Chandigarh

DF-II

CC/341/2016

Sh. Surinder Kumar - Complainant(s)

Versus

M/s SBI Life Insurance Co. Ltd., - Opp.Party(s)

Madhu P.Singh Adv.

16 Mar 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

Consumer Complaint  No	:	341 of 2016
Date  of  Institution	:	17.05.2016
Date   of   Decision	:	16.03.2017

 

 

 

 

Surinder Kumar s/o Late Sh.Kishori Lal, H.No.442, Sector 6, Panchkula.

 

              …………..Complainant

 

VERSUS

 

1]   M/s SBI Life Insurance Co. Ltd. through its Manager, SCO 127-128, Ist Floor, Sector 17-C, Chandigarh.

 

2]   M/s SBI Life Insurance Co. Ltd., through its Regional Director, SCO No.109-110, Ist Floor, Sector 17-B, Chandigarh. 

 

…………… Opposite Parties

 

BEFORE:   SH.RAJAN DEWAN          PRESIDENT

                                MRS.PRITI MALHOTRA           MEMBER

SH.RAVINDER SINGH            MEMBER

           

Argued by  Ms.Madhu P.Singh, Counsel for complainant.

Sh.Rajneesh Malhotra, Counsel for OPs.

 

 

RAVINDER SINGH, MEMBER

 

 

         The facts in issue are that the complainant on 5^th July, 2011 subscribed a SBI Life Money Back Policy Option 2 from OPs for a sum assured of Rs.2.00 lacs by paying premium of Rs.21,022/- (Ann.C-1).  The OPs also charged Rs.2670/- separately for Critical Illness Cover. The maturity date of the said policy is 5^th July, 2016 and the complainant is paying the premium regularly. 

 

         It is stated that unfortunately, the complainant had to undergo surgery for Coronary Artery Disease (CAD)- Unstable Angina and Post Percutaneous Transluminal Coronary Angioplasty (PTC) in March, 2014.  Thereafter, complainant applied to OPs for reimbursement of medical expenses under said policy, but the same was denied on frivolous ground vide letter dated 2.5.2014, which was received by the complainant on 19.5.2014.  It is also stated that the OPs have repudiated the claim of the complainant in a mechanical manner without due application of mind.  It is further stated that the complainant also wrote letter dated 23.5.2014 to the OPs, but it was not replied.  Hence, alleging the said repudiation as illegal and deficiency in service, therefore, the present complaint has been filed.

 

2]       The Opposite Parties have filed joint reply and while admitting the factual matrix of the case, stated that the complainant has been covered for basic sum assured and the critical illness rider since the date of commencement of the policy and not for medical cover, as alleged. It is denied that the treatment/surgery suffered/undergone by the complainant is covered under the critical illness defined in terms & conditions of the policy.  It is stated that the complainant had undergone PTCA and CAD and the same are not covered under critical illnesses defined under terms & conditions of the policy on Page No.16 & 17 of the policy document. It is submitted that medical opinion was taken on 21.4.2014 from the Chief Medical Officer of the OPs, who had opined that the illness suffered by the complainant does not fit into the Critical illness and thereafter, the claim was repudiated and intimated to the complainant vide letter dated 2.5.2014.  It is also submitted that the claim has rightly been repudiated.  Pleading no deficiency in service and denying rest of the allegations, the OPs have prayed for dismissal of the complaint.

 

3]       Parties led evidence in support of their contentions.

 

4]       We have heard the ld.Counsel for the parties and have carefully examined the facts and pleadings along with entire evidence on record.

 

5]       The complainant took SBI Life Insurance policy No.14040628808 on 5.7.2011 with Money Back Option-2.  The policy obtained by the complainant was a regular premium payment insurance policy for a term of 15 years w.e.f. 5.7.2011 to 5.7.2026, which provides Critical Illness Cover as per following details:-

 

Type of Cover	Term (years)	Sum Assured (Rs.)	Installment Premium (Annual) (Rs.)	Date of Last Premium payable.
Basic Plan	15	200000	18032	5.7.2025
Dhanvantari Supreme (Critical Illness Rider)	8	200000	2670	5.7.2018

 

    The survival benefit under the policy is payable as follows:

 

1st Survival benefit	5.7.2014	Rs.20,000/-
2nd Survival benefit	5.7.2017	Rs.30,000/-
3rd Survival benefit	5.7.2020	Rs.40,000/-
4th Survival benefit	5.7.2023	Rs.50,000/-
5th Survival benefit	5.7.2026	Rs.90,000/-

 

6]       The Critical Illness under the Dhanvantari Supreme (Critical Illness) Rider (UIN 111C004V02) Ann.C-1 of Policy document Money Back Plan Version 03, which is reproduced below:-

         a)  Cancer

         b)  Coronary Artery By-pass Surgery

         c)  Heart Attack

d)  Kidney failure

         e)  Stroke

         It is desired in the policy that the actual undergoing of open heart surgery for the correction of two or more coronary arteries, which are narrowed or blocked, by coronary artery bypass graft.  Angiographic evidence to support the necessity of the surgery will be required.  Angioplasty and/or any other intra-arterial procedure are excluded from the cover.

 

         The complainant admittedly has undergone Percutaneous Transluminal Coronary Angioplasty (PTCA) only in March, 2014, which does not cover under the insurance policy and specifically excluded for any benefit. 

 

7]       The insurance policy in question is a regular money back insurance policy with special benefit only  in  extreme  Critical  illness  and do not cover minor ailment to the insured and cannot be equated with any normal Health Insurance Medical Policy. 

 

8]       The claim of the complainant for medical expenses incurred on angioplasty in March, 2014 with reference to insurance policy NO.14040628808 issued by State Bank of India, as such is untenable and misconceived. 

 

9]       Keeping in view the facts as discussed in preceding paragraphs, the complaint is dismissed.  No order as to costs.

         The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

16^th March, 2017                                                                            

                                            Sd/-

(RAJAN DEWAN)

PRESIDENT

 

 

Sd/-

 (PRITI MALHOTRA)

MEMBER

 

 

                                                                                      Sd/-

(RAVINDER SINGH)

MEMBER