Haryana

Ambala

CC/109/2018

Monika - Complainant(s)

Versus

PNB Metlife India Inss - Opp.Party(s)

Naresh Kumar

02 May 2019

ORDER

 

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMBALA

 

 

                                                                        Complaint case no.        : 109 of 2018

                                                                       Date of Institution         :  26.03.2018

                                                                       Date of decision    : 02.05.2019

Monika wife of Shri Sushil Kumar resident of 952, Gangowala Peer, P.O.Mullana, Tehsil Barara, District Ambala.

……. Complainant.

1.       PNB Metlife India Insurance Co. Ltd. 2^nd & 3^rd  Floor, SCO No. 68-69, Sector-17-B, Chandigarh. 

2.       The Chairman, Claim Committee, PNB Metlife India Insurance Co. Ltd. Ist Floor, Techniplex-I, Techniplex Complex, Office Veer Sawarkar, FFly over, Gore Gaun(West) Mumbai- 400062 (Maharashtra)                     

 

     ….…. Opposite Parties.

3.       Punjab National Bank, Barara, Ambala.

                                                                   ......Performa respondent/OP.

Before:        Ms. Neena Sandhu,  President.

                   Ms. Ruby Sharma, Member,

Sh. Vinod Kumar Sharma, Member.                 

                            

Present:       Sh. Ravinder Pal Singh, Advocate, counsel for complainant.

Sh. Nikhil Handa, counsel for OPs No.1 & 2.

Sh. Munish Sharma, Advocate, counsel for OP No.3.

Order:         Smt, Neena Sandhu, President

Complainants have filed this complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as ‘the Act’) against the Opposite Parties(hereinafter referred to as ‘Ops’) praying for issuance of  following directions to them:-

1. To pay sum assured of Rs. 11,00,000,/- .  
2. To pay Rs.18,249.73 on account of Metlife Major illness Premium back cover.
3. To pay interest @18% per annum from the date of accrual of the above said benefits till the actual realization.
4. To pay other benefits accrued under the policy.
5. To pay Rs. 11,000/- as litigation charges.

or

Any other relief which the Hon’ble Forum may deem fit.

Brief facts of the case are that the OPs issued Metlife Major Illness Premium Policy bearing no.21989265 to the complainant for the period of 10 years, for sum assured of Rs.11 Lacs having, annual premium of Rs.17,590.10. On 14.09.2016, Complainant deposited Rs.18,249.73 alongwith premium and other taxes. The Ops issued the policy on 26.10.2016 with Metlife Major Illness Premium back cover, covering 35 diseases and supplied the list of 35 diseases covered under the policy to the complainant. Complainant suffered from heart problem and Dr. Sameer Bhate, Consultant Department of Cardio Vascular Surgeon of Institute of Medical Science & Research, Mullana, Ambala vide letter dated 15.07.2017 advised that the complainant requires heart surgery for repair of one valve (MITRAL) and for replacement of other valve (AORTIC) and the said Doctor told her that the total expenses for the said surgery would be Rs.11 lacs. Complainant requested the OPs No.1 & 2, by way of e-mail to pay the above said amount of Rs.11 lacs but they did not pay the said amount to her on one pretext or the other. Thereafter, the complainant served a legal notice upon the Ops through registered AD on 15.12.2017 but no reply was given by the Ops. Earlier the complainant had filed a complaint before this Forum but withdrew the said complaint due to technical defects and this Hon’ble Forum dismissed the same as withdrawn vide its order dated 15.02.2018. By not paying the amount of Rs.11 lacs/- the OPs No.1 & 2 have committed deficiency in service. Hence, the present complaint.

2.                 Upon notice, OPs No.1 & 2 appeared through counsel and filed written version, raising preliminary objections qua complaint is not maintainable; no jurisdiction; no cause of action; concealed and suppressed the material facts; and the complaint is frivolous and  vexations. On merits, it is stated that claim was filed by the complainant for Heart Valve Surgery. As per Clause 11 of the terms and conditions of the policy, the amount is payable only on actual undergoing of open-heart valve surgery. From the medical documents submitted by the complainant it is clear that the complainant was merely suggested to undergo Heart Valve Surgery but she has not under gone the said surgery.  Thus no claim was payable under Heart Valve Surgery. However, as a goodwill gesture claim of complainant was considered under Clause 10, ‘Heart Attack’ of the terms and conditions of the policy. On evaluation of medical documents, it was found that ECG was “within normal limit(WNL)” thus no claim was payable even under the said clause. Hence, the OPs No.1 & 2 have rightly repudiated the claim of the complainant in light of the terms of subject policy. It is also stated that it was duly informed to the complainant that in case she is not satisfied with the features or the terms and conditions of the policy she can withdraw/cancel the policy under the “Free Look Period” of 15 days from the date of receipt of policy documents. However, complainant retained the policy document and did not raise any objection.  Meaning thereby the complainant agreed with the terms and conditions of the policy. There is no deficiency in service on the part of Ops No.1 & 2 and prayed that the complaint filed by the complainant against the Ops No. 1 & 2 may be dismissed with heavy cost.

Upon notice, OP No.3 appeared through counsel and filed written version, raising preliminary objections qua complaint is not maintainable; no cause of action and no locus standi. On merits, it is stated that OP No.3, has no concern with the policy of the complainant. All other averments made in the complaint were denied and prayer has been made for dismissal of the complaint against it with special cost.

3.                 To prove her version complainant tendered affidavit as Annexure CW-1/A along with documents as Annexure C-1 to C-10 and closed the evidence. On the other hand, learned counsel for OP Nos.1 & 2 tendered affidavit as Annexure R-A alongwith documents as Annexure R-1 to R-6 and closed the evidence. Learned counsel for OP No.3 tendered document as Annexure R-3/1 and closed the evidence.

4.                 We have heard the learned counsel for parties and carefully gone through the case file. Written arguments filed by OPs No.1 & 2.

5.                 At the outset, the learned counsel for the OPs No.1 & 2 has raised the objection that the present complaint is liable to be dismissed on the ground of territorial jurisdiction because the policy in question was issued from the Chandigarh branch of the Ops. The complainant has impleaded  the PNBMET Life India Insurance Co. Ltd. Chandigarh, as OP No.1 and its office situated at Mumbai as OP No.2 in the arrays of OPs. No cause of action has arisen at Ambala, therefore, as per Section 11 of CP Act, 1986. The complainant has thus no locus standi to file the present complaint before this Forum and same may be dismissed for want of territorial jurisdiction.

The learned counsel for the complainant has argued that the premium for the policy in question was paid online through bank situated at Ambala, as such cause of action has arisen within the jurisdiction of Ambala District, thus this Hon’ble Forum has territorial jurisdiction to adjudicate upon the matter.

In the case of Melanie Dass Vs. Royal Sundram Alliance Insurance Co. Ltd. & Anr. 1 2014 CPJ 302 (NC), the Hon’ble National Commission has held that the amount of premium was paid through Punjab National Bank, Kapurthala as per the certificate given by the Senior Manager, Punjab National Bank, Kapurthala. Therefore, a part of cause of action has arisen in Kapurthala. The above judgment fortified the case of the complainant because from the statement of account, Annexure C-1, it is evident that complainant had paid the premium amount through ATM located at Baarara, District Ambala. As such part of cause of action has arisen at Ambala, thus as per Section 11 of the Act, this Forum has territorial jurisdiction to adjudicate the matter involved in this case. Thus this objection raised by the learned counsel for the OPs No. 1 & 2 is not tenable, hence rejected.

On merits, the learned counsel for complainant has argued that during the subsistence of policy in question, the complainant had suffered from heart problem and was advised for heart surgery for repair of valve for which she was to incur total expenses of Rs.11 lacs/-. Since, she was duly insured with the OPs No.1 & 2, therefore, she requested them to pay the said amount of Rs.11 lacs/-but they did not pay the said amount. By not paying the amount of Rs. 11 lacs/- the Ops No. 1 & 2 have committed  deficiency in service.

The learned counsel for the OPs No. 1 & 2 has argued that as per terms and conditions of the policy, the amount is payable only on actually undergoing open heart valve surgery. From the contents of the complaint and medical record it is evident that the complainant was suggested to undergo heart valve surgery but no such surgery was conducted. Thus, as per the terms and conditions of the policy, no amount is payable under clause 11, ‘Heart Valve Surgery’. As a goodwill gesture the claim of the complainant was considered for ‘heart attack’ under clause 10 of the terms and conditions of the policy. On evaluation of medical documents, it was found that ECG of the complainant was normal. Thus no claim was payable under the said clause also. 

Admittedly, complainant was duly assured with the Ops No.1 & 2 under the subject policy, when she had suffered from heart problem. From the perusal of clause no.11, ‘Heart Valve Surgery’ of the terms and conditions of the policy, Annexure C-10, which reads as under:

“The actual undergoing of open-heart valve surgery is to replace or repair one or more heart valves, as a consequence of defects in, abnormalities of, or disease-affected cardiac valve(s). The diagnosis of the valve abnormality must be supported by an echocardiography and the realization of surgery has to be confirmed by a specialist medical practitioner. Catheter bases techniques including but not limited to, balloon valvotomy/valvuoplasty are excluded”.

It is crystal clear that the insurance company is liable to indemnify the insured provided he or she undergoes open heart valve surgery but in the present case the complainant has not undergone the said surgery, therefore, the complainant is not entitled to get any benefits under the said Clause. From the ECG report (Echocardiogram Report) annexed with Annexure R-3, it is evident that the ECG of the complainant was normal. Therefore, no claim is payable under clause no.10 of the said policy also. Facing with this situation, we are of the view that Ops No.1 & 2 are not liable to pay any amount under the policy in question. Thus no deficiency in service is attributable against the Ops No.1 & 2 and the complaint filed against them is liable to be dismissed. Since, the OP No. 3 is just a performa party and neither any specific allegation has been levelled by the complainant against it nor proved, therefore, the complaint filed against it is also liable to be dismissed.  

6.                In view of the aforesaid discussion, we hereby dismiss the present complaint being devoid of merits. The parties are left to bear their own costs. Certified copies of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.

Announced on :02.05.2019

 

 

 

 

          (Vinod Kumar Sharma) (Ruby Sharma)     (Neena Sandhu)

              Member                        Member             President