| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BATHINDA C.C. No. 296 of 10-10-2017 Decided on : 19-09-2019 Kuldeep Jindal, aged about 38 years S/o Dev Raj Jindal, R/o. H. No. 1262, Mohalla Roop Nagar, Gidderbaha, District Sri Mukatsar Sahib. …...Complainant Versus ICICI Prudential Life Insurance Co. Ltd., Health Claims Cell, Vinod Silk Mills Compound, Ashok Nagar, Kandivali, Mumbai 400 101, through its M.D./Chairman ICICI Prudential Life Insurance Co. Ltd., Branch Office at Bathinda, through its Branch Manager .......Opposite parties
Complaint under Section 12 of the Consumer Protection Act, 1986. Quorum : Sh. M.P.Singh Pahwa, President Smt. Manisha Member Present : For the complainant : Sh. Manjeet Kumar Dhamija, Advocate. For the opposite parties : Sh. Ashok Bharti, Advocate. O R D E R M. P. Singh Pahwa, President Kuleep Jindal, complainant (here-in-after referred to as 'complainant') has filed this complaint under Section 12 of the Consumer Protection Act, 1986 (here-in-after referred to as 'Act') against ICICI Prudential Life Insurance Co. Ltd., Mumbai and another (here-in-after referred to as 'opposite parties'). Brief facts of the complaint are that the Insurance Adviser of the opposite parties at Bathinda approached complainant and induced him to purchase their medical Policy under the name Hospital Care Plan, in May, 2010. It was disclosed that complainant is required to deposit annual premium of Rs.8458/- for a period of 20 years and he will get hospital care upto annual limit of Rs.8,00,000/- and life time limit of Rs. 40,00,000/-. Considering it to be a good plan, the complainant bonafidely purchased the policy. Insurance adviser obtained his signatures on various documents and also got deposited first premium of Rs.8458/- on 19-05-2010 at Bathinda. The complainant received Policy No. 13924957 from the opposite parties. The complainant has been regularly depositing the amount of premium with the opposite parties every year. It is pleaded that complainant fell ill due to severe pain. He was got admitted in Usha Mission Hospital, General, Laproscopic, Endo Urological Surgery & Ultrasound Centre, Bhatti Road, Bathinda on 5-8-2016 with the history of fever and difficulty in micturition and lower abdominal pain. After ultrasound, it was revealed that Bladder stone with F/s/o outlet obstruction. Thereafter complainant was operated and V.I.U. (Visual Internal Urethrotomy) and Cystolitholapaxy was done. In post operative period, there was haematuria. Saline irrigation of the bladder was done till the haematuria stopped and urine was clear. Two surgeries were performed by the doctor concerned i.e. Ist Surgery for Urethra, Stricture, Urethrotomy (No.137 of Grade-I) and second surgery for Cystoscopic Removal (No.80 of Grade-II). The complainant was ultimately discharged from the hospital on 9-8-2016 in stable condition. The complainant spent a total sum of Rs. 48,147/- on his treatment. After discharge, the complainant applied for reimbursement of amount spent by him on his treatment. He supplied copies of all the relevant documents including medical certificate duly filled and counter signed by the concerned doctor but the opposite parties paid only Rs.38,000/- to the complainant by crediting the same in his account through NEFT on 21-2-2017 against Surgery at No. 137 of Grade-I. The opposite parties have failed to settle the claim of the complainant regarding another surgery at No. 80 of Grade-II. The claim of the complainant regarding Surgery No. 80 of Grade-II has been illegally and arbitrarily withheld by the opposite parties, without assigning any cogent reason. The complainant repeatedly approached the opposite parties with a request to make payment of the insurance claim to him regarding aforesaid both the surgeries i.e. the balance amount for the Surgery of Cystoscopic Removal (Surgery No. 80-Grade II). He also sent e-mail to the opposite parties on 26-2-2017 but to no response. It is also pleaded that due to this illegal act of the opposite parties, the complainant suffered great mental tension, harassment, humiliation and huge financial loss. For these sufferings, he has claimed compensation to the tune of Rs.50,000/-; Rs.1,00,000/- with interest @ 18% P.A. on account of second surgery and Rs. 5500/- as litigation expenses. Hence, this complaint. Upon notice, the opposite parties appeared through counsel and contested the complaint by filing written reply. In written reply, the opposite parties raised preliminary objections that complaint is false, frivolous and vexatious. That the Company received claim for hospitalization from 05-08-2016 till 09-08-2016 for Urethral Stricture Bladder Stone with Cystolitholipaxy. After careful evaluation of the records, the company duly accepted claim of Rs. 38,000/- and paid the same to complainant on 20-02-2017 through NEFT. The subject policy is Hospital Care Policy which is a fixed benefit product and is not a reimbursement plan. The amount payable does not depend on the actual expenses incurred. The opposite parties have acted strictly as per terms and conditions of the policy document. The complainant has not produced any record which suggests that he had approached the opposite parties with any concerns relating to non-receipt. The terms and conditions of the policy were duly sent to the complainant. The complainant has not availed option of cancellation under free look period. That the complainant has not approached this Forum with clean hands. That the complaint has been filed with ulterior motive and malafide intention. That the complainant is not entitled to any relief under terms and conditions of the policy. No deficiency in service can be attributed on the part of the opposite parties. On merits also, the opposite parties have controverted all the material averments and reiterated their stand as taken in preliminary objections and detailed above. The opposite parties have furnished the details of calculations as per policy, the reproduction of which is not considered at this stage. In the end, the opposite parties prayed for dismissal of complaint. In support of his complaint, the complainant has tendered into evidence his affidavit dated 27-2-2018 (Ex. C-1), photocopy of e-mail (Ex. C-2), photocopy of certificate (Ex. C-3), photocopy of letter (Ex. C-4), affidavit dated 23-3-2018 of Dr. Neelesh Bansal (Ex. C-5), phtocopy of bills (Ex. C-6 to Ex. C-9), photocopy of policy (Ex. C-10), photocopy of bill summary (Ex. C-11) and closed the evidence. In order to rebut this evidence, the opposite parties have tendered into evidence affidavit dated 24-3-2018 of Chittesha Sharma (Ex. OP-1/1), photocopy of application form (Ex. OP-1/2), photocopy of claim statement (Ex. OP-1/3), photocopy of policy documents ( Ex. OP-1/4) and closed the evidence. The complainant has also submitted written arguments. We have heard learned counsel for the parties, gone through written arguments of the complainant and the record. The learned counsel for the parties have reiterated their stand as taken in their respective pleadings . We have carefully gone through the record and have considered the rival contentions. Admittedly the complainant was under two surgeries for V.I.U i.e. Visual Internal Urethrotomy and Cystolitholapaxy i.e. Cystoscopic Removal. The complainant has lodged both claims but the opposite parties have accepted the claim regarding first claim and denied the claim regarding Cystoscopic Removal. Of course the opposite parties have not given any particular reason to justify repudiation of claim for second surgery. The opposite parties in written reply have revealed terms and conditions of policy which shows that for surgery of Cystolitholapaxy, the opposite parties have to pay Rs. 15,000/-. Therefore, terms and conditions relied by the opposite parties itself proves that complainant was entitled to reimbursement of Rs. 15,000/- on account of Cystolitholapaxy surgery, but the opposite parties have denied this claim. It amounts to deficiency in service on the part of the opposite parties. Resultantly, this complaint is partly accepted with Rs.5000/ as costs. The opposite parties are directed to pay Rs. 15,000/- to complainant being claim amount of second surgery i.e. Cystolitholapaxy The compliance of this order be made by the opposite parties jointly and severally within 45 days from the date of receipt of copy of this order. The complaint could not be decided within the statutory period due to heavy pendency of cases. Copy of order be sent to the parties concerned free of cost and file be consigned to the record. Announced : 19-09-2019 (M.P.Singh Pahwa ) President (Manisha ) Member
| |
