DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,  JALANDHAR

 

  Complaint No.20 of 2017     Date of Instt.11.01.2017         Date of Decision: 20.04.2021

Neeru Luther w/o late Mr. Ravinder Luther, r/o H.No. 412, New Jawahar Nagar, Jalandhar.

….. Complainant

Versus

 

1. PNB Metlife India Insurance Co. Ltd., registered office Unit No.701, 702 and 703, 7th Floor, West Wing, Raheja Towers, 26/27, MG Road, Banlgore 560001 (Karnataka) through its Chairman/Managing Director/Director.

2. The Chairman, Claims Committee PNB Metlife, First Floor, Techniplex-1 Techniplex Complex, Off Veer Sawarkar Flyover, Goregaon West, Mumbai.

3. PNB Metlife India Insurance Co. Ltd, Unit No.TF3, 3rd Floor, Eminent Mall, 261, Mahavir Marg, Near Guru Nanak Mission Chowk, Lajpat Nagar, Jalandhar (Punjab) 144006.

          …Opposite Parties

 

Complaint under the Provisions of Consumer Protection Act

 

QUORUM:

 

SH. KULJIT SINGH, PRESIDENT

SMT. JYOTSNA, MEMBER

ARGUED BY:

 

For complainant               : Sh.Umesh Dhingra, Advocate 

For OPs                            : Sh.Nitish Arora, Advocate

 

ORDER:-

 

KULJIT SINGH, PRESIDENT 

 

 The present complaint has been filed by complainant against the OPs on the averments that her husband approached OPs through their representative at the office of OP no.3 with an offer for giving the cover of Health Insurance. The husband of the complainant accepted the proposal of OPs and provided all the details about himself.  The husband of the complainant purchased the above said insurance policy for sum assured of Rs.5,00,000/- with premium of Rs.19,374/-. The said policy commenced from 15.04.2015 with maturity date fixed as 15.04.2025. OPs after acceptance of the insurance premium of the details issued policy dated 18.06.2015 vide policy no. 21569328 vide application no. 192674250 having date of commencement 15.04.2015  and maturity date 15.04.2025.  The name of the policy “metlife major illness premium back cover policy” and as per policy, Ops agreed to cover a life insurance contract and to pay benefits under this policy. Unfortunately, husband of the complainant met with accident on 25.06.2015 at about 10.00 am near area known as Cha-choki Teshil Phagwara District Kapurthala whereby the insured sustained multiple injuries on his head and on the other part of the body and gone under Coma. The insured taken to DMC Ludhiana where he was admitted for treatment from 25.06.2015 and remained there till 22.09.2015 under the treatment of Dr. R.K. Kaushal thereafter he shifted to Nasa Brain and Spine Centre at Jalandhar and remained there from 22.09.2015 to 22.10.2015. Due to said fatal accident, the insured had gone into Coma for which he was given the treatment of the critical illness of head injury. Unfortunately, insured could not survive and died on 26.11.2015.  The complainant had spent a total sum of Rs.12,66,334/- to the DMC & Hospital Ludhiana for the treatment and also Rs.6,79,000/- to Nasa Brain and Spine Centre Jalandhar for the said critical illness treatment.  Therefore, total sum of Rs.19,45,334/- had been spent by the complainant on the treatment of Ravinder Luther to save his life. The complainant submitted the claim form and supplied all the necessary medical treatment documents, history, bills and payment record for the settlement and payment of bills of medical treatment for insurance claim, which had been scrutinized by OPs. However, vide letter dated 26.05.2016 under clause 2.6 of the terms and conditions of the policy, no benefits  will be payable  if any critical illness or its signs or symptoms having occurred within the ‘waiting period’ of 90 days of the policy issue date or reinstatement date, whichever is later and had conveyed that they had no liability to accept the present claim. The said clause 2.6 shall not be operative for repudiation of the claim on the ground that the claim has occurred within 90 days or that there was no critical illness.  The complainant had no other option except to pay the entire hospital bill from her own source for the treatment taken from the hospital as such complainant is entitled to receive the reimbursement of the medical treatment expenses from the OPs along with future medical expense incurred by her directly from OPs. Due to above said act and conduct of OPs, the complainant has filed the present complaint and prayed that OPs be directed to pay sum of Rs.19,45,334/- along with interest @ 18% p.a and also directed to pay Rs.50,000/- as cost of litigation. 

Upon notice, OPs appeared and filed written reply and contested the complaint of the complainant by raising preliminary objections that the complainant has not come to the court with clean hands and as such the complainant is not entitled for any reliefs. The complainant has no locus standi and cause of action to file the complaint. The complaint is misuse of the legal process. On merits, it was averred that as per Clause 2.6 of the terms and conditions of the policy, no benefits will be payable if any critical illness or its signs or symptoms having occurred within the waiting period of 90 days of the policy issue date or reimbursement date, whichever is later.  The same was conveyed to the complainant vide letter dated 26.05.2016.  The OPs have strictly acted as per terms and conditions of the policy. OPs have rightly repudiated the claim of the complainant.  The life assured had himself signed the proposal form without any pressure. Rest of the averments made by the complainant were denied by OPs and they prayed for dismissal of the complaint.

The complainant has tendered in evidence her affidavit Ex.CW-1/A along with copies of the documents Ex.C-1 to Ex.C-7. On the other hand, OPs tendered in evidence  affidavit of Rajeev Sharma working as Senior Manager Legal as Ex.OP-A along with copies of the documents Ex.OP-1 and Ex.OP-2.

We have heard learned counsel for the parties and have also gone through the record very carefully.

The glance of evidence is required for settlement of the case. The complainant has tendered in evidence her affidavit Ex.CW-1/A in support of her case. She alleged deficiency in service and unfair trade practice on the part of OPs. Ex.C-1 is letter dated 11.06.2015 addressed to complainant by OPs in which the policy number, premium, name of nominee has been mentioned.  Ex.C-2 is copy of Metlife Major Illness Premium Back cover with detailed terms and conditions. Ex.C-5 is copy of letter dated 23.06.2016 addressed to the complainant by OPs.  Ex.C-6 is repudiation letter dated 26.05.2016 written to the complainant and informed that as per clause 2.6 of the terms and conditions of the policy, no benefits will be payable if any critical illness or its sign or symptom having occurred within the waiting period of 90 days  of the policy issue date or reinstatement date, whichever is later. 

To refute this evidence of the complainant, the OPs tendered in evidence affidavit of Rajeev Sharma Senior Manager Legal of PNB Metlife Indian Insurance as Ex.OP-A on the record. This witness stated that complainant had duly signed the proposal form after fully understanding and deliberating upon terms and conditions of the policy concerned. The terms and conditions set by IRDA and duly communicated to the complainant. This witness denied any deficiency on the part of OPs.  Ex.OP-1 is copy of policy on the record. 

7. It is an established fact that the complainant consumer of OPs, because he availed the services of the OPs. On the assurances given by OPs, he purchased Metlife Major Illness Premium Back Cover Policy from OPs bearing policy no.21569328. The date of commencement is 15.04.2015 and maturity date is 15.04.2025. The premium amount is fixed as Rs.19,374/- The insured paid the premium amount from time to time. Premium amount also received from the complainant by OPs, this fact is not disputed in this case.  Unfortunately, the husband of the complainant (since deceased) met with an accident on 26.11.2015 and the complainant spent total amount of Rs.19,45,334/- on  the treatment of her husband. The complainant submitted claim with OPs but OPs rejected the claim of the complainant vide its repudiation letter dated 26.05.2016, this letter was conveyed to the complainant. OPs repudiated the claim of the complainant on the ground that “as per clause 2.6 of the terms and conditions of the policy, “no benefit will be payable if any critical illness or its signs or symptoms having occurred within the ‘waiting period of 90 days’ of the policy issue date or reimbursement date, whichever is later.” But it is general principle of law, that if insured paid the premium amount then insurance company is liable to pay the claim. The insurance companies collect the premiums from the insured and find ways to decline the claims without any valid reasons. This fact is settled by Hon’ble Punjab and Haryana High Court at Chandigarh in case titled as New India Assurance Company Limited versus Smt. Usha Yadav and others reported in 2008(3) RCR (Civil) Page 111 held as under:-

“It seems that the insurance companies are only interested in earning the premiums and find ways and means to decline the claims. All conditions which generally are easily understood by a person at the time of buying any policy. The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay cost of Rs.5000/- for luxury litigation being rich.”

8. From considering the facts and circumstances of the case, we are of the considered opinion that the insurance companies find ways to decline the claim of the complainant without any valid reason. In the present case, there is clear cut deficiency in service or unfair trade practice on the part of OPs. At the time of insurance, the insurance companies gave many assurances to the insured persons but at the time of release the insured amount, they find different ways to decline the claim of the insured. If insurer paid the premium then insurance company liable to pay the insurance claim. Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. The complainant alleged in his complaint that due to accident, the insured remained admitted in DMC from 25.06.2015 till 22.09.2015  in Coma under treatment of Dr. R.K. Kaushal and further he was shifted to Nasa Brain and Spine Centre at Jalandhar and remained there from 22.09.2015 to 22.10.2015 but the complainant has not placed on record any bill for payment, which he has spent for the treatment or discharge summary from any of the hospital placed on record. The complainant failed to produce any record regarding treatment of the life assured and receipt of bills for payment which has spent by her in the treatment of life assured during the accident. So, the complainant is only entitled for sum assured amount of Rs.5,00,000/- .

9. In the light of our above discussion, we allow the complaint of the complainant and OPs jointly and severally directed to pay sum assured of Rs.5,00,000/- to complainant. The complainant is also entitled Rs.7000/- as compensation for mental harassment including costs of litigation. The opposite parties are also directed to deposit Rs.3000/- as costs in the Consumer Legal Aid Account maintained by this Commission.

10. The compliance of the order be made within 45 Days from receipt of copy of this order. The complaint could not be decided within stipulated period due to rush of work and spread of Covid-19.

11. Let copies of the order be sent to the parties, as permissible, under the rules. File be indexed and consigned to the record room after due compliance. 

Announced in open Commission

 

20th of April 2021

 

 

 

Kuljit Singh

(President)

 

 

 

Jyotsna

(Member)