BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.30 of 2016
Date of Instt. 14.01.2016
Date of Decision: 09.08.2017
Raman Kumar son of Sh. Darbari Lal aged about 46 years resident of 92, Kot Baba Deep Singh Nagar, Jalandhar, Punjab.
..........Complainant Versus
M/s Aviva Life Insurance Company Ltd, 1st Floor, PUDA Complex, Ladowali Road, Jalandhar 144001.
Through its Branch Manager.
….… Opposite party
Complaint Under the Consumer Protection Act.
Before: Sh. Karnail Singh, (President),
Sh.Parminder Sharma (Member)
Present: Sh. Sanjeev Chopra, Adv Counsel for complainant.
Sh. YV Rishi, Adv Counsel for OP.
Order
Karnail Singh (President)
1. This complaint filed by the complainant, wherein stated that he purchased On-Line health insurance policy from respondent company at their Jalandhar Branch, for a sum of Rs.3,50,000/-. In this regard, the complainant paid the requisite amount to OP, which was duly received by the company and issued policy No.NHP00047496.
2. That during the subsistence of above said health and insurance policy, the complainant suffered heart problem on 26.12.2012 and was treated at Dyanand Medical College and Hospital, Ludhiana. The complainant got treatment of CAD-Unstable Angina. The said disease leads to Heart Attack. As per terms and conditions of the policy, in case of acute illness of the complainant, he is entitled to lump sum amount of Rs.3,50,000/- from respondent company as health and insurance. The illness of the complainant being Heart Attack is fully covered under the definition of critical illness as defined under the insurance policy, therefore, the complainant is entitled to recover an amount of Rs.3,50,000/- from the respondent company.
3. That as per terms and conditions of the above said mediclaim policy, the complainant lodged his health insurance claim with OP but surprisingly OP has repudiated the said insurance claim of the complainant on flimsy grounds. The decision of the OP to repudiate the health insurance claim of the complainant is illegal, wrong and against the public policy on the following grounds:-
(a). That the main objection of the OP to repudiate the claim of the complainant is that unstable angina and CAD (Coronary Artery Disease) does not come under the definition of critical illness of Heart Attack, the inference drawn by OP is completely based upon conjectures and surmises. It transpires that OP is seeking false & frivolous pretext to refrain from giving true claims to deserving people. The complainant got treatment of CAD-Unstable Angina. The said disease leads to Heart Attack, therefore, the decision of the OP to repudiate the claim of the complainant is vague, indefinite and without any basis as such the OP took a wrong decision while repudiating the claim of complainant.
(b). That once the OP had received the money from the complainant and issued health insurance policy and during the subsistence of the said policy, the complainant suffered illness, therefore, OP is bound to pay lump-sum insurance claim to the complainant on account of critical illness.
4. That the OP has adopted unfair trade practices and is proved to be deficient in providing services to the complainant, therefore, they are covered under Consumer Protection Act and even the complainant through his counsel served a legal notice dated 17.01.2015 to the OP but remained un-reply and as such necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OP be directed to make the payment of Rs.3,50,000/- being a health insurance claim along with Rs.50,000/- as mental agony due to their illegal acts and the OP may also be directed to make the payment of Rs.11,000/- as legal fee of the counsel along with other charges, in the interest of justice.
5. Notice of the complaint was given to the OP, who filed a reply and contested the complaint by taking preliminary objections that the complaint of the complainant is hopelessly time barred because the insurance claim of the complainant was declined by the OP on 08.01.2013 stating clearly that his claim do not meet the critical illness benefit rider criteria but the complainant has filed the instant complaint on 14.01.2016 i.e. much beyond 2 years period prescribed under the Consumer Protection Act and therefore complaint is time barred under Section 24A of the Consumer Protection Act. It is further averred that no cause of action accrued to the complainant for filing the present complaint and further submitted that insurance policy had accident rider as well as a critical illness rider, the critical illness rider in clause 1 (xi) clearly stipulates that “Coronary Artery By-Pass Surgery means the undergoing of open heart surgery on the advice of a consultant cardiologist acceptable to us to correct narrowing or blockage of one or more coronary arteries with by-pass grafts. Angiographic evidence to support the necessity of the surgery will be required. Baloon angioplasty, lazer or any catheter-based procedures are not covered”. The rider inter alia further in standard terms and conditions of Aviva Health Plus Policy-Clause 1 Sub Clause (xvi) in interpretation and definitions that Heart Attack does cover “(a) Angina and (b) other acute Coronary syndromes, for example myocyte necrosis”. Complainant submitted a critical illness claim form with medical records pertaining to his treatment at Dayanand Medical College & Hospital, Ludhiana, whereby the attending Physicians diagnosed the complainant as admitted with CAD-Unstable Angina. Troponin-T was found to be negative. Patient was managed with LMWH, antiplatelets, beta blockers, nitrates, statins Ace inhibitors and other supportive measures. Coronary Angiography was done on 27.12.2012, which showed single vessel disease. Patient has been advised medical management. Patient is discharged in stable condition. The said treatment is clearly excluded from the coverage under the policy terms and conditions and on merit, the purchase of the policy by the complainant is admitted but remaining allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merit and the same may be dismissed.
6. In order to prove the case of the complainant, complainant himself tendered into evidence affidavit Ex.CA alongwith some documents Ex.C1 to Ex.C9 and closed the evidence.
7. Similarly counsel for the OP tendered into evidence affidavit of Jasbir Kaur, Assistant Manager as OP-A alongwith some documents Ex.OP-1 to Ex.OP-6 and closed the evidence.
8. We have heard the learned counsel for the respective parties and also gone through the case file very minutely.
9. After hearing the argument and from scrutiny of the case file, it has become clear that the factum in regard to purchase of health insurance policy by the complainant from OP, for a sum of Rs.3,50,000/- is not in dispute and even it is not in dispute that the complainant remained admitted in the DMC Hospital, Ludhiana for treatment but the claim of the complainant is repudiated by the OP, vide repudiation letter dated 06.05.2015, on the ground that the illness of the complainant does not meet the critical illness benefit rider criteria and question remains only whether the complainant was admitted in the hospital for treatment of the critical illness and definition of the critical illness is very much given in the terms and conditions of the policy, copy of the same is placed on the file by the OP as Ex.OP4 and as per Clause 1 Sub Clause (XI), whereby the treatment taken by the complainant is excluded from critical illness, the treatment and illness of the complainant is very much mentioned in the discharge summary Ex.C4 i.e. CAD-Unstable Angina and procedure done, Coronary Angiography (Single Vessel Disease) and now, we have to see whether this illness and procedure adopted by the doctor is covered under the term and condition, for that we can say that specifically this procedure and disease is excluded being non surgical techniques, the ailment of the complainant under CAD does not require a surgery. So, it is clear that the ailment of the complainant does not fall under the critical illness as defined in the term and condition of the insurance policy, therefore the claim of the complainant is rightly repudiated by the OP and in support of this observation, we like to place reliance upon a judgment of our own State Commission, cited in 2015 CPJ 8A (CN) (Punjab), title Bajaj Allianz Life Insurance Company Ltd & Another Vs. Bhupinder Kumar.
10. So, in the light of above detailed discussion, we do not find any substances in the argument put forth by learned counsel for the complainant and therefore the complaint of the complainant is dismissed with no order of cost. Parties will bear their own cost. Complaint could not be decided within stipulated time frame due to rush of work.
11. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Parminder Sharma Karnail Singh
09.08.2017 Member President
