Punjab

Rupnagar

RBT/CC/18/20

Seema - Complainant(s)

Versus

PNB Metlife Ins.Co.ltd - Opp.Party(s)

Mashkoor Alam Adv.

02 Jan 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION CAMP COURT AT LUDHIANA

Received by way of transfer Consumer Complaint No.20 of 2018

                                               Date of institution:09.01.2018

                                               Date of Decision:02.01.2023

 

Seema wife of Late Shareef Mohammad, Matania General Store, Bus Stand Ward No.1, Payal, Tehsil Payal, District Ludhiana, Punjab

…….Complainant

Versus

1. PNB  Metlife India Insurance Company, Kunal Tower, 4^th Floor, Mall Road, Ludhiana through its Branch Manager
2. PNB Metlife India Insurance Company, registered office Unit No.701-702-703, 7^th Floor, West Wing, Raheja Tower, 26/27-M, GT Road, Bangalore-56001, Karnatka
2.  

                                                             ……..Opposite Parties

 QUORUM:   

   HON’BLE MR. RANJIT SINGH, PRESIDENT.

                   HON’BLE MRS. RANVIR KAUR, MEMBER

 

PRESENT:

      

Sh.Mashkoor Alam, Adv. for complainant

Sh. Ritesh Mohindra, Adv. for OPs  

              
 

ORDER

RANVIR KAUR, MEMBER

 

1. The present order of ours will dispose of the above complaint filed under Consumer Protection Act, by the complainant against the Opposite Parties on the ground that the OP entered into a contract under a policy Medlife Major illness premium back cover vide policy No.22008638 with the Late Mr. Shareef Mohammad who was husband of the complainant Seema in the month of September, 2016. The policy holder duly nominated his wife i.e. the complainant Seema as his nominee to with money secured by the policy shall be paid in the event of his death. The policy holder Shareef Mohammad son of Ali Mohammad died in the Hazrat Haleema, Maternity and General Hospital, Malerkotla, in ward No.1, on Bed No.3, at 8.25 PM dated 20.2.2017 by heart attack. PNB Metlife claim decision letter dated 19.6.2017 about the said policy forwarded to the complainant who is wife and nominee of late Shareef Mohammad regarding the critical illness claim intimation under the said policy on the life of Shareef Mohammad. The complainant is not agree with your decision that this heart attack case does not satisfy the definition of heart and wants to reconsider the claimant definition of heart attack and your  impugned decision. The impugned judgment passed by the opposite party is against the law and facts on record nad against the policy. Terms and conditions and in your impugned decision the OP wrongly defined the definition of heart attack and the same is not sustainable in the eyes of law. The clam of the widow, nominee of policy holder, which was her husband on the basis of medical reports and human grounds. The complainant was also told the agent Pardeep Singh that this policy also covers life and health of the policy holder. The nominee of the policy holder has no source of income rather has facing responsibility of mother in law, two daughters one aged about 21 years and other aged 15 years and one son aged 9 months only for their maintenance and education in these days of inflation. After repeated requests of the complainant, the OPs has failed to settle the claim of the complainant. Hence, this complaint.      Thus, alleging deficiency in service on the part of the OPs. Therefore, the complainant prayed for the following reliefs against the OP:- 

1. To pay the amount of Rs.10,00,000/- as policy amount and Rs.2,00,000/- spent on the treatment of the husband of the complainant.

2. To pay Rs.2,00,000/- as compensation on account of mental tension, harassment, pain.

3. To pay Rs.25,000/- as litigation expenses.

2.  Upon notice, the OPs has filed written reply taking preliminary objections; that the present complaint is not maintainable; that the complicated facts and question are involved in this present complaint; that the present complaint is frivolous, false and vexatious; that the present complaint is liable to be dismissed on non joinder of necessary party; that there is no deficiency in service on the part of the answering OPs; that the complaint is devoid of any material particular and has been filed merely to harass and gain undue advantage and unjustified monies from the OPs; that the complainant has failed to set up a nexus between the damages claimed in the present complaint and the damage suffered by him. On merits, it is stated that insurance policy is to be construed strictly as per terms and conditions since the insurance contract between the insurer and the insured is a contract between the parties, hence, the terms of the agreement including applicability of the provisions and also its exclusion had to be strictly construed to determine the extent of the liability of the insurance company. As in present case manifestly, the treatment/procedure taken by the complainant from the hospital did not all within the ambit of critical illness and instead it is specifically excluded in the clause as specified in the policy and as such no liability could be fastened against the insurance company to reimburse expenses incurred over the procedure taken by the complainant. Thus, alleging no deficiency in service on the part of the answering OPs and prayed for dismissal the present complaint.    
3.  In support of the complaint, the complainant has tendered various documents. On the other hand, the OPs has also tendered documents in support of their evidence.
4. We have heard the learned counsel for the parties and have gone through the record of the file, carefully.
5. From the pleading of the parties and evidence lead by the them, the issue which comes out is that the contract of insurance is not denied and the occurrence during the subsistence of insurance is also not denied. Briefly, the assertions of the complainant are that  she is the wife and nominee of late Shareef Mohammad (policy holder) who died due to heart attack. Nominee of policy holder claimed the insurance amount and medical expenses which were covered under the policy on health and medical ground and the same was repudiated on technical and flimsy grounds by the OPs (Insurance Company) which is totally unjustify. However, the OP has admitted the factum of the policy claimed by the complainant but he has vaguely tried to justify the same without any corroborative evidence.
6. In the circumstances of the case and in the interest of justice of social equity and justice the case of the complainant succeeds and the OP is directed to pay the sum insured amount of Rs.10,00,000/- along with interest @ 7% per annum to the complainant payable from the date of filing the present complaint. Further, the complainant has demanded medical expenses to the tune of Rs.2,00,000/-, the bench has gone through the complaint of the complainant para No.____ but did not attach the bills, however, proved admission and disease of the deceased. Keeping in view of the nature of disease the OP is further directed to pay the medical expenses Rs.1,00,000/- to the complainant along with Rs.20,000/- as mental agony and Rs.11,000/- as litigation expenses. The OPs are directed to comply with the said order within 30 days from the date of receipt of certified copy of this order. Free certified copies of this order be sent to the parties, as per rules. The file be sent back to the District Consumer Commission, Ludhiana, for consigning the same to the Record Room.
7.  

January 02, 2023

(Ranjit Singh)

PRESIDENT

•  

                                   

 

(Ranvir Kaur)

MEMBER

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