Chandigarh

DF-II

CC/401/2015

Sunita Rani - Complainant(s)

Versus

Edelweiss Tokio Life - Opp.Party(s)

Sh.Mohit Jaggi Adv.

29 Apr 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Consumer Complaint  No	:	401 of 2015
Date  of  Institution	:	29.7.2015
Date   of   Decision	:	29.4.2016

 

 

 

 

 

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

                …..Complainant

Versus

 

 

Edelweiss Tokio Life office at SCO 2447-48, 2^nd floor, Sector 22-C, Chandigarh through its Branch Manager.

 

….. Opposite Parties

 

 

BEFORE:  SH.RAJAN DEWAN                 PRESIDENT

         SH.JASWINDER SINGH SIDHU       MEMBER

         MRS.PRITI MALHOTRA             MEMBER

 

 

 

For complainant(s)      :     Sh. Mohit Jaggi, Adv.

 

For Opposite Party(s)   :     Sh. Nitin Thatai, Adv.

 

 

PER PRITI MALHOTRA, MEMBER

 

 

          As per the case, the complainant purchased one health insurance policy under the name of Edelweiss Tokio Life- Wealth Building for the term of 10 years commencing from 30.5.2014 to 30.5.2024 and paid premium thereof. The premium frequency of the policy was yearly. It is pleaded that unfortunately the complainant suffered from coronary artery disease and initially she was taken to Alchemist Hospital where she spent Rs.9500/-. Thereafter, on her request she was taken to Shivalik Hospital, Sector 69, Mohali for further treatment. In the said hospital her coronary angiography as well as coronary angioplasty was performed and  stent was inserted.  It is claimed that the complainant spent a sum of Rs.2,58,800/- on the said treatment. It is further pleaded that the complainant raised her claim before the Opposite Party for reimbursement but it did not do anything qua it. Alleging the said act of OP as deficiency in service, this compliant has been filed.

   

2.     Opposite Party has filed reply and stated that the complainant was never issued a health insurance policy under the name of ‘Edelweiss Tokio Life-Wealth Builder’ rather it was a life insurance policy where the term of the policy is 10 years, the premium frequency is annual with a pay term of 5 years and commencement of the risk was from 30.5.2014.  Averred further that since the policy, in question was not a health policy therefore, no question of reimbursement of the medical expenses incurred by the complainant arises at all. Pleaded further that even the complainant paid only one premium and thereafter did not pay subsequent renewal premiums, resultantly the policy stood lapsed. Pleading no deficiency in service and denying rest of the allegations, it is prayed that the complaint be dismissed.
3.     The Complainant also filed rejoinder thereby reiterating the averments as made in complaint and controverting that of the Opposite Party made in the reply.
4.     Parties led evidence in support of their contentions.
5.     We have heard the ld. Counsel for the parties and have also perused the record.
6.     In the present complaint the complainant disputed that she opted for ‘Edelweiss Tokio Life-wealth building’ policy from Opposite Party whereby she was also covered for medical heath insurance including critical illness. She further claimed that the policy term was for 10 years and the risk covered in the said policy started on 30.5.2014, which was to be expired on 30.5.2024. It is disputed that despite being covered for critical illness the complainant’s claim for medical reimbursement is pending with Opposite Party, which they are not processing. Explaining further it is submitted by the counsel for the complainant that during the subsistence of the policy the complainant fell ill and suffered from coronary artery disease for which she was admitted to Alchemist Hospital and then on her request she was shifted to Shivalik Hospital, Sector 69 Mohali, where she undergone coronary angiography and coronary angioplasty and stent was inserted as part of treatment. In total she incurred
   Rs. 2,58,800/- for the treatment and raised the claim with Opposite Party being covered under the said policy but it did not respond to the same.
7.     The OP in defence pleaded that it neither provided any cover for medical insurance under the head of critical illness rider to the complainant nor the complainant had ever submitted any medical claim with the Opposite Party. It is admitted that the complainant submitted a proposal for insurance on 20.5.2014 for purchase of Edelweiss Tokio Life-Wealth Builder Plan alongwith critical illness rider without providing any standard age proof. It is further claimed that on the basis of the proposal, medical evaluation  was done and after investing the other requisite information provided by the complainant, the proposal was denied by the Opposite Party to the extent of critical illness rider on account of non-submission of standard age proof by the complainant and the complainant was issued a counter offer letter dated 26.5.2014 (Exhibit R-3) stating that the complainant’s proposal form can be considered by the company with altered terms on account of non-standard age proof. Opposite Party claimed that the said offer was accepted by the complainant by issuing consent letter dated 30.5.2014 (exhibit R-4).

        Submitting above the OP tried to justify its stand that the complainant was not covered for medical insurance under the head of critical illness rider.  The OP claimed that the complainant under the said policy paid only one premium for one year and did not pay further installments of the premium, which was to be deposited for five years annually. Thus due to non payment of renewal premium the policy goes into lapse mode and thus as per terms and conditions of the policy the Opposite Party is not liable for any claim raised by the complainant.

8.     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.

   

9.     In view of the above discussion, we are of the opinion that the complaint deserves to be allowed.  Accordingly, the complaint is allowed and the Opposite  Party is directed as under:-

        

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.

 

         The above said order shall be complied with by the Opposite Party within 45 days of its receipt, failing which it shall be liable to pay interest on the above awarded amount of at (a) and (b) @9% p.a. from the date of this order till it is paid, besides paying litigation expenses.

         The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

29.4.2016                                                                                sd/-

                                                                  (RAJAN DEWAN)

PRESIDENT

 

Sd/-

 (JASWINDER SINGH SIDHU)

MEMBER

 

Sd/-

(PRITI MALHOTRA)

MEMBER