PER DR. S.M. KANTIKAR, MEMBER 1. The relevant facts in this revision are ; Mr. Simant Dattatraya Sukale, (since deceased), the husband of Smt Rajashree, the Complainant No. 1, availed loan from ICICI Home Finance Company Ltd., He obtained two insurance policies from the OP/Petitioner herein, i.e., the ICICI Prudential Life Insurance Co. Ltd., for a loan amount as well as for securing his own life. Unfortunately, on 23.05.2009 i.e. during currency of policies, Mr. Simant expired. The OP honored the claim under the policy for securing home loan, but after considerable delay and paid a sum of Rs.4,57,888/- only to the Finance Company, but not paid the interest for delayed payment. With regard to another Life policy, for a sum assured of Rs.5,00,000/-, the OP refused to pay. Hence, aggrieved thereby the Complainants approached the District Forum, Pune through Consumer Complaint No 188/2010. 2. The District Forum partly allowed the complaint and held the OP liable for unfair trade practice and ordered to pay Rs.25,000/- as compensation, and to refund the premium amount of Rs.4,121/-, with interest @ 15% per annum, from 17.12.2009 and Rs.10,000/- as litigation expenses, to the complainants. 3. Aggrieved by the order of District Forum, the Complainants preferred First Appeal No. A/11/973 and the OP preferred A/12/282 before the State Consumer Disputes Redressal Commission, (State Commission) Maharashtra, Mumbai. The State Commission partly allowed the Appeal No. A/11/973 and dismissed the Appeal A/12/282. The State commission in its order, directed the OP to pay the Complainant a sum of Rs.5,00,000/- @ 9% pa from 17.12.2009, along with Rs.25,000/- for mental agony and Rs.10000/- towards costs. 4. Against the order of State Commission, the OP/Petitioner filed this revision. 5. We have heard the arguments of counsel for the petitioner at admission stage. He has submitted that the rejection of claim was proper, as the deceased Life Assured, was diagnosed of critical illness during the waiting period. Therefore, only the amount of premium was required to be refunded to the Complainants. 6. The Counsel for the OP vehemently argued that, the Crisis Cover policy was issued on 29.08.2008 and the waiting period ends on February 28, 2009. He also brought to our attention, the discharge summary of Aditya Birla Memorial Hospital dated 24.01.2009 that the deceased life assured was hospitalized and diagnosed with epato Cellular Carcinoma He further submitted that it was first time diagnosed with the said illness, during/within waiting period, hence the claim was denied. We have perused the details of waiting period from Clause (5) of Crisis Policy, the relevant para is reproduced as: Death Benefit: 1. In the event of death of the Life Assured while the Policy is in force on the date of death, the Company shall pay the Sum Assured mentioned in the Policy Certificate less the amount earlier claim paid, if any, towards the Critical Illness Benefit. On the admission of a claim for this benefit, Policy shall stand terminated forthwith. 2. Where within the waiting period, the Life Assured had been diagnosed of any one of the stated Critical Illness or the Life Assured had suffered from sickness resulting in total & permanent disability for which a claim could have been made and then death of the Life Assured occurs any time during the Policy term, the Company shall refund the premium paid (without interest and excluding any extra premiums paid, if any). No other benefit shall be payable and the Policy shall stand terminated thereafter. 3. Subject to the Policy being in force on date of death and subject to what is stated in the above Clause, in case of death of the Life Assured while the Claim for Critical Illness or Total and Permanent Disability is under consideration, the Company shall pay only the Sum Assured less the amount of earlier claim paid, if any, towards the Critical Illness Benefit. 7. We need to analyze very carefully, Clause 2 of the said policy which is as follows: 2. Waiting Period for the purpose of receiving Claim benefit under the Policy: The benefit towards Critical illness or towards Total and Permanent Disability due to sickness shall be payable after a period of six months from the Policy Issue Date or after a period of three months from the Policy reimbursement where the Policy had been lapsed for more than three months. Where the Policy is reinstated within six months from the Policy Issue Date the waiting period shall continue till the date on which a period of six months from the policy issue date ends or till the date on which a period of three months from the policy reinstated date ends, whichever is later. The waiting period shall not be applicable where the Claim has occurred as a result of , i) Critical illness or Total and Permanent Disability of the Life Assured due to an accident. ii) Death of the Life Assured. 8. If we read and analyze Clause 5 (2), along with Clause 2, it is quite clear that the deceased suffered from critical illness, as ancerand died. The complainant did not ask benefit under Critical illness Total and Permanent Disability due to sickness; but she asked benefit towards Death Claim. Hence, the OP could not take benefit of Clause 5 (2) to refund the premium only. 9. Therefore, we are of considered view that, the repudiation of death claim by OP was a wrong decision. The OP is liable for such deficiency in service. We agree with the considered order rendered by the State Commission passed in FA-A/11/973, filed by the Complainant. Accordingly, the present revision petition is dismissed. Parties are directed to bear their own cost. |