Haryana

Yamunanagar

CC/1159/2011

Narinder Singh age 44 years s/o Gurbax Singh - Complainant(s)

Versus

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

Arvinder Singh Chahal

21 Apr 2017

ORDER

BEFORE THE PRESIDENT DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, YAMUNA NAGAR AT JAGADHRI.

                                                                                                Complaint No. 1159 of 2011.

                                                                                                Date of institution: 16.11.2011

                                                                                                Date of decision: 21.04.2017.

Narinder Singh aged about 44 years son of Sh. Gurbax Singh, C/o Hira Motors, Yamuna Nagar.                                                                                                                                                                                                                                                                                                                                                                                                  

                                                                                                                                                     …Complainant.

                                    Versus

Life Insurance Corporation of India, Post Box No. 52, Opp. Madhu Petrol Pump, Jagadhri Road, Yamuna Nagar through its Branch Manager.

                                                                                                                                  

                                                                                                                                        …Respondent.

BEFORE:       SH. ASHOK KUMAR GARG, PRESIDENT.

                        SH. S.C.SHARMA, MEMBER.

                        SMT. VEENA RANI SHEOKAND, MEMBER.

 

Present: Sh. A.S.Chahal,  Advocate, counsel for complainant.

              Sh. Rajiv Gupta, Advocate, counsel for respondent.  

 

ORDER   (ASHOK KUMAR GARG PRESIDENT)

 

1.                       Complainant has filed the present complaint under section 12 of the Consumer Protection 1986.  

2,                     Brief facts of the present complaint as alleged by the complainant, are that he purchased a Life Insurance Policy bearing No. 173752655-7712 Table No. 149/64/22 on 15.01.2004 for an amount of Rs. 5,00,000/-. After purchasing the said policy the complainant renewed the same from time to time and lastly renewed his policy on 07.10.2010. During the effective period of the policy, the policy was lapsed for some time as the complainant did not deposit the premium amount, but the same was again renewed on the same terms and conditions as was of previous life insurance policy. During the currency of the insurance policy in question, the complainant diagnosed Coronary Artery Disease- unstable Anginan and got himself admitted in the Fortis Hospital, Mohali with the complaint of retrosternal chest heaviness on exertion and admitted in the hospital on 28.02.2011 and remained admitted up to 01.03.2011. On 28.02.2011, complainant underwent Coronary Angiography and PTCA and stent to RCA was done and after getting the treatment from the Fortis Hospital, Mohali, the complainant was discharged on 01.03.2011 vide IPD No. IP00109784. On his treatment, the complainant paid Rs. 3,89,402/- to the Fortis Hospital vide bill No. FHM/10-11/I/Cs/00010933 dated 01.03.2011 and in addition to that amount, the complainant has also made other expenses to the tune of Rs. 45,000/- and thus the complainant has incurred approximately Rs. 4,35,000/- on his treatment, to which the OP Insurance Company is liable to pay. Thereafter, the complainant lodged his claim under the policy in question with the OP Insurance Company but he was astonished when he received a letter dated 15.07.2011 wherein it was intimated by the Branch Manager of the OP Insurance Company that his claim has been repudiated as critical illness benefits was not payable as there is waiting period of six (6) months from the date of revival of the policy whereas the revival of the policy of the complainant was done on 07.10.2010 and first diagnosed was done on 28.02.2011 i.e. within a period of six (6) months. Upon which, the complainant approached the OP Insurance Company and requested that he is policy holder since 2004 and not a fresh policy holder and he is availing the claim only first time against the policy in question but the official of the OP did not listen the genuine request of the complainant and remained adamant not to pay the claim amount which constitute the deficiency in service and unfair trade practice on the part of OP Insurance Company. Lastly, prayed for directing the OP Insurance Company to pay amount of Rs. 4,35,000/- alongwith interest and also to pay compensation as well as litigation expenses. Hence, this complaint.

3.                     Upon notice, OP Insurance Company appeared and filed its written statement by taking some preliminary objections as such complaint is not maintainable; there is no negligence or deficiency in service; the complainant has not come to this Forum with clean hands; the complainant/ insured has obtained one insurance policy bearing No. 173752655 for a sum of Rs. 5,00,000/-  date of commencement 15.01.2004 under term table 14/64/22 at a quarterly premium of Rs. 7712/-. The policy in question had lapsed for want of payment of premium due from October, 2007, however, the policy was revised on 07.10.2010 on payment of 12 premiums due from October 2007 at the ordinary terms. It has been further submitted that each date of revival is taken as a new contract and all the conditions which are applicable to a new contract are applicable to a renewal of the policy. On 28.01.2011, the complainant underwent a Coronary Artery Grafting i.e. after a period of 4 months and 21 days of the revival of the policy in question and within six (6) months of the revival. Even, the treatment taken by the complainant relates to a critical illness and as per clause 2-A of the Insurance Policy, the Critical Illness benefit is not payable since a waiting period of six (6) months apply from the date of commencement of the revival of the policy to the first diagnosis of the critical illness under consideration, so, the benefits of critical illness and the amount incurred there upon was not payable under the terms and conditions of the insurance policy and on merit controverted the plea taken in the complaint and reiterated the stand taken in the preliminary objections and lastly prayed for dismissal of complaint.

4.                     To prove the case, counsel for the complainant tendered into evidence affidavit of complainant as Annexure CX and documents such as Photo copy of terms and conditions of Group Insurance Scheme of LIC as Annexure C-1, Photo copy of discharge summary of Fortis Hospital as Annexure C-2, Photo copy of bill of amounting to Rs. 3,89,402/- as Annexure C-3, Photo copy of receipt of amount of Rs. 3,00,000/- of Fortis Hospital as Annexure C-4, Photo copy of receipt of amounting to Rs. 79,252/- as Annexure C-5, Photo copy of receipt of amounting to Rs. 10150/- as Annexure C-6, Photo copy of claim form as Annexure C-7, Photo copy of repudiation letter dated 17.05.2011 as Annexure C-8, Photo copy of critical illness rider sale brochure as Annexure C-9 and closed the evidence on behalf of complainant.

5.                     On the other hand, counsel for the OPs tendered into evidence affidavit of Sh. P.K. Saxena as Annexure RW/A and documents such as Photo copy of proposal form as Annexure R-1, Photo copy of insurance policy alongwith its terms and conditions as Annexure R-2, Photo copy of revival quotation dated 07.10.2010 as Annexure R-3, Photo copy of detail of installments paid as Annexure R-4, Photo copy of repudiation letter dated 15.07.2011 as Annexure R-5, Photo copy of history of premium transaction as Annexure R-6, Photo copy of insurance policy as Annexure R-7 and closed the evidence on behalf of OP Insurance Company.

6.                     We have heard the learned counsel for both the parties and have gone through the written arguments, pleadings as well as documents placed on file very minutely and carefully.

7.                     It is not disputed that the complainant Sh. Narinder Singh obtained an insurance policy bearing No. 173752655 under table No. 149/64/22 for a sum insured of Rs. 5,00,000/- on 15.01.2004 from the OP Insurance Company. It is also not disputed that the policy in question remained lapsed from October 2007 to October 2010 and the same was revived on 07.10.2010 on the payment of 12 premiums due from October, 2007 to October, 2010 at the ordinary terms. It is also not disputed that the complainant remained admitted in the Fortis Hospital w.e.f. 28.02.2011 to 01.03.2011 and spent Rs. 3,89,402/- which is duly evident from the copy of bill Annexure C-3 and discharge summary Annexure C-2.

8.                     The only plea of the complainant is that the genuine medical claim of the complainant has been wrongly and illegally repudiated by the Op Insurance Company on the flimsy ground which constitute the deficiency in service and unfair trade practice on the part of OP Insurance Company. Learned counsel for the complainant draw our attention towards the terms and conditions of the insurance policy of group scheme Annexure C-1 and argued that as per clause 3 there was only 90 days waiting period not the six (6) months as alleged by the OP Insurance Company and referred the case law titled as New India Assurance Company Ltd. Versus Murari Lal Bhusri, 2011(4) CLT page 358.

            Learned counsel for the complainant further referred the case law titled as New India Assurance Company Ltd. & Another Versus Murari Lal Bhusri, 2011(4) CLT page 358 and also referred the case law titled as Oriental Insuracne Company Ltd. Vs. Madan Kumar Dutta, 2008 (2) CLT page 265. Lastly prayed for acceptance of complaint.

9.                     Whereas on the other hand, learned counsel for the OP argued at length, that the claim of the complainant has been rightly repudiated by the OP Insurance Company as per terms and conditions of the Insurance Policy. The complainant underwent a Coronary Artery Grafting on 28.02.2011 i.e. after a period of 4 months and 21 days of the revival of the policy in question and within six (6) months of the revival as the policy in question was revived on 07.10.2010 after a lapsed period of 3 years. The treatment taken by the complainant relates to critical illness and as per clause 2(A) of the Insurance Policy, Critical Illness benefits was not payable since a waiting period of six (6) months apply from the date of commencement of revival of the policy to the first diagnosis of the critical illness under consideration.  Hence, the claim of the complainant has been rightly repudiated. Learned counsel for the Op Insurance Company draw our attention towards the condition No. 2(A) under the head conditions and restrictions which are reproduced here as under:

Conditions and Restrictions.

            Waiting Period: A waiting period of six (6) months will apply from the date of commencement of risk or revival of the policy to the first diagnosis of the Critical Illness under consideration. This would means that the benefits of the policy schedules is not applicable if any of the contingencies mentioned in condition 2(B) occurs (i) at any time on or after the date on which the risk under the policy has commenced but before the expiry of six (6) months reckoned from that date or (ii) before the expiry of six (6) months from the date of revival.  The date of occurrence of Critical Illness will be reckoned for the above purpose as the date of diagnosis of the illness/conditions. It will be the date on which the medical examiner first examine the Life Assured and certifies the diagnosis of any of the illness/conditions.

            Learned counsel for the OP Insurance Company further argued that terms and conditions placed on file as Annexure C-1 is relating to Group Scheme i.e. Group Critical Illness Rider not to the individual critical illness rider as mentioned in the terms and conditions of the insurance policy for individual Annexure R-7. So, the complainant cannot take the benefits of the conditions mentioned in the document Annexure C-1 wherein it has been mentioned that “No Critical Illness Benefits shall become payable to a member if the disease occurs within 90 days of the start of the coverage for that member of the scheme”.   Learned counsel for the OP Insurance Company draw our attention towards the manual of the LIC claims placed on file during the course of arguments and argued that in this manual also waiting period of six (6) months has been mentioned from the date of commencement of the risk or revival to the first diagnosis of the critical illness under consideration. Learned counsel for the OP Insurance Company draw our attention towards the case law titled as United India Insurance Company Limited Versus Harchand Rai Chandan lal, 2004(2) CPC page 686 and referred another case law titled as Export Credit Guarantee Corpn of India Ltd. Versus Garg Sons International, Civil Appeal No. 1557 of 2004 decided on 17.01.2013.   Lastly, prayed for dismissal of complaint.

10.                   After hearing both the parties, we are of the considered view that there is no deficiency in service or unfair trade practice on the part of the OPs Insurance Company as from the perusal of Insurance policy in question condition No.2(a) under the Head Condition under Restriction, it is clearly evident that there was a waiting period of six months month from revival of the policy. In the instant case, the complainant got revived his insurance policy on 07.10.2010 after a lapse period of more than 3 years as the policy in question was lying in lapse mode since October, 2007. The complainant lodged his claim with the OPs Insurance Company for reimbursement of the medical expenses for the treatment w.e.f. 28.02.2011 to 01.03.2011 i.e. within a period of 4 months and 21 days, meaning thereby that the complainant remained under treatment for angioplasty and angiography etc. within a period of 6 months from the date of revival of policy which is not covered under the terms and conditions of the Insurance Policy. Further, as per arguments advanced by the counsel for the OPs Insurance Company the ailment suffered by the complainant i.e. treatment of angioplasty and all other intra-arterial, catheter based techniques, “Keyhole” or laser procedures are excluded as per terms and conditions of the insurance policy in question as only Coronary Artery bye-pass surgery is covered under the policy in question. The plea of the counsel for the complainant that there was only 90 days waiting period for the critical illness as per Annexure C-1 is not tenable as the terms and conditions mentioned in the Annexure C-1 are relating to Group  Scheme- Group Critical Illness Rider not to the individual policy issued to the complainant called Jeewan Anand policy Annexure R-7 as in the terms and conditions of the policy in question Annexure R-7 under clause 2(B) a waiting period of six (6) months has been mentioned from the date of commencement of risk or revival of the policy to the first diagnosis of critical illness under consideration. It is not the case of the complainant that the policy in question alongwith its terms and conditions Annexure R-7 were not supplied to the complainant. When a particular policy was issued to the complainant then its terms and conditions will apply to both the parties. It is a settled proposition of law that the insurance policy is a contract between the parties and both the parties are bound by its terms and conditions. The authorities tendered by the counsel for the complainant is not disputed but not helpful in the present case whereas the case law referred by the Op Insurance Company titled as United India Insurance Company Limited Versus Harchand Rai Chandan Limited (Supra) is fully applicable in the present case.    

11                    Resultantly, in the circumstances noted above, we are of the considered view that there is no merit in the present complaint and the same is hereby dismissed with no order as to costs. 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: 21.04.2017

                                                                                          (ASHOK KUMAR GARG)

                                                                                           PRESIDENT

                                                                                           DCDRF,YAMUNANAGAR

 

 

                              (VEENA RANI SHEOKAND)          (S.C.SHARMA)

                               MEMBER                                            MEMBER