Date of Filing : 12.11.2010
Date of Order : 15.11.2011
BEFORE THE II ADDITIONAL DISTRICT CONSUMER
DISPUTES REDRESSAL FORUM,
SESHADRIPURAM, BANGALORE – 560 020
Dated 15th day of November 2011
PRESENT
Sri.H.V.Ramachandra Rao B.Sc., BL …. President
Sri. BALAKRISHNA V. MASALI, B.A., LL.B.(SPL) …. Member
COMPLAINT NO. 2575/2011
Sri.Vishwanath N,
S/o.late.Nagaraj,
Aged about 39 years,
R/at No.6, Jagadeshwara Nilaya,
2nd Main, 4th Cross,
Ittumadu, BSK 3rd Stage,
Bangalore 560 085.
(By Advocate Sri.L.T. Gopal) ……. Complainant
V/s.
M/s ICICI Prudential Life Insurance
Company Limited,
Residency Road,
Bangalore 560 025.
Rep. by its Manager.
(By Advocate Sri. N.B.Nijalingappa) …… Opposite Party
ORDER
(By the President Sri. H.V.RAMACHANDRA RAO)
The brief antecedents that yet to be filing of the complaint under section 12 of the Consumer Protection Act seeking direction to the OP to pay a sum of Rs.2,15,000/- are necessary:
1. The complainant has obtained ICICI Pru Health saver policy on 29.12.2009 from the OP by paying a yearly premium of Rs.25,000/-. In last week of January 2010 the complainant was suffering from cough and the doctor who treated him advised him to get ECO test. Accordingly the complainant went to Jaideva Hospital wherein it was found that he was suffering from DVR(Double Valve Replacement) and advised to undergo surgery. He was admitted to the hospital on 27.01.2010, was operated on 01.02.2010 and discharged on 10.02.2010. This was informed to the OP with all medical documents and sought payment of the amount on 24.02.2010. The OP collected the documents on 16.04.2010 made correspondence on 30.04.2010 and on 19.08.2010 repudiated the claim on untenable ground which is unfair trade practice and deficiency in service. Hence this complaint.
2. In brief the version of the OP are: signed the proposal on 23.12.2009 by the complainant and paid Rs.25,000/- on that day as the first year premium. In the proposal form itself it is clearly stated about the waiting period at clause No.2. Clause No.4.1 speaks about the free look period. The policy was taken and issued on 29.12.2009. The complainant was admitted to the hospital on 27.01.2010. Hence within 30 days the complainant was admitted to the hospital. Hence within the waiting period he is not entitled to any medical reimbursement. Hence the complaint has to be dismissed.
3. To substantiate their respective cases, the parties have filed their respective affidavits. On 04.01.2011, when the case was posted for arguments none appeared. Hence perused the records.
4. The points that arise for our consideration are:
A) Whether there is any deficiency in service ?
B) What order ?
5. Our answers are :
A) Positive
B) As per the detailed order for the following reasons
REASONS
6. Reading the pleadings in conjunction with the affidavits and documents on record it is an admitted fact that the complainant had made an application/proposal for ICICI Pru Health Saver Plan plicy by paying Rs.25,000/- on 23.12.2009. He has signed the proposal form and paid the premium amount to the OP on 23.12.2009,(vide para 6(1) of the version and the copy of the proposal form submitted by the OPs). But the OP has issued the policy on 29.12.2009. It does not say the policy commences only from 29.12.2009. The policy is deemed to have commenced on the date of application. The application it has been accepted by the OP on that date and it never stated that the policy will be issued from future date. Here it is also an admitted fact that the complainant was admitted to Jaideva Hospital on 27.01.2010 for DVR. He was operated on 01.02.2010 and discharged on 10.02.2010 and the complainant has spent Rs.1,65,0000/- towards the medical expenses. The complainant also made a claim in this regard. But the Op has repudiated on the ground that this has happened within 30 days that is in the waiting period.
7. Clause 4 of the policy reads thus “Initial waiting period:30 days from the policy commencement date(except for injuries due to an accident” that is to say that if any medical expenses is incurred within 30 days from the policy commencement of the policy that is excluded. Here on 23.12.2009 itself the amount has been paid and the proposal has been signed by the complainant and has been accepted by the OP. Hence taking that as the date of the commencement of the policy then the treatment given on 27.01.2010 will be beyond 30 days and OP is liable to reimburse medical expenses. That means when the application has been signed and given and accepted by the OP that is the date of commencement of the policy and not another date of commencement of the policy even if it is mentioned in the policy; is the law laid down by the Hon’ble High Court of Karnataka in a case between NIAC Ltd., Vs Divakar Shetty and another in Miscellaneous First Appeal No.4879/2008(MV) dated 24.08.2009. Hence repudiating the claim is nothing but unfair trade practice. Hence under these circumstances OP bound to reimburse the amount to the complainant. Hence we hold the above points accordingly and pass the following:
ORDER
1. Complaint is allowed in part.
2. OP is directed to pay to the complainant a sum of Rs.1,65,000/- together with interest thereon at 12% per annum from 10.02.2010 until payment within 30 days from the date of this order.
3. OP is also directed to pay to the complainant a sum of Rs.2,000/- as cost of this litigation.
4. OP is directed to send the amount as ordered at para 2 and 3 above to the complainant by DD through RPAD and subit to this Forum a compliance report with necessary documents within 45 days from the date of this Order.
5. Return the extra sets to the concerned parties as under regulation 20(3) of the consumer protection Regulation 2005.
6. Send copy of this Order to both the parties free of cost immediately.
Pronounced in the Open Forum on this 15th day of November 2011
MEMBER PRESIDENT
