DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

PATIALA.

                                      Consumer Complaint No. 17 of 23.1.2017

                                      Decided on: 24.12.2020

1. Jagjit Singh S/o Sh.Dalip Singh aged 56 years, H.No.B-56,DLF Colony, Near Sirhind Road, Patiala.
2. Jaspreet Singh S/o Jagjit Singh aged 33 years, H.No.B-56,DLF Colony, Near Sirhind Road, Patiala.
3. Jashandeep Singh S/o Jagjit Singh aged 29 years, H.No.B-56,DLF Colony, Near Sirhind Road, Patiala.
4. Gagandeep Kaur w/o Sh.Jatinder Pal Singh aged 36 years, R/o P-97,Jiwan Bima Nagar, 7^th Main, 10^th Sector Bangalore.

                                                                   …………...Complainants

                                      Versus

ICICI Prudential Life Insurance Company Ltd., Branch Leela Bhawan Market, Patiala through its Manager.

                                                                   …………Opposite Party

                                      Complaint under Section 12 of the

                                      Consumer Protection Act, 1986.

QUORUM

                                      Sh. Jasjit Singh Bhinder, President

                                      Sh.Vinod Kumar Gulati, Member

                                      Sh.Y.S.Matta, Member 

ARGUED BY

                                      Sh.D.P.S.Anand, counsel for complainant.

                                      Sh.Pankaj Verma, counsel for OP.   

 ORDER

                                      JASJIT SINGH BHINDER,PRESIDENT

1. This is the complaint filed by Jagjit Singh and others  (hereinafter referred to as the complainants) against ICICI Prudential Life Insurance Ltd.(hereinafter referred to as the OP/s) under the Consumer Protection Act,1986(hereinafter referred to as the Act)
2. The brief facts of the complaint are that Arvinder Kaur wife of complainant No.1 purchased save and protect policy from the OP bearing No.00464427 on 17.7.2003 with yearly premium of Rs.12093/- for a sum of Rs.3lacs and the complainant paid the installments upto date. It is averred that the complainant also purchased critical illness rider including cancer and ADBR rider upto the extent of Rs.3lacs
3. It is averred that unfortunately Arvinder Kaur suffered from loose motion and constipation and contacted doctors of Columbia Hospital, Patiala on 9.5.2016 where some tests were got conducted in the hospital. Thereafter she went to Max Hospital Mohali where she admitted on 11.5.2016 and discharged on 16.5.2016. In the said hospital she was diagnosed as a case of Metastatic Carcinoma Rectum  and was operated upon for cancer. For the said treatment the hospital charged Rs.3,42765/- out of which complainant paid Rs.97332/- and the remaining amount was paid by New India Assurance Co. Ltd. Patiala from where she has taken Floater Medi Claim Policy alongwith her husband for a sum of Rs.3lac each for the period from 26.12.2015 to 25.12.2016. Arvinder Kaur was also suggested chemotherapy and as many as 8 chemotherapies were got conducted by her. Thereafter she went to Fortis Hospital Bangalore for better management and  was got admitted there on 18.10.2016 and major surgery for removal of malign  cancer tumor was conducted .She remained admitted there upto 5.11.2016. The hospital authorities charged Rs.7,66,361/- for the treatment.
4. It is further averred that unfortunately some complications in post operative period Bangalore were developed  as a result of which she was again admitted in Fortis Hospital Bangalore  and was discharged on 14.11.2016 and Rs.56216/- were charged by the doctors of the hospital. Thereafter she was shifted to Patiala but again some complications of Pus formation and infection developed on the operative parts of the body and she was again taken to Max Hospital, Mohali, where she was admitted on 21.11.2016 to 4.12.2016 and the hospital authorities charged Rs.5,08,874/- on account of treatment charges.
5. It is further averred that she is still under treatment and is on the bed and has to appoint a regular nurse and is paying Rs.15000/- per month to her. It is further averred that Arvinder Kaur with her attendant had to go to Bangalore by air and remained there for 20 days and had to spend Rs.50,000/- on air fare and other charges and local transportation.
6. It is further averred that the complainant lodged the claim with the OP by sending a registered letter dated 27.5.2016 but the same was not replied by the OP. The husband and son of Arvinder Kaur also visited the office of the OP but to no effect. There is thus deficiency in service and unfair trade practice on the part of the OP which caused mental tension and harassment to the complainants.
7. On the background of these facts, the complainants have filed this complaint with the prayer to accept the same by giving direction to the OP to pay Rs.15lac, the amount spent on treatment alongwith interest @12% per annum from the date of treatment; compensation of Rs.one lac for the damages caused due to non settlement of the claim and Rs.25000/- as litigation expenses.
8. Upon notice, OP appeared through counsel and filed written reply. In the written reply preliminary objections have been raised that the complaint is not maintainable; that the policy under question was issued by the OP on 17.7.2003 with premium payment term as 30 years and on the basis of the information provided by the life assured in the proposal form. The premium under the policy was to be paid on yearly basis, the complainant has concealed and suppressed the material and relevant facts of the case.
9. It is submitted that thereafter Life assured made some payment of premiums but failed to pay further renewal premiums and the policy lapsed. The complainant approached this Hon’ble Forum vide CC No.428/2012 for getting the policy revived. The order was passed to revive the policy after taking the requisite pending premiums. The policy was revived and is presently in force as the complainant was making regular payment of premiums.
10. The OP further raised the objection that the complainants till date have not submitted the death claim intimation-claimant’s statement form and the requisite documents(medical and other) , whenever any claim  is submitted a thorough verification has to be done, the status of the policy has to be checked thereafter claim can be processed; that this Hon’ble Forum has no jurisdiction to entertain the complaint as no consumer dispute has been highlighted by the complainants and is liable to be dismissed.
11. On merits the OP denied the other averments made in the complaint and have reiterated the facts as raised in the preliminary objections and prayed for the dismissal of the complaint.
12. In evidence the ld counsel for the complainant tendered affidavit Ex.CA of Jagjit Singh alongwith documents Ex.C1 to C22 and closed the evidence.
13. The OP tendered in evidence Ex.OPA affidavit of Thejus Joseph, Sr.Manager Legal alongwith documents Edxs.OP1 to OP4 and closed the evidence.
14. We have heard the ld. counsel for the parties and have also gone through the record of the case carefully.
15. The ld. counsel for the complainants has argued that Arvinder Kaur who has since died has purchased Save and Protect policy of OP on 17.7.2003 with yearly premium of Rs.12093/- for a sum of Rs.3lacs and the complainant had paid the regular installments upto date. The complainant also purchased critical illness rider including cancer and ADBR rider covering the risk of critical illness upto the extent of Rs.13lacs.The ld. counsel further argued that she suffered from loose motion and constipation and contacted doctors of Columbia Hospital on 9.5.2016 and some tests were conducted. Thereafter she went to Max Hospital Mohali where she was admitted on 11.5.2016 and discharged on 16.5.2016 and she was diagnosed as a case of cancer and hospital charged Rs.3,42,765/- out of which she paid Rs.97,372/- and remaining amount was paid by New India Assurance Co. Ltd. she was  having floater medi claim policy alongwith her husband for a sum of Rs.3lac each. The ld. counsel further argued that chemotherapy was conducted and she remained admitted from 1.6.2016 to 3.6.2016.The ld. counsel further argued that various diagnoses and near about 8 chemo therapies were conducted there. The ld. counsel further argued that thereafter she shifted to Fortis Hospital Bangalore for better management. She was admitted in Fortis Hospital Bangalore on 18.10.2016 and major surgery for removal of malign cancer tumor was conducted and she remained admitted till 5.11.2016.The hospital authorities charged Rs.7,66,361/-.The ld. counsel further argued that complications in post operative treatment developed. The ld. counsel argued that she remained admitted in Fortis Hospital Bangalore and was discharged on 14.11.2016 and a sum of Rs.56216/- were charged by the hospital. The ld. counsel further argued that from Fortis Hospital, Bangalore she was shifted to Columbia Hospital, Patiala and again some complications developed and she was shifted to to Max Hospital, Mohali on 21.11.2016 and discharged on 4.12.2016 .Rs.508874/- were charged by the hospital. The ld. counsel further argued that as the complainant was under regular treatment and was on the bed so she appointed a regular nurse on the payment  of Rs.15,000/- per month. It is further argued that the claim was lodged with the OP but the same has not been settled and has prayed that the complaint be accepted.
16. The ld. counsel further submitted that during pendency of complaint Arvinder Kaur died and LRs have been impleaded in the complaint.
17. On the other hand, the ld. counsel for the OP has argued that the complaint is not maintainable in the present form and is liable to be dismissed. The ld. counsel further argued that the complainant was issued the policy for 30 years. The ld. counsel further argued that the complainant made some payment of premiums and failed to pay renewal premiums as a result of which policy lapsed. The complainant approached the Forum for getting the policy revived and the policy was revived. The ld. counsel further argued that the complainant has died but death claim letter has not been submitted. The ld. counsel further argued that the complainants twisted and distorted the facts to suit her own convenience and has mislead the Forum. The ld. counsel further argued that no claim has been lodged till date so there is no ground of deficiency in service and the complaint is liable to be dismissed.
18. To prove the case after death of Arvinder Kaur her husband Jagjit Singh has tendered his affidavit, Ex.CA and has entirely deposed as per the complaint and has also tendered the entire hospital record. Ex.C1 is health summary and bill of Columbia Hospital for Rs.1187/-, Ex.C2 is slip of Max Hospital, Mohali,Ex.C3 is discharge summary of Max Hospital, Mohali and bill  of Rs.72611/-,Ex.C4 is insurance policy of New India Assurance Co.Ltd.,Ex.C5 discharge summary of Max Hospital,Mohali,Ex.C6 discharge summary and bill of Rs.59,937.72,Ex.C7 is also bill of Max Hospital Mohali of Rs.24417.58,Ex.C8 is bill of Max Hospital Mohali for Rs.24034/-,Ex.C10 bill of Max Hospital Mohali, Ex.C11 bill of Max Hospital Mohali for Rs.24,275/-. From Max Hospital Mohali, she was shifted to Fortis Hospital, Bangalore and the report and bill of that hospital are Ex.C14 to C15.Then she was shifted to Max Hospital, Mohali.The bill of Max Hospital,Mohali is Ex.C16 for Rs.508874.49.Then she was shifted to Columbia Hospital, Patiala and is bill is Ex.C17 for Rs.2872 .Again she was shifted to max Health Care Mohali and the bill is Ex.18 for Rs.3,20629.94. Total amount is Rs.19,46,359.87 .All the medical record and reports has been placed by the LRs of Arvinder Kaur on the file.Ex.C20 is letter written by Jagjit Singh, husband of Arvinder Kaur to the Insurance company for the payment of the bills.
19. On behalf of the OP Thejus Joseph,Senior Manager Legal has tendered his affidavit,Ex.OPA and has deposed as per his written reply,Ex.OP1 is proposal form of the OP company in the name of Arvinder Kaur.
20. Admittedly Arvinder Kaur has paid all the installments from 2003 to 2017 till her death. This payment is material for the disposal of the present case. Ex.OP2 is policy document and is material document. In the policy document on page 8 at point 7, it is mentioned as under:

“The maximum aggregateof Critical illness benefit granted by the companyunder this and all the other policies of the Life Assured shall not exceed Rs.10,00,000/-(Rs.10lacs)”

21.  So it is clear that the policy of the OP guarantee an amount of Rs.10lac in the case of critical illness benefits granted by the company. In the present case all the documents from Exs.C1 to C8 clearly show that  complainant Arvinder Kaur was suffering from cancer and she underwent treatment at Columbia Hospital, Patiala, Max Hospital, Mohali and Fortis Hospital, Bangalore. Again Max Care Hospital, Mohali, Columbia Asia  Hospital, Patiala and Max Care Hospital, Mohali and ultimately she  died. All the documents were submitted by the LRs to the insurance company but the insurance company has not paid the payment to the complainants.
22. As per the documents on the file, the claim was lodged by Jagjit Singh on 27.5.2016 under registered cover Exs.C19 and C20. After the death of Arvinder Kaur, her husband and sons visited the office of OP but in  vain. So it is clear that despite various visits and filing of documents that it is a case of cancer which falls under the critical disease of illness as per Ex.OP2, the OP has committed deficiency in service and has not paid the payment of bills to the LRs of Arvinder Kaur.
23. From the various record of hospital and reports, it is clear that late Arvinder Kaur suffered from lot of mental agony and harassment for long time but still despite submitting of all the documents the insurance company has committed deficiency in service and has not paid the bill.
24. The complainants have claimed the amount of Rs.19,46,000/- but this amount cannot be paid to them because as per maximum limit in the case of critical illness benefits is of Rs.10lacs.
25. So due to our above discussion, the complaint stands allowed and taking into view all the record and reports of the hospitals i.e. Columbia Asia Hospital, Patiala, Max Hospital, Mohali and Fortis Hospital, Bangalore, it is clear that Arvinder Kaur underwent treatment for critical illness and her LRs are entitled to recover Rs.10lac from the OP alongwith interest @6% per annum from the date of treatment i.e. 11.5.2016 till realization in equal share.They are also entitled to Rs.25,000/-as compensation and Rs.25,000/- as litigation expenses. We order accordingly.            

Compliance of the order be made by theOP within a period of 45 days from the date of the receipt of the certified copy of this order.

ANNOUNCED

DATED:24.12.2020     

          Y.S.Matta              Vinod Kumar Gulati           Jasjit Singh Bhinder

            Member                       Member                                    President