Before the District Consumer Disputes Redressal Forum, Rohtak.
Complaint No. : 608.
Instituted on : 25.10.2017.
Decided on : 28.01.2019.
Surinder Singh Yadav(Age-46 years), s/o Sh. Lakhmi Ram Yadav R/o H.No.B-228 Preet Vihar Colony, Near Old Housing Board Colony, Rothak(Mobile 9034306426).
………..Complainant.
Vs.
- Life Insurance Corporation of India, SCO No.3,4,5, Sector-1, HUDA, Divisional Office, Market Plaza, Rohtak-124001 through its Senior Divisional Manager.
- Life Insurance Corporation of India, Jeevan Jyoti, Subhash Road, Opposite Akashwani Bhawan, Rohtak through its Branch Manager.
……….Opposite parties.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
SH. VED PAL, MEMBER.
SMT. SAROJ BALA BOHRA, MEMBER.
Present: Smt. Lovina Singla, Advocate for the complainant.
Sh.Sameer Gambhir, Advocate for the opposite parties.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Brief facts of the case are that complainant became the member of the opposite party bearing policy No.504746333 under the health insurance scheme and deposited the premium of policy. That the date of commencement of the policy was 17.10.2016. That at the time of enrolling the complainant as member, opposite party informed the complainant that it is the policy of the company to inform its members well in advance to submit its due installment. That complainant received the letter dated 03.06.2017 vide which it was informed by the opposite party that the policy subscribed by the complainant has lapsed on account of non payment of premium of Rs.12852/- which fell due on 17.04.2017. That the act of opposite party of not informing the complainant about the due date is illegal. That the complainant revived the policy by paying the late fees of Rs.265/-. That the policy was revived by the company and a certificate was issued in this regard on dated 19.07.2017. That the complainant got a major health problem and he was diagnosed heart disease at Holy Heart Hospital, Rohtak on 07.08.2017 and was shifted to Medanta Hospital, Gurugram on the same day. That complainant spent an amount of Rs.450000/- on his treatment. He submitted the claim form with the opposite party but the opposite party vide letter dated 29.09.2017 has repudiated the claim on the ground that : “Not accidental claim and hospitalization within 45 days from the date of revival of the policy”. That the act of opposite party of rejecting the genuine claim of the complainant is illegal and amounts to deficiency in service on their part because at the time of revival of the policy, the complainant was not informed about the clause W04 by the company. Hence this complaint an-d it is prayed that Ops may kindly be directed to pay compensation/insurance amount of Rs.1000000/- alongwith interest and litigation expenses to the complainant as explained in relief clause.
2. After registration of complaint, notice was issued to the opposite parties. Opposite parties filed their written reply submitting therein that the policy of the complainant was lapsed since 17.05.2017 on account of non payment of premium amount due on 17.04.2017 after grace period. The policy of the complainant was revived on 19.07.2017 and the claim is not admissible within 45 days of from the date of revival as per terms and conditions of the policy. So the repudiation letter dated 29.09.2017 was sent to the complainant and the cause of repudiation is that as per Repudiation code-W04, Non accidental claim and hospitalization within 45 days from the date of revival of policy is not payable. There is no deficiency in service on the part of OPs and dismissal of complaint has been sought.
3. Ld. counsel for the complainant has tendered affidavit Ex.CW1/A, documents Ex.C1 to Ex.C8 and closed his evidence. On the other hand, ld. counsel for OPs tendered affidavit Ex.RW1/A, documents Ex.R1 to Ex.R14 and closed his evidence.
4. We have heard learned counsel for the parties and have gone through material aspects of the case very carefully.
5. After going through the file and hearing the parties it is observed that the claim of the complainant has been repudiated by the opposite party on the ground that claim is only admissible after 45 days of revival of policy. Ld. counsel for the OPs has also placed reliance upon the law of Hon’ble National Commission, New Delhi in Revision Petition No.7/8/9 of 2010 titled as LIC of India vs. Smt. Gurjeet Kaur whereby Hon’ble National Commission has held that “NCDRC has observed that there is no unfair trade practice followed by LIC in rejecting the claim of DAB as the death is not within 180 days of accident and the relevant clause is a part of policy bond”. Ld. counsel has also placed reliance upon the order of Hon’ble Apex Court in case titled as Middle High School Vs. HDFC Ergo Gen. Ins. Co. decided on 22.11.2017, order held in 2015 in case titled B.S industries Vs. Export Credit Guarantee Corp., 2009(4)CLT 313 Vikram Greentech Vs. New India Assurance. On the other hand, contention of ld. counsel for the complainant is that the policy in question was revived. Hence the repudiation of claim is unjustified. Ld. counsel for the complainant also placed reliance upon the judgment dated 10.01.2018 of Hon’ble Supreme Court in civil Appeal No.3167 of 2017 titled as I.C.Sharma Vs. Oriental Insurance Co. Ltd. But the same is not fully applicable on the facts and circumstances of the present case as the facts of the present case are different. In the present case, the policy was issued on 17.10.2016, next premium was due on 17.04.2017, grace period was upto 16.05.2017. Policy was lapsed due to non payment of premium within grace period. Intimation was given to the complainant vide letter dated 03.06.2017 and the policy was revived on 19.07.2017 after payment of premium of Rs.12852/- with late fee of Rs.265/-. On 07.08.2017, the complainant was admitted in hospital and discharged on 10.8.2017. As the claim arise only before 45 days of revival of policy, hence the same was repudiated by the opposite party vide letter dated 29.09.2017 placed on record as Ex.C8 on the ground that repudiation code W04- and the cause of repudiation is that “Not accidental claim and hospitalization within 45 days from the date of revival of the policy”. We have also placed reliance upon the condition no.14 of Terms and conditions of the policy placed on record as Ex.R11 whereby it is mentioned that : “If the policy is revived after discontinuance of the cover than the following shall apply in respect of each insured: a) If the request for revival is received by the Corporation within 90 days from the due date of the first unpaitd premium, then there shall be a general waiting period of 45(forty five) days from the date of revival in respect of each insured”.
6. In view of the facts and circumstances of the case it is observed that the policy of the complainant was revived on 19.07.2017 and the date of treatment of complainant is 07.08.2017. Hence as per terms and conditions of the policy, claim is not admissible within 45 days of from the date of revival. The another contention of complainant is that the opposite parties have not intimated the complainant regarding the deposit of premium amount with them. The perusal of Ex.C1 itself shows that the complainant had opted an option for half yearly premium regarding the policy but the same was not deposited by the complainant himself. It has not been mentioned anywhere that regarding the premium, respondent officials will intimate to their policy holders. So the alleged plea of the complainant cannot be considered. Hence, the claim has rightly been repudiated by the opposite parties and there is no deficiency in service on the part of opposite parties. Accordingly the present complaint stands dismissed with no order as to costs.
7. Copy of this order be supplied to both the parties free of costs.
8. File be consigned to the record room after due compliance.
Announced in open court:
28.01.2019. ................................................
Nagender Singh Kadian, President
..........................................
Ved Pal Hooda, Member.
……………………………….
Saroj Bala Bohra, Member.
