The present complaint case has been filed by the complainant Raj Kumar Jha r/o Grant Estate, Dumka (Jharkhand) against O.P’s namely the Branch Manager, ICICI Prudential Life Insurance Company, Ltd, Dumka Branch, the Divisional Manager ,ICICI Prudential Life Insurance Company Ltd, Shri Krishna Plaza Ground floor, Bank More, Dhanbad and the General Manager ,ICICI Prudential Life Insurance Company, Ltd ,ICICI Prulife Towers, Prabhadevi, MUMBAI (Maharastra),U/S-12 CONSUMER P ROTECTION ACT,1986 (herein after called as C.P.Act,1986) for illegally and arbitrarily repudiating the medical claim of the complainant in gross negligency and deficiency in services and thereby causing mental tension, agony and loss to the complainant. The complainant has prayed to direct the O.P’s to pay Rs.30,000/-(Thirty thousand) as the medical expenses bill, further direct to pay Rs.20,000/-(Twenty thousand) as compensation for mental tension, agony etc. and also to pay a sum of Rs.1,000/-(One thousand) towards cost of litigation etc. Besides the complainant has prayed to grant interest on the awarded amount @ 12% p.a. from the date of claim till its payment.
2. The brief facts of the complainant case as revealed in the complaint petition, documents annexed therein as well as from the short notes of argument dated 14.08.2018 are as follows:-
That the complainant Raj Kumar Jha purchased ICICI Pruhealth saver policy from ICICI Prudential Life Insurance Company Ltd. Dumka branch vide policy No.12269600 for a sum assured of Rs.3,00,000/-(Three lac) for reimburshment his health care expenses mainly towards medicine and drugs expenses, diagnostic expenses, dental expenses and other miscellaneous expenses . The said policy commenced on 13.08.2009 and it covered the risk till 13.08.2037. The complainant has been regularly paying the premiums on each and every due date.
The further case of the complainant is that after passing three years from the date of commencement of the policy the complainant fell ill and suffered from Morbid Obesity Gird and then he went for treatment to the Medenta Medicity Hospital under the Global Health Pvt. Ltd. at E-18, Defence Coloney, New Delhi-24 After treatment in the said Hospital the complainant became normal and fit and was discharged with medicines as prescribed by the Doctor. After discharge the complainant lodged a claim for reimburshment of the expenses incurred in treatment with the O.P’s for sum of Rs.30,000/-(thirty thousand) along with material papers,bills and other relevant document on 26.02.2011 as per policy terms and conditions ,but the O.P’s repudiated his claim vide letter dated 30.11.2011.
The complainant subsequently sent a legal notice to the O.P’s on 26.02.2013 which was replied on 12.03.2013 by the O.P’s and whereby denied the claim. The complainant having found no alternative lastly filed this case before this forum on 10.10.2013 for redressal of his grievance.
3. Having received the complaint petition on 10.10.2013 the case was admitted on 24.02.2014 and the O.P’s were noticed to file their written version of the case. Thereupon, O.P’s appeared on 28.03.2014 and filed their joint written version on 16.05.2014.
4. The O.P’s in their joint written statement besides being taken preliminary objection such as maintainability lack of cause of action for the case and it does not disclose any Consumer dispute has admitted that the complainant submitted duly filled proposal form for insurance under ICICI Pru- Health Saver plan which was accepted by this answering O.P’s. and issued policy bond on 13.08.2009 bearing policy No-12269600 on annual premium of Rs.17,000/- (Seventeen thousand) .
The further case of the O.P’s is that after acceptance of proposal form the answering O.P’s sent policy document along with forwarding letter to the complainant clearly mentioning that in case he was not satisfied with the features of the terms and conditions of the policy he can withdraw/return the policy within 15 days i.e. under the Free look period provision but he did not return the same to the O.P’s for cancellation of the policy during the Free look period in accordance with clause 4 (1) and clause 6 (2) of the Insurance Regulatory and Development Authority(Protection of policy holders Interests) Regulations 2002 and thereby implying that he agreed to all the policy terms and condition mentioned in the policy bond.
The further case of the O.P’s that they received claimant’s statement form information that the complainant was Hospitalized on 08.11.2011 at Medenta Medicity and was discharged on 10.10.2011 after getting treatment for obesity and GERD-Gastroesophageal Reflux disease.
The further case of the O.P that while processing the claim of the complainant and careful evaluation of medical records and investigation it revealed that the treatment stated to be undergone by the complainant was excluded from the Hospitalization insurance benefit and in consequence thereof, claim was repudiated and the same was intimated to the complainant through letter dated 30.11.2011.Thereafter the answering O.P’s received a legal notice on 26.02.2013 calling upon to make payment of Rs.30,000/-(thirty thousand) with interest which was duly replied by them wherein they denied the allegations made by the complainant.
The answering have also given parawise reply to the averments made in the complaint petition. In reply to the averment made in para-4 of the complain petition it has been replied that the treatment undergone by the complainant is excluded from insurance benefit under clause-8 sub clause-27 of the terms and Conditions of the policy and therefore, the claim of the complainant was rejected and complainant not entitled for the reimbursement of the expenses incurred by him for the said treatment .It is also claimed that the present complaint does not raise any consumer dispute and therefore this complaint case is liable to dismissed in view of Sec-26 of the Consumer Protection Act,1986. It is also claimed that there was no deficiency of services on the part of the answering O.P’s and hence complaint is liable to the dismissed with exemplary cost.
5. We have heard the argument of both the parties and gone through the records along with the material and documents attached therewith.
6. Now only point for discussion is whether the complainant is entitled to get the reliefs as prayed for?
7. The complainant in support of his case has filed affidivated statement of two witnesses namely C.W-1 Nishith Ghosh, a witness on facts and C.W-2 Gour kant Jha another witness on facts .Besides oral evidence complainant has adduced following documents evidence .
Ext.1- Policy certificate ICICI Pru health saver plan issued by ICICI Prudential Insurance vide policy no.12269600 dated 13.08.2009;
Ext.2- Premium deposit Receipt No-951862 dated -24.01.2009 for Rs.17,000/-(seventeen thousand);
Ext.3- Premium deposit Receipt No-2109631 dated 16.08.2010 for Rs.17,000/-(seventeen thousand);
Ext.4- Premium deposited receipt dated-29.07.2011 for Rs.17,000/-(seventeen thousand);
Ext.5- Discharge summery of Medenta Medicity of Globel Health Pvt. Ltd. New Delhi;
Ext.6- Hospital Bill of Golden Health Pvt. Ltd.;
Ext.7- Cash receipt No-GHIPRC/12042202 dated 08.11.2011 of Medenta Medicity at New Delhi for Rs.11,500/-(Eleven thousand five hundred )only;
Ext.8- Cash receipt No.GHIPRC dated- 10.11.2011 of Medenta Medicity at New Delhi-24 for Rs.19,018/-(Nineteen thousand eighteen);
Ext.9- Letter issued by ICICI Prudential Life Insurance, Dumka in connection of claim no- CL9003324;
Ext.10-Legal Notice with postal r3eceipt of registered post through lawyer by the complainant ;
Ext.11-Reply given by the ICICI Prudential Life Insurance Co. Ltd against the legal notice;
Ext.12-Letter of Civil Surgen cum CMO,Dumka with report of medical board.
F I N D I N G S
8. The admitted facts of the contesting O.P’s ICICI Prudential Life Insurance Company Pvt. Ltd. is that the complainant Raj Kumar Jha had taken a Health Care Policy from this answering O.P’s called as ICICI Pru-Health Saver for his own Health Care towards medical expenses reimbursement vide policy No-12269600 which commenced on 13.08.2009 and the risk to be covered till 13.08.2037 and the complainant has been paying yearly premiums regularly. It is further admitted fact that after passing of three years from the date of commencement of the policy the answering O.P’s received claimants statement about reimburshment of expenses incurred toward hospitalization and treatment for obesity and GERD- Gastroesophageal Reflux disease at Medenta Medicity Hospital New Delhi from 08.11.2011 to 10.11.2011. It is further, admitted fact that the answering O.P’s after examining the complainants claim repudiated the same on the ground that the ailment of the complainant was excluded from the terms and conditions of the Company’s policy.
9. On the basis of pleadings as well as argument raised from the parties we need to decide the following issues:-
- Whether the ICICI Prudential Life Insurance Company Ltd indicated any reference about the exclusion clause either in the proposal form or in the policy bond issued to the complainant?
- Whether policy documents related to terms and conditions of the policy were served to the complainant along with policy bond?
- Whether Morbid obesity GERD is a life style disease which is easily controllable by conservative medication and repudiation of claim was unjustified?
10. The first and second issues are inter related with each other hence for convenience taken up together. In both these issue the points to be discussed is whether in the proposal form or policy cover reference of exclusion clause were mentioned and whether policy document were sent along with policy cover to the complainant. The O.P’s (insurances company) has come up with main ground of repudiation that as clause -8 sub clause 27 of the terms and condition of the policy document, the company is not liable to make any payments under the policy in respect of any expenses incurred by any insured person in connection with medical or surgical treatment of obesity and any other weight control programme, services or supplies. The said policy document containing terms and conditions were sent along with forwarding letter to the complainant in view of clause 4(1) and clause 6(2) of the Insurance Regulatory and Development Authority (Protection of policy holders Interests) Regulations 2002 and thereby complainant was asked if he is satisfied with the policy then he may retain the policy or if not then return or withdraw within 15 days but complainant retained the policy so he is bound by terms and conditions.
On the other hand learned Counsel for the complainant has argued that the O.P’s company only sent policy cover note (Ext.1) to the complainant and no policy documents containing terms and condition was ever sent or no forwarding letter received. Besides, there was no reference of exclusion clause either in the proposal form or in cover note (policy bond). So he had no prior knowledge of information of the said exclusion clause.
In this connection the complainant in support of his case has filed policy certificate (Ext.1) premiumdeposit receipts ( Ext.2,3 and4) legal notice (Ext.10) On other hand O.P’s have only filed policy documents containing terms and conditions and photo copies of proposal form and policy certificate (Ext-A). From perusal of photocopy of proposal form and the policy certificate, we do not find any reference of exclusion clause for hospitalization insurance benefit for treatment of obesity and weight control program, services or supplies. However there is no material on the record to show that the Morbid obesity was noted down in the policy bond. Apart from it there is no evidence to show that policy document were ever sent along with a forwarding letter mentioning to withdraw or return policywithin 15 days if not satisfied with the same.
Learned counsel for the complainant vehemently argued that the terms and Conditions and the policy clause where never provided but only cover note was supplied by the O.P.no.1. The counsel took over attention to policy certificate (Ext-1).Which shows that the policy was issued on 13.08.2009 and there is no mention about exclusion clause in it. On the other hand the from side of company (O.P’s) have produced the policy documents related to the complainant for the first time non 28.07.2018 and he could not give any satisfactory answer as to why the terms and Conditions of the policy related to exclusion clause of the treatment of obesity was not provided to the complainant at the stage of entering in to contract by accepting the proposal form or at the time of issuing policy certificate. Besides it is also evident from annual premiums receipt Ext.3, and Ext-4 that there is no mention of any exclusion clause for reimbursement of the treatment for the obesity disease.
The O.P’s filed terms and Conditions of the policy on 28.07.2018 in which under clause-8 subclause-27 exclusion from insurance benefit for the treatment of obesity has been mentioned. These terms and Conditions of the policy has been brought in to picture for the first time on 28.07.2018 moreover O.P’s have not filed any paper showing that policy document along with and forwarding letter were served upon the complainant after the proposal form was accepted and the Contract of health cover insurance came in to being. On the other hand it is consistent case of the complainant that he never knew about the terms and condition of the company.
Therefore in view of above facts and evidence it is clear that the O.P’s (ICICI Prudential Life Insurance Company) had not provided any policy document containing terms and conditions to the complainant. Besides, there is no reference of exclusion clause in the proposal form or in the policy certificate. O. P’s have also not produced any evidence of service of forwarding letter on the complainant. Therefore we come to conclusion that the complainant was completely unaware of the terms and conditions of the company’s policy and it was brought to his knowledge during pendency of this case and repudiation of claim is unjustified and against law. Hence, both the points are decided against O.P’s (ICICI prudential life Insurance Comp. Ltd.) and in favour of the complainant.
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It was contended by the complainants counsel that Morbid Obesity GERD is a life style disease which is supported by the medical Board constituted by Civil Surgeon –cum- CMo, Dumka and hence such disease should not be excluded in the policy document by the O.P’s. In this connection we have obtained report from Civil Surgeon-cum-CMo, Dumka, who has sent report enclosing opinion of medical board which is marked as Extr.12. This document reads as under:- “when a person has excess body fat and body mass index is greater than 35 then such person may develop health problems like diabetes, stroke, heart disease, high B.P. and arthritis and as these conditions are oftencausing disabilities or even death.” Thus medical opinion show that excess body mass or fat is life style disease.
In this context the complainant has examined two witnesses, out of them C.W-1Nishith Ghosh in his affidavited statement stated in Para-3 that in the year 2011 Raj Kumar Jha under gone serious illness. He was unable to move as his body became bulky and he put on heavy weight. He used to get tired shortly hence, was taken for treatment to a doctor at Dumka, where he was referred for better treatment to Burdhman (W.B) and from there he has taken to Delhi for better treatment in the month of November-2011. After undergoing treatment at Delhi health condition of Raj Kumar Jha got normalized. C.W-2 Gour Kant Jha the another witness in his affidavited statement has stated that Raj Kumar jha is known to him as he was posted as Assistant Engineer in P.W.D, at Dumka. He was residing in his house on rent. In the year 2011 Raj Kumar Jha got seriously ill and unable to move due to heavy weight and bulky body and used to get tired shortly. He was taken to Doctor at Dumka for treatment where he accompanied with him and then he was referred for better treatment to some other place. Thereupon Raj Kumar Jha was taken to Burdhman (W.B) and thereafter to Delhi for better treatment.
Both these witnesses have clearly proved that due to excess body weight which caused stress on the knee complainant was unable to move hence taken for treatment at Delhi. Ext-5 is the discharge summary of the complainant about diagnosis and treatment issued by Medanta MedicityHospital, Delhi. From perusal of this documents it is proved that the complainant was suffering from Morbid Obisity GERD. In course of treatment his condition improved satisfactorily, hence discharged on 09.11.2011. He was advised to take one tablet twice daily. Ext-6,7,8 are hospital bill of Golden Pvt. Health Ltd. and cash receipts of Medanta Medicity New Delhi. These documents clearly shows that complainant incurred appox. Rs.30,000/-(thirty thousand) towards treatment of disease.
Therefore on the basis of Discharge summary and the repoprt of Civil Surgeon-cum-CMo and the medical board, Dumka it is proved that Morbid Obisity GERD is a life style disease which is easily controllable by the conservative medication hence, the reimbursement of the treatment bills should have been paid by the O.P’s. It was not justified to reject the genuine claim of the complainant.
Learned counsel for the complainant insupport of his contention he has relied upon following case law’s:-
- 2014(1) CPR 13 (HP) in a case of ICICI LOMBARD General Insurance Co. Ltd versus Jasbir Singh.
- 2016(1) CPR 150(NC) in case of New India Assurance Co. Ltd. versus Anil Manglunia .
In the first ruling Hon’ble Himachal PradeshState Consumer Disputes Redressal Commission, Shimlaheld”In the proposal form ,there was no reference even to disease of diabetes — The fact that this disease found mention in the policy ,suggested that that disease was noted down in the policy from the record of themedical examination — That record had been withheld by appellantfor the reasons best known to it —Appellant held liable to an adverse inference for withholdingsaid record — Apart from that Hypertension had been held to be a life style disease and easily controllablewithconservativemedicine — Appeal is dismissed”.
In the 2nd ruling Hon’ble National Consumer Dispute Redressal Commission, New Delhi held “Excess body weight places additionalstress on joints, especially knees ,hips and back — Itcan also cause cartilage damage which is hallmark of osteoarthritis — Almost every one will eventually develop some degree of osteoarthritis — Osteoarthritis is a generalized term—Petitioner/OP took frivolous ground that it was age realted osteoarthritis—OP failed to provide policy clause to the complainant and rejected genuine claim of complainant — Revision Petition dismissed”.
The above case laws fully support the complainant’s case. We are of the view that the repudiation of the complainant’sclaim on the ground of exclusion clause mentioned in clause-8(27) of the Terms and Condition of the policy without providing any such paper or any letter of the company’s prior to contract of insurance to the complainant was completely unjustified. The disease Morbid Obesity GERD is a life style disease which is easily controllable with medication and hence mention of such disease in exclusion clause was is not at all justified. Thus we are of the view that repudiation of the claim is besides deficiency in services it also amounted to unfair trade practice, hence rejectionof claim for about reimbursement of the bills of the hospital is illegal and unjustified.
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In the result,
O R D E R E D
That the case be and the same is allowed on contest against the O.P’s i. eBranch Manager, ICICI Predential LifeInsurance Co. Ltd, Dumka , the Divisional Manager, Bank More, Dhanbad and the General Manager, Mumbai of the Company. Therefore, we direct the O.P’s to pay Rs.30,000/- (thirty thousand) towards the bill submitted by the complainant, further direct to pay Rs.20,000/- (Twenty thousand) towards mental tension and agony substained by the complainant and also to pay litigation cost of Rs.1,000/-(One thousand).Further also the O.P’s are directed to pay interest on the awarded amount @12% p.a. from the date of claim i.e 26.02.2013 till its final payment.
The order must be complied within 30 days from the date of receipt of this order failing which necessary action as completedU/S 25 and 27 of the Consumer Protection Act,1986.shall be initiated .
The office clerk is directed to furnish copy of this order to the parties or their advocate free of cost.
This case, is thus disposed, accordingly.
