O R D E R

By Smt.Sreeja.S , Member :

          The complainant subscribed a critical illness policy issued by opposite parties at the promises of the agent.  The 2^nd complainant continuously renewed her policy and having a valid policy for the period 31/12/12 to 31/12/13 bearing policy No.2822200180620-301000 having  benefit of Rs.5,00,000/- for critical illness as sum insured.  2^nd complainant was diagnosed  cancer and admitted in the hospital from 30/9/13 till 3/10/13 and from 31/10/13 till 12/11/13.  She was discharged on 12/11/13.  Later, on 28/11/13 she died due to the illness.  After that complainants approached 1^st opposite party for reimbursement of claim amount of sum insured for the above mentioned critical illness death.  1^st opposite party ;informed the 1^st complainant that the claim amount is deposited in 1^st complainant’s bank account, but on enquiry it was known that no such amount was deposited in the account.  So the complainant send claim request letters to 2^nd opposite party company at Mumbai & Chennai offices on 9/1/2014 and on 29/1/2014.  But there was no reply or action form opposite parties side.  After that 1^st complainant contacted opposite parties office over telephone and opposite parties officer told him that no such letter was received in opposite parties office.  At last 1^st complainant gave a complaint to Senior Superintendent of Postal, Thrissur on 11/2/2014.  On enquiry the postal authority found that complainant’s letters were received by opposite parties office well in advance and warned that they will take legal action against opposite parties company.  The opposite parties company send a reply on 16/2/2014 and that reply states that ‘As per the policy terms and term section I insured should survive for at least 30 days from the date of diagnosis.  Date of diagnosis is 31/10/2013 and date of death is 28/11/13.  Hence the claim repudiated’.   The complainants were shocked to see such a reply.  The date of diagnosis of the deceased was not 31/10/2013 as she was treated prior to that for the same.  Opposite parties company is avoiding payment saying hyper technical reasons.  If such conditions are known earlier, nobody will avail this policy.  Moreover opposite parties have supplied only the policy documents without terms and conditions.  The illness was diagnosed before the admission to the hospital.  The reason mentioned in opposite parties reply for rejection of claim amount to complainants is wrong.  The very next day ie. on 17/2/2014  complainants  received another letter from opposite parties office stating that complainants  have not submitted the claim documents as enlisted by opposite parties company and hence company is closing the claim.  Complainants have submitted all documents. Opposite parties company is cheating genuine clients after receiving exorbitant premium amounts.  Opposite parties have not given the terms and conditions of the policy since last four  years.  Hence there is gross deficiency in service.  So 1^st complainant  sent a lawyer notice to the 1^st opposite party company on 20/3/2014 demanding the opposite parties to pay claim  amount of Rs.5,00,000/- as promised in the policy which is due to complainants along with interest at the bank rate from the date of death along with compensation. After accepting the above said notice the opposite parties did not send any detailed reply to such a notice.  The complainants were under bonafide belief that the opposite parties would pay the amount of policy but the said opposite parties failed to pay the amount which is a deficiency in services of the opposite parties.  The complainants are entitled to get the amount from opposite parties.  The deceased was aged 43 at the time of death.  The amount of Rs.5,00,000/- is to be paid to the complainants by opposite parties as compensation.  The split up of the amount are Medical Bill and Medical Miscellaneous expenses of Rs.1,00,000/-, compensation for pain and suffering loss of  happiness/shock and anxiety Rs.50,000/- compensation for dependency 2,50,000/- loss of amenities and convenience etc. Rs.50,000/- and loss of expectation of life Rs.50,000/- total claim of compensation is Rs.5,00,000/-.  The complainants are entitled for damages for the mental shock, agony and suffering suffered due to the deficiency in service of opposite parties.  They are also entitled for costs of the complaint proceedings.

          Version of the opposite parties is as follows: The complaint is not maintainable.  The opposite parties admit that the 1^st opposite party has issued a critical illness policy vide policy No.2822 2001 8062 0301 000 in the name of Prem Prakash for a period from 31/12/12 to   31/12/13 and the sum insured is Rs.5,00,000/- subject to the conditions, limitations and exceptions of the policy.  As per the policy condition No.1 the insured should survive for at least 30 days from the date of the diagnosis.  The date of diagnosis is only 31/10/13.  The date of scan report is on 2/11/13.  The date of death is on 28/11/13 ie, before 30 days of diagnosis.  The policy benefits will be available to the insured only if death occurs after 30 days of diagnosis of the decease.  Since death occurred before 30 days of diagnosis of disease, these opposite parties are not liable to pay any compensation.  These opposite parties sent a letter on 16/1/14 to the complainant asking the following documents.  First consultation papers with all previous consultations and investigation reports related to this ailment, To provide treating doctor certificate mentioning exact duration of CA Rectum and date of diagnosis, Attested copy of Indore case papers from hospital, Discharge summary of hospitalization for  hysterectomy surgery.  As per the submitted documents by the complainant to these opposite parties it was revealed that the insured expired within 30 days of diagnosis of the disease.  Hence the claim was rightly repudiated on 16/2/14 stating the above reason.  There is no deficiency in service on the part of these opposite parties in repudiating the claim  The claim is repudiated based on the policy condition and upon verifications of medical records.  She died within 30 days of diagnosis of cancer.  On receiving the claim application 1^st opposite party informed the complainant that the claim amount is deposited in 1^st complainant’s bank accounts.  This opposite party has sent a reply on 16/2/14 to the letter received to these opposite parties.  The conditions of the policy were known to the insured and the original policy with terms and conditions were given to the insured and the insured was well aware of the policy conditions, limitations, and exceptions of the policy.  These opposite parties deny the averment that opposite party company is cheating genuine clients after receiving premium These opposite parties deny the averment that the terms and condition of the policy was not given to the insured since last 4 years.  The original policy and its terms and conditions were given to the insured.  No deficiency in service is committed by these opposite parties.  These opposite parties deny the averments in para 8,9 and 10 of the petition.  The complainant is not entitled to get an amount of Rs.1,00,000/- under the head compensation for pain and sufferings, Rs.15,000/- under the head loss of happiness, shock and anxiety, Rs.50,000/- under the hear dependency, Rs.2,50,000/- under the head loss of amenities and convenience etc. and   Rs.50,000/- under the head loss of expectation of life.  Hence prayed for dismissal.

          Points for consideration are :

1)1s there any deficiency in service on the part of opposite parties?

2)If so reliefs and costs

          Complainant produced 16 documents and marked as Exts.P1 to P16.  Ext.P1 Critical illness policy Ext.P2 case sheet, Ext.P3 (SP)copy of certificate of Dr.V.K.Abdul Azeez, Ext.P4 copy of discharge summary, Ext.P5 Death certificate, Ext.P6 series (2 Nos.)postal receipts, Ext.P7 copy of letter dtd. 11/2/14, Ext.P8 letter dtd.12/2/14 of postal dept., Ext.P9 series copy of letter dtd.11/2/14 and  detailed  track events, Ext.P10 copy of claim repudiation letter, Ext.P11 cpy of letter dtd. 17/2/14, Ext.P12 Family membership certificate, Ext.P13 copy of lawyer notice dtd.30/3/14, Ext.P14 postal receipt, Et.P15  A/D card, Ext.P16 copy of identity card.  From the side of opposite parties 11 documents produced and marked as Exts.R1 to R11.  Ext.R1 copy of Critical illness policy, Ext.R2 copy of discharge summary, Ext.R3 copy of report of ultrasound scan abdomen, Ext.R4 CT scan report – Abdomen and Pelvis, Ext.R5 copy of claim repudiation letter, Ext.R6 copy of claim form, Ext.R7 copy of death certificate, Ext.R8(SP)CD, Ext.R9 Histopathology examination report, Ext.R10 copy of certificate of Dr.V.K.Abdul Azeez, Ext.R11 copy of Critical illness policy. 

          Points: The case of the complainant is that they subscribed  critical illness policy.  Ext.P1 is the policy.  Ext.P1 proves the same.  The opposite party admit the same.  The sum issued was 5 lakh and valid from 31/12/12 to 31/12/13.  Therefore it is proved that there was a valid policy in the name of Sujatha Prem Prakash, who is the wife of 1^st complainant. 

          The crux of the case  is that she has been diagnosed cancer and admitted  the hospital during the period and consequently succumbed to the same and took her last breath on 28/11/13.  Ext.P2 case sheet is produced.  Ext.P3 support Ext.P2.  Ext.P4 confirms the disease.  Ext.P5 is the death certificate is also produced.  There is no case for the opposite party that cancer is not a critical illness. 

          Ext.P11 letter has been produced requiring the document to be produced for considering the claim.

          The case of the opposite party is that the policy condition No.1 states that the insured should survive for at least 30 days from the date of diagnosis.  In this case the death occurred before 30 days. Same defeat the policy condition No.1 and  hence they are not liable to pay compensation.  It is very strange and irrational to  arrive at an agreement definitely stating the period, date or time of death.  The condition No.1 as aforesaid is only intends to defeat the right of the consumers to get a genuine claim.  On the face of records the policy named as ‘critical illness policy’ and fixing an exclusion period to death due to the critical illness is only  to curtail  the purpose and end of the policy and inclusion of the same is against the bonafide will of consumers as a whole and same is deprecated.  We find such a policy condition that too under critical illness is absolutely  bad and the same result  into unfair trade practice and denial of the claim under its guise amounts to culpable deficiency in service.  Therefore we find that the repudiation of the claim holding violation of condition No.1 is against  the interest of consumer community and the bonafide interest need to be protected.

          We have gone through entire evidences on record.  The repudiation of the claim caused high mental agony and irreparable loss to the complainant especially when the deceased found  and started treatment for cancer from 30/9/2013 and died on 28/11/2013.  It is true that the mental agony and sufferings need to be compensated.    Hence we are inclined to allow this complaint along with cost and compensation.

          In the result complaint is allowed and hereby direct the opposite party to pay Rs.5,00,000/- (Rupees Five lakh only) being the sum insured with 9% interest from the date of preferring the claim till realization.  The opposite party is further directed to pay compensation of Rs.20,000/- (Rupees Twenty thousand only) each to the complainants along with cost of Rs.10,000/- (Rupees Ten thousand only).  The cost and compensation shall be paid within 15 days from the date of receipt of copy of this order and failing in which the same would carry an interest of 6% from the date of this order.

            Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Commission  this the  31^st   day  of December   2021.

Sd/-                                                             Sd/-

Sreeja.S                                                       C.T.Sabu                       

Member                                                       President                           

                                      Appendix

Complainants Exhibits

Ext.P1 Critical illness policy Ext.P2 case sheet, Ext.P3 (SP)copy of certificate of Dr.V.K.Abdul Azeez, Ext.P4 copy of discharge summary, Ext.P5 Death certificate, Ext.P6 series (2 Nos.)postal receipts, Ext.P7 copy of letter dtd. 11/2/14, Ext.P8 letter dtd.12/2/14 of postal dept., Ext.P9 series copy of letter dtd.11/2/14 and  detailed  track events, Ext.P10 copy of claim repudiation letter, Ext.P11 cpy of letter dtd. 17/2/14, Ext.P12 Family membership certificate, Ext.P13 copy of lawyer notice dtd.30/3/14, Ext.P14 postal receipt, Et.P15  A/D card, Ext.P16 copy of identity card.                                    

Opposite Parties Exhibits                                               

Ext.R1 copy of Critical illness policy, Ext.R2 copy of discharge summary, Ext.R3 copy of report of ultrasound scan abdomen, Ext.R4 CT scan report – Abdomen and Pelvis, Ext.R5 copy of claim repudiation letter, Ext.R6 copy of claim form, Ext.R7 copy of death certificate, Ext.R8(SP)CD, Ext.R9 Histopathology examination report, Ext.R10 copy of certificate of Dr.V.K.Abdul Azeez, Ext.R11 copy of Critical illness policy                                                                               

Id/-

Member