Chandigarh

StateCommission

A/276/2017

ICICI Prudential Life Insurance Company Limited - Complainant(s)

Versus

Kulwant Singh - Opp.Party(s)

Gaurav Bhardwaj, Adv.

21 Nov 2017

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

U.T., CHANDIGARH

                                                                 

Appeal No.	:	276 of 2017
Date of Institution	:	17.11.2017
Date of Decision	:	21.11.2017

 

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.  

.…Appellants/Opposite Parties.

Versus

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

…. Respondent/Complainant.

Appeal under Section 15 of the Consumer Protection Act, 1986.

 

BEFORE:   JUSTICE JASBIR SINGH (RETD.), PRESIDENT.

                SH. DEV RAJ, MEMBER.

                SMT.PADMA PANDEY, MEMBER.

               

Argued by:

Sh. Gaurav Bhardwaj, Advocate for the appellants.

 

PER DEV RAJ, MEMBER

              This appeal has been filed by the Opposite Parties against the order dated 04.09.2017, rendered by the District Consumer Disputes Redressal Forum-II, U.T., Chandigarh (in short ‘the Forum’), vide which, consumer complaint bearing No.154 of 2017 filed by complainant was allowed against the Opposite Parties:-

“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/-.”

2.         The facts in brief are that on 28.12.2011, the complainant purchased a policy from the Opposite Parties bearing NO.16252040 – ICICI Pru Whole Life covering accident & disability benefit rider for the sum assured Rs.1,00,000/-, commencing from 29.12.2011 and due date of last premium was 29.6.2022.  It was further stated that as per the said policy, it also had Accidental & Disability Benefit Rider i.e. in case of total and permanent disability due to an accident, 10% of the rider sum assured was to be paid out every year for 10 years (Annexure C-1).  It was further stated that the complainant paid regular premiums of the said policy without any default or delay (Annexure C-2 to C-9 colly.). It was further stated 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 was further stated that in the said accident, the complainant lost his left eye and declared 30% permanent disabled by doctors of PGI (Annexure C-10). It was further stated that thereafter, the complainant lodged claim with the Opposite Parties and submitted all requisite documents, as demanded, but the same was refused/denied vide letter dated 13.9.2016 (Annexure C-11).  It was further stated that a legal notice was also sent by the complainant to the Opposite Parties but to no avail. It was further stated that the aforesaid acts of the Opposite Parties amounted to deficiency, in rendering service, and indulgence into unfair trade practice. When the grievance of the complainant, was not redressed, left with no alternative, a complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter to be called as the Act only) was filed seeking various reliefs.

3.           The Opposite Parties, in their joint written statement, while admitting the factual matrix of the case, stated that there is only 30% disability in the present case as was evident from the Disability Certificate issued by PGIMER, Chandigarh on 19.8.2016.  It was further stated that the disability suffered by the Life Assured did not qualify to be total and permanent in nature as per the conditions mentioned in the policy document and, hence, no benefit was payable under the same. It was further 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 was not covered under Accident & Disability Benefit Rider terms of the policy as the medical certificate showed the percentage of disability as 30%, whereas, as per terms & conditions of the policy, there should be complete and irremediable loss of sight in both eyes and, as such, the claim was rightly rejected. It was further stated that neither there was any deficiency, in rendering service, on the part of the Opposite Parties, nor they indulged into any unfair trade practice. The remaining averments, were denied, being wrong.

4.         The parties led evidence, in support of their case.

5.         After hearing the Counsel for the parties and perusing the record, the Forum allowed the complaint against the Opposite Parties, as stated above.

6.          Feeling aggrieved, the Opposite Parties have filed the instant appeal.

7.         We have heard the Counsel for the parties and have gone through the evidence and record of the case, carefully.

8.         Counsel for the appellants stated that any benefit under the policy becomes payable only in accordance with the terms and conditions and the parties are contractually bound by the same. It was further stated that claim was payable only for such illnesses as were clearly defined in the policy documents. It was further stated that neither there was loss of limb (entire hand or foot) nor complete & irremediable loss of sight in both eyes. It was further stated that as per the policy terms and conditions, there should be complete and irremediable loss of sight in both eyes. It was further stated that the Forum miserably failed to properly appreciate the Disability Certificate issued by PGI, Chandigarh as nowhere in the said certificate/report, the doctors have mentioned that one eye of the complainant was completely damaged and there was irremediable loss of vision in any eye as mentioned in the order. Lastly, a prayer to allow the appeal and set aside the impugned order has been made.

9.         After going through the evidence on record and submissions of the Counsel for the appellants, we are of the opinion that the appeal is liable to be dismissed at the preliminary stage for the reasons to be recorded hereinafter.

10.       It is evident on record that vide letter (Annexure C-11), the claim of the complainant under policy Plan ICICI Pru Whole Life bearing No.16252040 was rejected by the Opposite Parties stating that the injury/ailment was diagnosed as Bilateral open globe injury with Lt. Phthiscal Eye as the medical certificate showed percentage of disability 30 percent only.    

11.       While settling the controversy at rest, the Forum in Para 7 and 8 of its order held as under:-

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.”

It may be stated here that according to the Disability Certificate (Annexure C-10) issued by PGIMER, Chandigarh, the overall permanent physical/mental impairment of the complainant was assessed as 30% and he was diagnosed as “B/L open Globe Injury Lt Phthiscal Eye” and a case of Multiple Disability and extent of impairment was found to be permanent. The appellants/Opposite Parties were wrong in repudiating the claim of the respondent/complainant. In our opinion, the Forum rightly observed that the Opposite Parties erred in treating the total impairment/damage of one eye of the complainant not a permanent disability. The Forum also rightly held that the Opposite Parties caused injustice to the complainant by denying claim under the policy. Therefore, the appeal deserves to be dismissed and the impugned order passed by the Forum is liable to be upheld.

12.       No other point was raised by the Counsel for the parties.

13.       For the reasons recorded above, this appeal being devoid of any merit, is dismissed, at the preliminary stage, with no order as to costs. The impugned order passed by the District Forum is upheld. Accordingly, the application for condonation of delay in filing the appeal also stands dismissed having been rendered infructuous.

14.       Certified copies of the order be sent to the parties free of charge.

15.       File be consigned to the Record Room after completion.

Pronounced

21.11.2017.

[JUSTICE JASBIR SINGH (RETD.)]

PRESIDENT

 

 

 

(DEV RAJ)

MEMBER

 

 

 

(PADMA PANDEY)

MEMBER

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