated the stand taken in the preliminary objections and lastly prayed for dismissal of complaint.  

5.                     To prove the case, complainant tendered his affidavit as Annexure CX and documents such as copy first premium receipt as Annexure C-1, Photo copy of life insurance crises cover as Annexure C-2,  Complaint dated 03.10.2014 as Annexure C-3, Photo copy of Out Patient Ticket of PGI as Annexure C-4, Photo copy of Post Cardiac Catheterization Notes as Annexure C-5, Photo copy of Echo-cardiology report as Annexure C-6,  Photo copy of letter dated 10.07.2009 as Annexure C-7, Photo copy of treating doctor’s certificate as Annexure C-8, Photo copy of letter for receiving the documents for assessment of claim on 17.08.2009 as Annexure C-9, Photo copy of letter dated 06.01.2010 for lapsation of policy as Annexure C-10, Photo copy of certificate issued by Dr. Rakesh K. Jaswal as Annexure C-11, Photo copy of OPD slip of Dr. Rakesh K. Jaswal as Annexure C-12, Photo copies of bills of PGI Chandigarh as well as receipt and bill of medicines as Annexure C-13 to C-34, Photo copy of report of Nuclear Medicine, PGIMER Chandigarh as Annexure C-35, Copy of insurance policy as Annexure C-36 and Photo copy of essentiality certificate as Annexure C-36 and closed his evidence.

6.                     On the other hand, counsel for the OPs Insurance Company tendered into evidence affidavit of Sudha Sharma, Senior Manager as Annexure RX and documents such as Photo copy of proposal form as Annexure R-1, Photo copy of OPD slip of Santosh Hospital as Annexure R-2 to R-4, Photo copy of terms and conditions of insurance policy as Annexure R-5, Photo copy of letter dated 03.03.2010 as Annexure R-6 and closed the evidence on behalf of OPs.

7.                     We have heard the learned counsel for both the parties and have gone through the pleadings as well as documents placed on file very carefully and minutely. The counsel for the complainant reiterated the averments mentioned in the complaint and prayed for its acceptance whereas the counsel for OPs reiterated the averments made in the reply and prayed for dismissal of complaint.

8.                     It is not disputed that complainant got himself insured through policy bearing No. 09955097 dated 06.10.2008 for a sum of Rs. 3,00,000/- by getting a mediclaim policy for 10 years. The only version of the complainant is that he informed the OPs Insurance Company and completed all the formalities as required by the OPs Insurance Company vide letter dated 10.07.2009 and requested the OPs Insurance Company to pay sum insured of Rs. 3,00,000/-, so, that he able to get the treatment of his heart problem which was diagnosed by the Doctors of Santosh Hospital Yamuna Nagar (Annexure R-2 and Annexure R-3) dated 06.05.2009 and 18.05.2009, but the OPs did not bother to accede the request of the complainant, so, the complainant, to save his life, approached to the PGI for treatment, where the Doctor of the PGI carried out angiography on 11.05.2010 and  suggested the complainant to operate himself and got install stunt in his heart.  Accordingly, the complainant approached the Ops Insurance Company but the OPs Insurance Company declined to pay any heed to the genuine request of the complainant at least the complainant got himself operated and get angioplasty as well as installing of stunt in his heart. Learned counsel for the complainant argued that the complainant has spent Rs. 7514/- on angiography as well as Rs. 1,47,948/- on installing of the stunt in his heart but the OPs Insurance Company put off the matter on one pretext or the other and lastly refused to pay the claim of the complainant. Learned counsel for the complainant further draw our attention towards the insurance policy (Annexure C-36) wherein under the column A angioplasty and other invasive treatment for Coronary Artery Disease has been shown as critical illness and argued that the plea of the OPs Insurance Company that disease in question is not covered under the insurance policy is totally incorrect.  Further Learned counsel for the complainant draw our attention towards the medical bills Annexure C-13 to C-34 and argued that the complainant is also entitled to get the reimbursement of these bills.

9.                     On the other hand, counsel for the OPs hotly argued at length that ailment “Coronary Artery Disease and angina on exertion” was not covered under the critical illness mentioned in the crises cover policy which was provided cover against 35 critical illness death of TPD. However, it has been admitted that angioplasty was covered under the Insurance policy in question subject to its terms and conditions.  The complainant has submitted documents for ailment of the Santosh Hospital Yamuna Nagar (Annexure R-2 & R-3) wherein he was advised angioplasty however, the complainant never submitted any documents to the company to show that he had underwent angioplasty. On the basis of the documents of Santosh Hospital submitted by the complainant, the complainant was not entitled to any benefits under the terms and conditions of the policy and in this regard he was duly informed vide letter dated 03.03.2010 (Annexure R-6). It has been further argued by the counsel for the OPs Insurance Company that complainant had paid only a single premium on 06.10.2008 and due to the non-payment of the premium amount the policy of the complainant got foreclosed on 06.10.2011. Lastly, prayed that as the complainant has never submitted any documents to the company stating that he has underwent angioplasty, so, the complaint is liable to be dismissed. Further the plea of the complainant is also contrary, as the complainant has mentioned in the claim statement that he has underwent angioplasty at Santosh Hospital, whereas in this complaint he is stating that he has taken treatment at PGI Chandigarh hence, the claim of the complainant was lawfully rejected by the OPs Insurance Company in the terms and conditions of the Insurance Policy and prayed for dismissal of complaint. Learned counsel for the OPs referred the case law titled as Suraj Mal Ram Niwas Oil Mills (P) Ltd. Vs. United India Insurance Co. Ltd. (2010) 10 SCC page 567.

10.                   After hearing both the parties at length and going through the documents, it is clearly evident that complainant has filed the present complaint on 28.07.2010 whereas as per his own version, he got angioplasty from PGI Chandigarh allegedly on 05.10.2010 i.e. after 2 months from filing the present complaint and spent huge amount on this account. Further as per version of the complainant himself, prior to getting angioplasty from the PGI Chandigarh, he visited Fortis Hospital Mohali and get opinion and estimate of expenses which is evident from letter dated 07.08.2010 issued by Dr. R.K. Jaswal (Annexure C-11) but he did not took any treatment from the Fortis Hospital, Mohali due to financial crises and later on got treatment from PGI to save the money. Meaning thereby that at the time of filing the present complaint i.e. on 28.07.2010 and further at the time of lodging the claim with the OPs Insurance Company on 21.05.2010, complainant did not get any angioplasty from any hospital. As per version of the complainant, he got treatment for angiography and angioplasty from PGI Chandigarh during the pendency of the complaint but failed to file any cogent evidence that complainant ever submitted the original documents i.e. Medicals Bills / treatment papers with the OPs Insurance Company for reimbursement of medical expenses. Whereas ops insurance Co. has taken specific plea that the complainant has not submitted any documents for reimbursement of medical expenses and in absence of these documents how the ops Insurance Co. can settled the claim of the complainant. It was the duty of the complainant to submit the documents to the OPs Insurance Company under proper receipt. Neither the complainant submitted the original documents/bills before this Forum nor moved any application to hand over the same through this Forum, whereas his complaint is pending in this Forum from the last 6 years.

11                    Generally, in the medicals reimbursement cases, a set procedure has been developed by the IRDA to save the skin of the consumers/insured from the official of the Insurance Co. by setting up the Third Party Agency (TPA) but in the present complaint, it is no where mentioned by the complainant that he ever followed that procedure and submitted the originals Bills and treatment papers to the TPA or directly to the Ops Insurance Co. and in the absence of any cogent evidence, it cannot be held that the claim of the complainant has been wrongly and illegally withheld by the ops insurance Co. Ltd.    

12                    Resultantly, In these circumstances noted above, we are of the considered view that complainant has totally failed to prove that he ever submitted the original Bills and document of treatment from PGI Chandigarh with ops Insurance Co. Ltd or to the TPA hence we have no hesitation to held that there is no deficiency in service or unfair trade practice on the parts of OPs Insurance Company. Accordingly the complaint is hereby ordered to be dismissed. The same is hereby dismissed.  However complainant is at liberty to submit the original documents/bills to the OPs Insurance Company or TPA under proper receipt, if he so desired, and further the OPs insurance Company is also directed to settled the claim of the complainant as soon as possible within a period of 3 months from the receipt of original bills/documents. Copies of this order be sent to the parties concerned free of costs as per rules. File be consigned to the record room after due compliance.

Announced in open court. 21.06.2016.

 

                                                                                    (ASHOK KUMAR GARG)

                                                                                     PRESIDENT

 

 

 

                                                                                    (S.C.SHARMA )

                                                                                     MEMBER