Punjab

Sangrur

CC/148/2017

Naresh Kumar - Complainant(s)

Versus

Life Insurance corporation of India - Opp.Party(s)

Sh.Amit Aggarwal

20 Jul 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

 

                                                               

                                                Complaint No.    148

                                                Instituted on:      07.04.2017

                                                Decided on:       20.07.2017

 

Naresh Kumar son of Shri Ram Gopal C/o Singla Electric Store, Near SBOP, Sunam Distt. Sangrur.

                                                        …Complainant

                                Versus

1.     Life Insurance Corporation of India, Railway Road, Jiwan Jyoti Building, Sangrur through its Manager.

2.     Life Insurance Corporation of India, Northern Zone,  Divisional Office, Jiwan Prakash,  Sector 17-B, Chandigarh through its Divisional Manager.

                                                        ..Opposite parties

 

 

For the complainant    :       Shri Amit Aggarwal, Adv.

For OPs                    :       Shri Amit Goyal, Adv.

 

 

Quorum:    Sukhpal Singh Gill, President

                Sarita Garg, Member

                Vinod Kumar Gulati, Member

 

 

Order by : Sukhpal Singh Gill, President.

 

1.             Shri Naresh Kumar, complainant (referred to as complainant in short) has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the complainant got himself insured with the Ops for the sum of Rs.5,00,000/- in the year 2010 vide policy bearing number 164683848 dated 27.5.2010, but no terms and conditions were supplied to the complainant. It is further averred that the complainant was covered for any serious injuries/illness for the sum of Rs.5,00,000/- under the policy.  The case of the complainant is that he met with an accident in the year 2013 and got multiple serious injuries and as such he took treatment from Jindal Institute of Medical Science, Model Town Hissar as both hips were got fractured and the hip/organ were replaced.  Thereafter the complainant lodged the claim with the Ops to pay the sum of Rs.5,00,000/-, but nothing was paid despite serving of legal notice dated 2.3.2017 upon the OPs, rather the claim of the complainant was denied by the Ops. Thus, alleging deficiency in service on the part of the Ops, the complainant has prayed that the Ops be directed to pay to the complainant an amount of Rs.5,00,000/- along with interest @ 18% per annum and further claimed compensation for mental torture, agony and harassment and  litigation expenses.

 

2.             In the written reply filed by the Ops, preliminary objections are taken up on the grounds that the complaint is not maintainable, that the complainant has not come to the court with clean hands and has suppressed material facts, that the complainant has dragged the Ops into unwanted litigation and prayed for dismissal of the complaint. On merits, it is admitted that the complainant obtained the policy in question for Rs.5,00,000/- on 27.5.2010, but the remaining allegations are denied.  It is stated that all the terms and conditions of the policy were duly supplied to the complainant. However, it has been denied that it was told to the complainant that in case he suffers from serious injury/illness, then the complainant will be entitled to get an amount of Rs.5,00,000/-. It is stated further that factually the policy in question is not a health insurance policy, rather the same is Jeevan Anand Policy with critical illness rider for the sum of Rs.5,00,000/- against the specified illnesses as per the policy such as heart attack, stroke (cerebro vascular accident), cancer, kidney failure, major organ transplant, paralysis, 3^rd degree burns, blindness, coronary artery bye pass surgery, heart valve replacement or repair and aorta graft surgery.  As there is no such circumstances in the present case, as such the claim is rightly said to be not payable vide letter dated 14.3.2017. The other allegations levelled in the complaint have been denied in toto.

 

3.             The learned counsel for the complainant has produced Ex.C-1 affidavit, Ex.C-2 to Ex.C-10 copies of other documents and closed evidence. On the other hand, the learned counsel for the Ops has produced Ex.OP-1 affidavit, Ex.OP-2 to Ex.OP-7 copies of documents and closed evidence.

 

4.             We have very carefully perused the complaint, version of the opposite parties, evidence produced on the file and written submissions and also heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits dismissal, for these reasons.

 

5.             It is an admitted case of the parties that the complainant took the insurance policy from the OPs on 27.5.2010 for Rs.5,00,000/-.  It is also not in dispute that the complainant met with an accident and suffered serious injuries and got admitted in Jindal Institute of Medical Science Hissar where he got replaced both the hips.  It is also not in dispute that the complainant lodged the claim with the OPs for payment of Rs.5,00,000/-.

 

6.             In the present case, the dispute is between the parties regarding non payment of the claim amount of Rs.5,00,000/- by the Ops.   It is an admitted fact that the claim is regarding replacement of both hips at Jindal Institute of Medical Sciences Hissar, as is evident from the copy of critical illness form Ex.C-6 and discharge card of the complainant on record is Ex.C-10.  On the other hand, the stand of the OPs is that the claim of the complainant is not covered under the policy Ex.OP-3 on record and further the Ops have produced the affidavit of Shri J.P.K.Minhas, Manager (Legal) Ex.Op-1, whereby it has been clearly mentioned that the policy in question is provided with critical illness rider, whereas the complainant is interpreting the illness with injuries suffered in accident.  The critical illness rider provides for protection against specific critical illnesses as per the table such as, heart attack, stroke (cerebro vascular accident), cancer, kidney failure, major organ transplant, paralysis, 3^rd degree burns, blindness, coronary artery bye pass surgery, heart valve replacement or repair and aorta graft surgery.  Further it is stated in the affidavit that the term “major organ transplant as defined by LIC means, actual undergoing of any of the below organs as a recipient or the inclusion of an official organ transplant waiting list for any of the organs such as heart, liver, kidney, pancreas or human bone marrow using haematopoietic stem cells preceded by total bone marrow ablation.   We have also perused the copy of the document critical illness rider Ex.OP-4, but we find again that under the column benefits, it again mentioned the same critical illnesses such as , heart attack, stroke (cerebro vascular accident), cancer, kidney failure, major organ transplant, paralysis, 3^rd degree burns, blindness, coronary artery bye pass surgery, heart valve replacement or repair and aorta graft surgery.  But, we find that in the present case, the hips replacement is not covered under the policy of insurance as claimed by the complainant in the case.   Under the circumstances, we find that the complainant has miserably failed to establish his case by producing cogent, reliable and trustworthy evidence on record to show that the case of the complainant is covered under the terms and conditions of the policy as mentioned above.  Further mere saying that he did not receive the terms and conditions of the policy is not sufficient, more so when, he has received the policy in question and obviously the same must have been received by the complainant along with the policy.  Even otherwise,  the claim is payable to the complainant according to the terms and conditions of the policy.  Since the claim of the complainant is not covered under the policy, we are unable to accept the contention of the complainant that any claim is payable to the complainant. 

 

 

7.             So, in view of our above discussion, we dismiss the complaint of the complainant. However, the parties are left to bear their own costs.  A copy of the order be issued to the parties free of cost. File be consigned to records.  

                Pronounced.

                July 20, 2017.

                                                        (Sukhpal Singh Gill)

                                                           President

 

 

                                                         

                                       

                                                                (Sarita Garg)

                                                                    Member

 

 

 

                                                        (Vinod Kumar Gulati)

                                                                   Member