DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BARNALA, PUNJAB.
Complaint Case No : 612/2016
Date of Institution : 16.08.2016
Date of Decision : 23.02.2018
Tejinder Pal aged about 42 years s/o Sh. Janak Raj Street No. 1, Near City Police Station; Tapa Mandi, Tehsil Barnala District Barnala.
…Complainant
Versus
Life Insurance Corporation of India Yogakshema, Jiwan Bima Marg, Mumbai-400021 through its Managing Director. National Bank, 7 Bhikaji Kama Palace, New Delhi through its Managing Director.
Life Insurance Corporation of India Branch Office Barnala 22 Acre Scheme Barnala Tehsil & District Barnala through its Branch Manager.
…Opposite Parties
Complaint Under Section 12 of Consumer Protection Act.
Present: Sh. R.K. Jain counsel for the complainant.
Sh. J.S. Sandhu counsel for opposite parties.
Quorum.-
1. Shri Sukhpal Singh Gill : President
Ms. Vandna Sidhu : Member
ORDER
(SUKHPAL SINGH GILL, PRESIDENT)
The complainant namely Tejinder Pal has filed the present complaint against Life Insurance Corporation of India through Managing Director Mumbai and Life Insurance Corporation of India through Branch Manager Barnala (hereinafter called the opposite parties). It is alleged that the complainant took an insurance policy from the opposite parties vide policy number 162594541 for a sum of Rs. 3,50,000/- with date of commencement as 28.12.2003 with an annual premium of Rs. 14,193/- with critical illness rider and premium waiver benefit. No terms and conditions or exclusion clauses were supplied alongwith the policy.
2. It is further alleged that on 5.7.2015 the complainant suffered a heart attack and admitted to Hero Dayanand Medical College and Hospital, Ludhiana and was discharged on 10.7.2015, where he was diagnosed as a case of Acute Coronary Syndrome-Unstable Angina. On 10.7.2015 the complainant lodged the claim with the opposite parties and submitted all the necessary documents. The opposite parties vide their letter no. claims/016 dated 3.11.2015 repudiated the claim of the on the ground that the claim is not covered by the policy. Complainant made several visits to the office of opposite party No. 2, but no one listened to the pleas of the complainant and refused to consider the case of the complainant. It is further alleged that the complainant approached the Insurance Ombudsman to get justice but the Ombudsman also did not get the record produced and simply decided the case as per the statement of opposite parties. Hence, the present complaint is filed for seeking following reliefs:-
To pay the claim of the CIR benefit amounting to Rs. 3,50,000/- as per policy.
To pay Rs. 1,00,000/- on account of mental agony and physical harassment and Rs. 11,000/- as litigation expenses.
3. Upon notice of this complaint, the opposite parties No. 1 & 2 appeared and filed written version taking legal objections on the grounds of no locus standi or cause of action, complaint is bad for non-joinder and mis-joinder of necessary parties, maintainability not come to the Forum with clean hands etc. On merits, it is admitted that policy No. 162594541 was issued to Tejinder Pal on 28.12.2003 under plan 14-30 for sum assured Rs. 3,50,000/- yearly and mode of premium Rs. 14,193/- with Critical Illness Rider Benefit and Premium Waiver Benefit. As per the record submitted by the complainant to them, the complainant had suffered Heart Attack on 5.7.2015 and he was admitted in DMC & H Ludhiana on 5.7.2015 and discharged on 10.7.2015. It is submitted that the complainant had undergone Coronary Angiography, PTC with stenting to Lad at DMC & H Ludhiana on 5.7.2015. As ailment suffered by the complainant is specifically excluded as per terms and conditions of CIRB, his claim for Critical Illness Benefit and waiver of future premiums were rejected vide letter dated 3.11.2015. The ailment suffered by the complainant was Acute Coronary Syndrome-Unstable Angina and as per provisions of CIRB-Angina is specifically excluded. It is further submitted that before rejection of his claim the opposite parties had referred to DMR (Divisional Medical Refree) for his expert opinion about coverage of contingency under his plan and the DMR has opined that as per medical record of complainant LA did not have typical heart attack, he was having Acute Coronary Syndrome-Unstable Angina-Pectoris for which Coronary Angina PTCA & Stenting was done. As such it does not meet the Critical Illness definition. So, the act of the opposite parties is not unfair trade practice or falls under deficiency in service, as they acted strictly according to terms and conditions of CIRB and finally prayed for the dismissal of complaint.
4. To prove his case, the complainant tendered in evidence his affidavit Ex.C-1, copy of letter dated 1.8.2015 Ex.C-2, copy of discharge summary Ex.C-3, copies of claim form Ex.C-4 & Ex.C-5, copy of Coronary Angiography Ex.C-6, copy of ECG Ex.C-7, copy of claimant statement for CIRB Ex.C-8, copy of discharge under critical illness rider benefit Ex.C-9, copy of canceled cheque Ex.C-10, copy of letter dated 8.4.2016 Ex.C-11, copy of policy Ex.C-12, copy of letter dated 28.9.2015 Ex.C-13, copy of letter dated 3.11.2015 Ex.C-14, copy of letter dated 5.7.2016 Ex.C-15 and closed the evidence.
5 To rebut the case of the complainant, the opposite parties tendered into evidence copy of policy Ex.O.P1.2/1, copy of discharge summary Ex.O.P1.2/2, copy of CIRB Ex.O.P1.2/3, copy of DMR's opinion Ex.O.P1.2/4, copy of Write up of CIRB Ex.O.P1.2/5, copy of Ombudsman decision Ex.O.P1.2/6, affidavit of J.S. Sandhu Counsel for opposite parties as Ex.O.P1.2/7 and closed the evidence.
6. We have heard the learned counsel for the parties and have gone through the records.
7. It is admitted fact that the opposite parties have issued policy number 162594541 for a sum of Rs. 3,50,000/- with date of commencement as 28.12.2003 and the date of maturity is 28.12.2032 with an annual premium of Rs. 14,193/- which is evident from copy of insurance policy Ex.C-12. It is also admitted fact that complainant has taken treatment from DMC & Hospital Ludhiana from 5.7.2015 to 10.7.2015 and in support of his contention the complainant produced on record Ex.C-3.
8. On the other hand, learned counsel for the opposite parties has contented that no claim amount is payable to the complainant and the claim has been rightly repudiated on the ground that disease does not cover in the insurance policy and the same is come under the exclusion clause.
9. The only question is involved in the present case is that whether the opposite parties can take the benefit of exclusion clause to repudiate the claim of the complainant.
10. Ld. Counsel for the complainant has argued that no terms and conditions have been supplied to the complainant and as such terms and conditions are not binding upon him and the same does not brought to the knowledge of the complainant since the year, he taking the policy in question. In support of this contention, learned counsel for the complainant has cited judgment of Hon'ble Apex Court 2000 (2) SCC 734 in M/s Modern Insulators Ltd. Vs Oriental Insurance Company Ltd., where in the Hon'ble Apex Court has held that exclusion clause never included in policy nor it was disclosed to the insured respondent cannot claim benefit of that clause and the complainant has cited judgment of J R Banik Vs National Insurance Company Ltd. 2017 (2) CLT 376 (NC), wherein, the same view has been taken by the Hon'ble Commission and it reveals that the complainant has demanded many times terms and conditions from the opposite parties, but they failed to do so. Even, the complainant has filed the application under the Right to Information Act for demanding the CIRB and PWB endorsement, but the opposite parties failed to supply the same and reply of the same is Ex.C-15. The opposite parties have not filed any document on the file, which proves that they have supplied the terms and conditions to the complainant. From the perusal of the policy Ex.C-12 it is also clear that only 4 pages have been supplied to the complainant. Even, from the perusal of Ex.C-15 it shows that docket of policy number 162594541 is not available in their record and EDMS image is also not available in the record of opposite parties. Even, the opposite parties have not produced any postal receipt or courier receipt and copy of dispatch register from which it shows that terms and conditions have been supplied to the complainant.
11. The insurance companies are in the habit to take these type of projections to save themselves from paying the insurance claim. The insurance companies are only interested in earning the premiums and find ways and means to decline claims. The above said view was taken by the Hon'ble Justice Ranjit Singh of Punjab and Haryana High Court in case titled as New India Assurance Company Limited versus Smt. Usha Yadav and others 2008 (3) R.C.R. 9 Civil III.
12. So, in view of the above discussion, the present complaint is allowed and the opposite parties are directed to pay Rs. 3,50,000/- to the complainant alongwith interest @ 9% per annum from the date of filing the present complaint till realization. The opposite parties are further directed to pay Rs. 5,000/- as compensation and Rs. 5,000/- as litigation expenses to the complainant. This order shall be complied with within 30 days from the date of the receipt of this order. Copy of this order be supplied to the parties free of costs. The file be consigned to the records.
ANNOUNCED IN THE OPEN FORUM:
23rd day of February 2018
(Sukhpal Singh Gill)
President.
(Vandna Sidhu)
Member
