Haryana

StateCommission

A/1394/2017

ICICI PRUDENTIAL LIFE INSURANCE CO. LTD. - Complainant(s)

Versus

NEHA GUPTA - Opp.Party(s)

KARANDEEP SINGH

09 Aug 2018

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                 

First Appeal No  :    1394 of 2017

Date of Institution:      17.11.2017

Date of Decision :      09.08.2018

1.     ICICI Prudential Life Insurance Company Limited Health Claim Cell, Vinod Silk Mills Compound, Ashok Nagar, Kandivali (E) Mumbai-400101 through its Executive Director.

2.     ICICI Prudential Life Insurance Company Limited SCO No.9, 1^st Floor Brass Market, Rewari Tehsil and District Rewari through its Branch Head.  

                                      Appellants-Opposite Parties

Versus

 

Neha Gupta w/o Sh. Mukesh Gupta, 272/3, near Col. Maha Singh Chowk, Krishna Nagar, Garhi Bolni Road, Rewari at present Resident of House No.110, Sector-3, Part-II, HUDA, Rewari, Tehsil and District Rewari.

                                      Respondent-Complainant

 

CORAM:             Hon’ble Mr. Justice Nawab Singh, President.

                             Mr. Balbir Singh, Judicial Member.

                                                                                                         

Argued by:          Shri Hitender Kansal, Advocate for appellants.

                             Shri Shashikant Gupta, Advocate for respondent.

 

                                                   O R D E R

 

BALBIR SINGH, JUDICIAL MEMBER

 

        This appeal has been preferred against the order dated September 08^th, 2017 passed by District Consumer Disputes Redressal Forum, Rewari (for short ‘the District Forum’).

2.                Neha Gupta-complainant (respondent herein) was provided ICICI Pru Health Saver Insurance Policy bearing No.13957225 by ICICI Prudential Insurance Company (for short ‘the Insurance Company’) mentioning date of commencement as May 28^th, 2010 and annual limit as Rs.5,00,000/-. Sahil Gupta and Vinayak Gupta sons of the complainant were also covered under the above mentioned insurance policy. Sahil Gupta minor son of the complainant was suffering from Nasal obstruction and PND & sneezing for the last three months. Sahil Gupta was got admitted in Sir Ganga Ram Hospital, Delhi where operation of Sahil Gupta regarding the disease mentioned above was conducted by Dr.Devinder Rai on November 08^th, 2012. Sahil was discharged from the hospital on November 09^th, 2012. The complainant deposited all needed documents of the above mentioned insurance policy with Third Party Administrator (TPA) branch of the hospital on November 08^th, 2012 for reimbursement of the medical expenses. On November 09^th, 2012 the complainant was asked to deposit an amount of Rs.83,791/- as hospital treatment bill because by that time confirmation could not be possible from TPA department of the hospital. The complainant was assured to make refund of the amount as and when confirmation was to be received. The insurance claim submitted by the complainant amounting to Rs.83,791/- was repudiated by the opposite parties-Insurance Company vide letter dated November 30^th, 2012. It is the case of the complainant that he is entitled to receive an amount of Rs.1,00,000/- spent by the complainant for treatment of Sahil Gupta along with interest, compensation and litigation expenses.

3.                The complainant filed complaint under Section 12 of the Consumer Protection Act, 1986 with a prayer to direct the opposite parties to pay an amount of Rs.1,00,000/- as reimbursement of the medical bill and other medical expenses; to pay an amount of Rs.50,000/- on account of un-necessary harassment, mental agony and an amount of Rs.20,000/- as litigation expenses with interest at the rate of 18% per annum from the date of filing of the complaint.

4.                The opposite parties – ICICI Prudential Life Insurance Company Limited have taken plea in their written version that the complaint is not maintainable in the present form and that the complaint has been filed with malafide intension to cause un-necessary harassment to the opposite parties. It is pleaded that terms and conditions of the insurance policy are binding upon the complainant as the insured did not use her option for cancellation of the insurance policy within 15 days the Free Look Period after receiving insurance policy and other documents. The proposal form and other documents concerned with the insurance policy were sent to the complainant. As provided under Exclusion Clause 8 of the terms and conditions of the Insurance Policy, the Insurance Company shall not be liable to make any payment under this policy in respect of any expenses incurred by the insured in connection with or in respect of any expenses incurred during the first two years from the policy commencement date or revival date in case the revival of the policy was after 60 days from the date of first unpaid premium regarding future disease like  Functional Endoscopic Sinus Surgery/Septoplasty for deviated nasal Septum/Sinusitis.

5.                In this case first premium of the insurance policy was paid on the date of commencement May 28^th, 2011 and second installment of the premium of the sum insured was to be paid on or before May 28^th, 2011. The complainant deposited the second installment of the premium amount on July 30^th, 2011 instead of on or before May 28^th, 2011 after more than a period of 60 days from the due date. As per terms and conditions of the insurance policy, the insured was entitled to make payment of the premium amount within 30 days also from the due date being grace period. In this case the second installment of the premium was to be paid on or before May 28^th, 2011 or within 30 days grace period from May 28^th, 2011 we may say up to June 28^th, 2011 but the premium amount was deposited on July 30^th, 2011 and the policy was got revived on August 16^th, 2011. As per terms and conditions of the insurance policy and guidelines, the insured can request the insurance company for revival of the insurance policy within a period of two years. Anyhow legally and technically, the insurance policy stood lapsed when the complainant did not deposit the premium amount even within 30 days grace period also. As the insurnace policy was revived after more than a period of 60 days from the date of default in payment of premium amount, the case of the complainant is covered under clause 9 (e) of the terms and conditions of the insurance policy, which is reproduced below:-

“9(e) There shall be a waiting period of 30 days from the date of revival applicable for all insured person(s) where the policy was lapsed for a period of more than 60 days from the date of first unpaid premium. Also, all exclusions applicable at the policy commencement date shall once again become applicable.”

 

6.                Under Clause 9 (d) of the terms and conditions, it is mentioned that “No Waiting Period will be applicable for any revival within 60 days from the due date of the first unpaid premium.” In this case as the insurance policy was revived with a gap of more than 60 days of exclusions applicable shall once again become applicable at the policy commencement date. The case of the complainant falls under exclusions and the complainant is not entitled to receive any amount spent for his treatment. It is prayed that the complaint filed by the complainant be dismissed with costs.

7.                Parties led evidence in support of their respect claims before the District Forum.

8.                After hearing arguments, vide impugned order dated September 08^th, 2017 passed by the learned District Forum, the complaint filed by the complainant was allowed directing the opposite parties to pay the total bill amount of Rs.83,791/- as mentioned in Exhibit C-8 to the complainant with interest at the rate of 9% per annum and to pay an amount of Rs.20,000/- as litigation expenses.

9.                Aggrieved with the impugned order dated August 08^th, 2017 the opposite parties filed the present First Appeal No.1394 of 2017 with a prayer to set aside the impugned order passed by the learned District Forum and to dismiss the complaint filed by the complainant.

10.              We have heard learned counsel for the parties and perused the case file.

11.              During the course of arguments it was common case of both the parties that the complainant was provided Insurance Policy No.13957225 by the opposite parties mentioning the date of commencement as May 28^th, 2010 Cover Cessation Date as May 28^th, 2050 and annual limit up to Rs.5,00,000/-. The complainant herself and her children Sahil Gupta and Vinayak Gupta were covered under the above mentioned insurance policy. It is also admitted fact that Sahil Gupta minor son of the complainant who was suffering from Nasal obstruction and PND & sneezing got admitted in Sir Ganga Ram Hospital, New Delhi on November, 08^th, 2012. Operation was conducted on the same date by Dr. Devinder Rai and patient was discharged from the hospital on November 09^th, 2012. It is evident from the hospital bill Exhibit C-8 that an amount of Rs.83,791/- was deposited by the complainant in the hospital at the time of discharge. During the course of arguments, there was not much controversy regarding amount spent by the complainant at the time of treatment of Sahil Gupta. Findings are required to be given as to whether the complainant is entitled to reimbursement of the above mentioned amount from the insurance policy or not. After depositing the second installment of the premium on July 30^th, 2011, Personal Health declaration form Exhibit OP-4 was submitted on August 09^th, 2011. The Insurance Policy was revived on August 16^th, 2011. The insurance claim of the complainant was repudiated vide letter dated November 30^th, 2012 Exhibit OP-5 mentioning exclusion clause mentioning that the insurance policy remained lapsed for more than a period of 60 days from May 28^th, 2011 up to August 16^th, 2011 mentioning that the insured Sahil Gupta got admitted in hospital for his treatment on November 08^th, 2012 within two years from the date of revival of the insurance policy. The exclusion clause is applicable as the insurance policy remained lapsed for a period of more than 60 days and Sahil Gupta got treatment within two years from the date of revival of the insurance policy.

12.              Learned District Forum at the time of giving findings has shown suspicion regarding execution of the personal health declaration form Exhibit OP-4 dated August 9^th, 2011 mentioning that there are few cuttings in this document mentioning that on first page date is mentioned as August 09^th, 2011; on the last page date is shown as August 03^rd, 2011 and the place of declaration is mentioned as Hisar after cuttings. We find the place of preparation of declaration form is mentioned as Hisar on the last page at one place without cutting and at another place it is mentioned as Rewari after cutting. We feel due to these minor cuttings, version of the opposite parties cannot be disbelieved. Sometimes, documents are prepared with minor correction also to avoid preparation of that particular document again. We also feel that the validity of the declaration form Exhibit OP-4 is not so much important for decision of this case. It stands proved that the complainant did not take any step regarding revival of the insurance policy within 60 days from the due date. It is the version of the complainant herself that first step regarding revival of the insurance policy was taken on July 30^th, 2011 when the premium amount was deposited. When the premium amount was deposited after more than a period of 60 days, certainly findings can be given that the insurance policy remained lapsed for more than a period of 60 days and ultimately the insurance policy was revived vide letter dated August 16^th, 2011.

13.              It is admitted fact that Sahil Gupta got treatment from Sir Ganga Ram Hospital, New Delhi from November 08^th, 2012 up to November 09^th, 2012 as he was suffering from Nasal obstruction and PND & sneezing. Operation was conducted. The case is covered under Clause 8 (8)(1) exclusion for Hospitalization Insurance Benefits, which is reproduced below:-

                   “8.     Exclusions for Hospitalization Insurance Benefit.

The Company shall not be liable to make any payments under this Policy in respect of any expenses whatsoever incurred by any Insured Person(s) in connection with or in respect of any of the following.

8.      Any Expense incurred during the first 2 years from Risk Commencement Date or revival date in case the revival is after 60 days from the date of first unpaid premium shall not be payable for the following Diseases/surgeries & any complications arising out of them.

(1)     Functional endoscopic sinus surgery / septoplasty for deviated nasal septum / sinusitis…”

 

14.              After close perusal of exclusion clause 8 (8) (1) of Hospitalization Insurance Benefit, there remains no doubt of any type that the complainant is not entitled for refund of the total amount paid to the hospital as disease under the treatment of Sahil Gupta is covered under exclusion clause and the patient was admitted for treatment within two years from the date of revival of the insurance policy which was revived after 60 days from the date of first unpaid premium.

15.              As a result as per discussions above in details, findings can be safely given that the total amount spent by the complainant for treatment of Sahil Gupta Rs.83,791/- or any other amount can not be reimbursed and paid to the complainant. Learned District Forum has committed an error while passing the impugned order and by allowing the complaint. Hence, the impugned order passed by the learned District Forum is held illegal. Accordingly, the appeal filed by the appellant is allowed, the impugned order passed by the learned District Forum is set aside and the complaint filed by the complainant is dismissed.

16.              The statutory amount of Rs.25,000/- deposited at the time of filing the appeal be refunded to the appellants against proper receipt and identification in accordance with rules, after expiry of period of appeal/revision, if any.

 

Announced: 09.08.2018

(Balbir Singh) Judicial Member

(Nawab Singh) President

 

CL