Chandigarh

StateCommission

A/206/2016

Edelweiss Tokio Life Insurance Company Ltd. - Complainant(s)

Versus

Sunita Rani - Opp.Party(s)

Nitin Thatai, Adv.

26 Jul 2016

ORDER

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

U.T., CHANDIGARH

Appeal No.	:	206 of 2016
Date of Institution	:	19.07.2016
Date of Decision	:	26.07.2016

 

Edelweiss Tokio Life Insurance Company Ltd. office at SCO 2447-48, 2nd floor, Sector 22-C, Chandigarh through Ms.Shirin Patel, Head- Legal & Compliance

 

……Appellant

V e r s u s

Sunita Rani wife of Shri Madan Lal, resident of House No.1049/4, Gurunanak Colony, Ismailabad, Kurukshetra 136129, Haryana.

 

           ....Respondent

 

         Appeal under Section 15 of the Consumer Protection

               Act, 1986.

 

BEFORE:      JUSTICE JASBIR SINGH (RETD.), PRESIDENT.

                        MR. DEV RAJ, MEMBER.

                        MRS. PADMA PANDEY, MEMBER

 

Argued by:      Mr.Nitin Thatai, Advocate for the appellant.

                               

 

PER JUSTICE JASBIR SINGH (RETD.), PRESIDENT

              This appeal has been filed by the Opposite Party against an  order dated 29.4.2016, rendered by the District Consumer Disputes Redressal Forum-II, U.T., Chandigarh (in short the Forum only), allowing a     complaint, filed by the respondent/complainant.

2.        The respondent purchased one health insurance Policy from the appellant, valid for a period of 10 years i.e. from 30.5.2014 to 30.5.2024 against yearly payment of premium. As per terms and conditions of the Policy, it covered medical health insurance and critical illness. The respondent fell ill and she was taken to Alchemist Hospital on 14.7.2014. Thereafter, she was shifted to Shivalik Hospital. She underwent coronary angiography as well as coronary angioplasty. In the entire process of her treatment, she spent an amount of Rs.2,58,800/-. She raised a claim/bill for reimbursement of the above amount. When she failed to get any positive response, a consumer complaint was filed on 29.7.2015 claiming reimbursement of the amount paid with interest. Compensation for mental tension and agony was also pressed.  
3.        Upon notice, reply was filed. It was specifically stated that the respondent was not covered for medical expenses under the head ‘critical illness rider’.  It was further stated that no claim was submitted for reimbursement, as alleged in the complaint. Purchase of insurance Policy was admitted. However, it was stated that the proposal to cover  medical expenses on critical illness was not accepted. A counter offer was made which was accepted. It was further stated that terms and conditions of the Policy constitutes a contract binding upon the parties. It was further stated that the premium was not paid after one  year, on account of which, the Policy has lapsed and  as such the respondent will not fall under the definition of a ‘consumer’.
4.      Both  the parties led their respective evidence. Written arguments were also submitted. The Forum, on analyzing of  the pleadings, evidence and arguments of the parties, partly allowed the complaint, granting  following relief to the respondent/complainant ;

            a]    To reimburse bill amount of
Rs. 2,58,800/- raised by the hospital, to the complainant towards her claim.

b]    To pay Rs.20,000/- as compensation for causing mental agony and physical harassment to the complainant.

C]    To pay Rs.10,000/- towards litigation expenses.

5.        When granting above relief, the Forum observed as under ;

“After considering the submissions of both the parties and after thorough perusal of the record it is noticed that the complainant vide its proposal form (at page 22 of paper book of the complaint) applied for the policy having product name ‘wealth builder’ where the sum assured was Rs.3.00 lacs and the basic premium was Rs.30,000/- for five years to be paid annually. The complainant in order to avail the policy  paid a total amount of Rs.35,945/- vide cheque No.933897 to the complainant which included Rs.5018/- for the rider attached with the policy as mentioned in column 4 where product details are to be filled Riders mentioned in colum 4 of the proposal form, reads as under:-

Rider: CI- critical illness, ADB Accidental Death Benefit. ATPD Accidental Total and Permanent disability, HCB-Hospital cash benefit. WOP waiver of premium.

In the same column at the right hand side it is mentioned as under:-

	Choice of riders*(sum assured in Rs)
CI	ADB	ATPO	HCB	Term	WOP
300000	___________	___________	___________	___________	___

 

Even under column 5 of the proposal form the basic plan premium mentioned as Rs.30,000/- and total rider premium is mentioned as Rs.5018/- and against column total premium including service tax Rs.35945/- is mentioned and it also reveals that the complainant paid Rs.35945/- vide cheque No.933897 dated 19.5.2014 to the Opposite Party to be payable at Chandigarh Branch.

From above it is clear that that the complainant opted to be covered for critical illness and also paid premium on that account.

             Further perusal of the benefit Illustration at page 26 of the paper book confirms that the complainant was to pay Rs.5018/- in order to get covered under critical illness rider which she paid vide cheque No.933897 which too is  acknowledgement by the OP at page 16 of the written statement. It is further revealed that the Opposite Party also acknowledged payment of Rs.620/- paid in cash by the complainant towards the balance of premium and to our belief such balance of premium was deposited in furtherance of consent given by the complainant to pay extra premium for non standard age proof.  The paper book of Op at page 20 contains the consent of the complainant whereby she consented to pay for extra premium of Rs.2/- per annum per Rs.1000/- of sum assured and the said consent is also signed on the date of submission of proposal form. These observations nullify the plea of the Opposite Party that the proposal of the complainant was declined to the extent of critical illness rider on account of non submission of standard age proof by the complainant.

The claim of the Op that they issued counter offer on 26.5.2014 and in response they received the consent letter dated 30.5.2014 of the complainant seems to be manipulated in order to frustrate  the claim of the complainant. It is surprised that once the Opposite Party accepted the consent as well as amount to cover up non standard age proof requirement then how a letter could be issued afterwards in this regard. The Opposite Party has failed to prove on record dispatch proof of the said letter dated 26.5.2014 alleged to have been counter offer and also there is no proof of receipt of consent letter alleged to have sent by the complainant to the OP. By which mode the Opposite Party had received the consent letter dated 30.5.2014 is also not unveiled by the Opposite Party.  The counter offer letter and acceptance letter  relied upon by the Opposite Party are disputed, thus, cannot be relied upon to believe the contention of the Opposite Party. It is on record that Opposite Party acknowledged the receipt of Rs.35945 and Rs.620/- i.e. in total a sum of Rs.36565/- whereas the policy schedule issued to complainant shows the premium amount of Rs.32,007.38  and the record is silent about balance amount which till date remained unpaid to the complainant. This further strengthen the claim of the complainant that she is covered for critical illness under the policy.

We are of the considered opinion that it is a case where the Opposite Party received all the premium amount as required under the policy alongwith the payment of premium on account of coverage of critical illness but afterward declined her request unilaterally. It is a case where the OP tried to befool the complainant who is not a well educated person as his qualification mentioned in the proposal form is just 10+2. Therefore, we hold that the complainant is entitled for reimbursement of his medical claim amount to be paid by the Opposite Party.  The complainant is also  liable to be compensated by the Opposite Party on account of deficiency in service and indulgence into unfair trade practice.”

6.         After hearing  Counsel for the parties, and going through the record, we are of the opinion that the view taken by the Forum is perfectly justified. Purchase of the insurance Policy namely “Wealth Builder’ against yearly premium of Rs.30,000/- is proved on record. First premium was paid through a cheque for an amount of Rs.35945/-. It is on record that the respondent paid an amount of Rs.5018/- to cover those diseases which were mentioned in “Rider” Column 4 of the proposal form. The said rider excludes critical illness etc. from operation of the Policy unless higher premium is paid. It has been found, as a matter of fact that normal annual premium of Rs.35945/-  including Rs.5018/- was paid to cover diseases like critical illness etc. It is contention of the appellant that a counter offer was made on 26.5.2014 which was accepted by the respondent on 30.5.2014, showing that critical illness was not covered under the Policy, in question. It was specifically stated by the Forum that the said counter offer appears to be manipulated.  There is nothing on record to prove that the letter through which it was  conveyed, was ever despatched by the appellant.  It was further rightly said that there  is no proof how the counter offer was received.  Both the letters are disputed. At the time of arguments, it was specifically asked from  Counsel to show any proof regarding despatch and receipt of above said letters.  However, he failed to show any evidence in that regard.

7.     Under the above circumstances, no ground, whatsoever, has been made out by the appellant, to make interference, in the order under challenge.

8.        For the reasons recorded above, the appeal, being devoid of merit, must fail, and the same is dismissed, at the preliminary stage, with no order as to costs. The order of the District  Forum is upheld.

9.        Certified copies of this order, be sent to the parties, free of charge.

10.      The file be consigned to Record Room, after completion.

Pronounced.

26.07.2016                                                   Sd/-

 

[JUSTICE JASBIR SINGH (RETD.)]

PRESIDENT

 

 

 

                                                                  Sd/-

(DEV RAJ)

MEMBER

 

 

 

                                                       Sd/-

(PADMA PANDEY)

       MEMBER

 

 

JS

 

 

 

 

 

 

 

 

 

 

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