The Complainant has filed this case alleging deficiency-in-service by the O.Ps, where O.P No.1 is Max Life Insurance Company Ltd., Being represented through its Branch Manager, Bhubaneswar, O.P No.2 is Axis Bank Ltd., Being represented through its Branch Manager, Kantabania Branch, Kantabania, Balasore, O.P No.3 is Max Life Insurance Company Ltd., Being represented through its Authorised Signatory-Cum-the Chairman/ Claims Cell, Gurgaon, Haryana and O.P No.4 is Max Life Insurance Co. Ltd., New Delhi.

                    2. Shorn of unnecessary details briefly stated the case of the Complainant is that the Complainant opened a Max Life Insurance Policy vide No.255735813 named “Traditional Participating Endowment Insurance Plan” with O.P No.2 on 11.12.2014, term of Policy-15 years with an annual premium of Rs.29,100.97 ps. (Rupees Twenty nine Thousand one hundred and ninety seven paisa) only with guaranteed maturity sum of Rs.2,77,787/- (Rupees Two Lacs seventy seven thousand seven hundred eighty seven) only including guaranteed death benefit as on date of commencement of Rs.3,20,110.67 ps. (Rupees Three Lacs twenty thousand one hundred ten and sixty seven paisa) only, where the Complainant has paid two nos. of annual premium and obtained Policy bond. But, the Complainant had sustained severe chest pain on 03.07.2015 and was admitted in District Head Quarter Hospital, Balasore and as per advice of the attending physicians, the Complainant was admitted in Aditya Care Hospital, Bhubaneswar on the same day i.e. on 03.07.2015 and was discharged on 08.07.2015, after treatment and incurred a sum of Rs.2,70,975.98 ps. (Rupees Two Lacs seventy thousand nine hundred seventy five and ninety eight paisa) only for his treatment. The Complainant on 07.06.2016 put forth his grievances to O.Ps No.1 to 3 for medical benefit out of the above said Policy through Regd. Post with AD and on receipt of the same, the aforesaid Insurance Company replied to his wife on 17.06.2016 requesting to provide relevant documents as mentioned there in to settle the death claim of the Complainant, though the Complainant is alive on date. Since the Insurance Company did not consider his grievance, being aggrieved upon the said Insurance Company, the Complainant filed this case to get the terminal illness benefit of the said Policy as per terms and conditions of such Policy with interest along with compensation and litigation cost.

                    3. The O.Ps No.1, 3 and 4 have filed the written version through their Advocate, where they have denied on the point of maintainability. The O.Ps have also submitted that the above said Policy was issued to the Complainant on 14.12.2014 and the O.Ps received the living benefit claim intimation from the Complainant along with related documents on 14.06.2016 claiming for suffering from heart attack under Terminal illness benefit. But, on 17.06.2016, these O.Ps treating it as a death claim, a condolence letter was sent to the nominee of the Complainant mentioning therein that the O.Ps are ready to settle the death claim and thereby, requested to provide necessary documents in order to process the claim, and on evaluation by the case Manager, it was observed that the Life insured (Complainant) is alive accordingly, it was changed from claim to no claim status. The Complainant filed the present complaint against these O.Ps on 22.08.2016 for claiming benefits under Terminal illness clause, where as he had suffered from heart attack, which is not maintainable as per terms of the Policy and “Terminal illness cover” is vastly different from the “Critical illness cover”, wherein the latter covers critical illness like cancer, heart attack, stroke etc., which was clearly explained to the Complainant at the time of proposal and signing the Policy document. It was also submitted that the Insurance Policy is a legal contract laying down terms of the contract and the Parties to insurance are bound by such terms and conditions, which are applicable to the Insurer and the insured as Parties to the contract. The Complainant after signing the Policy is bound by terms of the Policy. It is further submitted that this O.P received a duly signed and filled proposal form from the Complainant, wherein the Complainant under the head- Declaration admitted that he fully understands the terms and conditions of the Policy. The Complainant opted for Policy of his own choice and it was only after such choice was made unilaterally by the Complainant that the terms and conditions of that Policy contract were explained to him accordingly by this O.P.

                    4. Though sufficient opportunities were given to the O.P No.2, but neither he appeared nor filed his written version in this case. So, the O.P No.2 is set ex-parte.

                    5. In view of the above averments of both the Parties, the points for determinations of this case are as follows:-

(i) Whether this Consumer case is maintainable as per Law ?

(ii) Whether there is any cause of action to file this case ?

(iii) To what relief the Complainant is entitled for ?   

                    6. In order to substantiate his plea, the Complainant has filed certain documents as per list. Perused the documents filed. The O.Ps have not filed any documents in their support. It has been argued on behalf of the Complainant that he has obtained a Life insurance policy named "Traditional Participating Endowment Insurance Plan" from the O.Ps for a guaranteed maturity sum of Rs.2,77,787/- (Rupees Two Lacs Seventy seven thousand seven hundred eighty seven) only with guaranteed death benefit of Rs.3,20,110.67 ps. (Rupees Three Lacs twenty thousand one hundred ten and sixty seven paisa) only and he has paid two numbers of annual premium of Rs.29,100.97 ps. (Rupees Twenty nine thousand one hundred and ninety seven paisa) only each and obtained the Policy bond. The Complainant has not filed the entire Policy bond, but filed the first page of it. However, he became ill and treated at Aditya Care Hospital, Bhubaneswar and expended Rs.2,70,975.98 ps. (Rupees Two Lacs Seventy thousand nine hundred seventy five and ninety eight paisa) only and after intimation of the same to the O.Ps-Insurance Company, when the Insurance Company did not comply his relief, he has filed this case in the Forum praying for Insurance claim with interest along with compensation and litigation cost. On the other hand, it has been argued on behalf of the O.Ps that on receiving the living benefit claim from the Complainant, they treated it as a death claim and issued a condolence letter to the nominee of the Complainant and mentioned that they are ready to settle the death claim. However, it is not correct due to alive of the Complainant. As the Complainant suffered from heart attack and he was under treatment, it doesn't come under Terminal illness, but comes under Critical illness. The Complainant has signed this Policy after knowing all the terms and conditions of the Policy and he is not entitled to get benefit under Terminal illness. According to general procedure and Insurance Laws, Critical illness insurance otherwise known as critical illness cover or a dread disease policy, is an insurance product in which the insurer is contracted to typically make a lump sum cash payment if the policy holder is diagnosed with one of the specific illnesses on a predetermined list as part of an insurance policy. So, from the list of diseases under Critical illness, heart attack is found. But, Terminal illness is an incurable disease that cannot be adequately treated and is reasonably expected to result in the death of the patient within a short period of time. This term is more commonly used for progressive diseases such as cancer or advanced heart disease than for trauma. In popular use, it indicates a disease that will soon progress until death with near absolute certainty, regardless of treatment. A patient who has such an illness may be referred to as a terminal patient, terminally ill or simply terminal. Often, a patient is considered terminally ill when their estimated life expectancy is six months or less, under the assumption that the disease will run its normal course.

                    7. So, now on careful consideration of all the materials available in the case record and hearing both the sides, this Forum come to the conclusion that the illness of the Complainant doesn't come under Terminal illness rather it comes under Critical illness. So, the Complainant is not entitled to get the relief as prayed for. But, the O.Ps issued a condolence letter to the nominee of the Complainant for settlement of the death claim when the Complainant is alive. Hence, the O.Ps are directed to pay a compensation of Rs.10,000/- (Rupees Ten Thousand) only to the Complainant within 60 days of receipt of this order and failure to comply the same will carry interest @ 10% per annum, which will meet the ends of Justice in this case. Hence, Ordered:-

                                                     O R D E R

                         The Consumer case is allowed in part on contest against O.Ps No.1, 3 and 4 and on ex-parte against O.P No.2. The O.Ps are directed to pay a compensation of Rs.10,000/- (Rupees Ten Thousand) only to the Complainant within 60 days of receipt of this order, failing which it will carry interest @ 10% per annum from the date of order till realization. The Complainant is also at liberty to realize the same from the O.Ps as per Law, in case of failure by the O.Ps to comply the Order.

                         Pronounced in the open Forum on this day i.e. the 21st day of September, 2017 given under my Signature & Seal of the Forum.