State Consumer Disputes Redressal Commission
Icici Prudential Life Insurance vs Anil Kumar Jain on 1 February, 2010
IN THE STATE COMMISSION:DELHI IN THE STATE COMMISSION: DELHI (Constituted under Section 9 of The Consumer Protection Act, 1986) Date of Decision: 01.02.2010 Appeal No. FA-09/27 ICICI Prudential Life Insurance Appellant Company Limited Registered Office at ICICI Pru. Life Towers, 1089, Appasahab Marathe Marg, Prabhadevi, Mumbai-400025. Also at: ICICI Prudential Life Insurance Company Limited, IIIrd Floor, Videocon Towers, Jhandewalan, New Delhi. Versus Sri Anil Kumar Jain Respondent S/o Sri Mangal Sen, R/o H.No. 4537, Opposite Syndicate Bank, Main road, Pahari Dhiraj, Sadar Bazar, Delhi. CORAM Justice Barkat Ali Zaidi President Mr. M.L. Sahni Member
1. Whether Reporters of local newspapers be allowed to see the judgment?
2. To be referred to the Reporter or not?
Justice Barkat Ali Zaidi(Oral)
1. This is an appeal against an exparte order. The District Forum(Central) in complaint case of the complainant awarded an amount of Rs. 1,91,437/- towards reimbursement of medical expenses with interest @ 9% payable from 28.11.2000 and a compensation Rs. 5,000/-, litigation costs Rs. 3,000/- in favour of the complainant and against the OP.
2. That is what brings the appellant OP Insurance Co. here in appeal in this Commission.
3. Allegations of the complainant in the complaint are that he is the life insurance policy holder containing nine Critical Illness Benefits effective from 24.7.03 to 24.7.2019 for a sum of Rs. 3 lacs.
He suffered from heart attack on 11.11.07 and was hospitalized wherefrom he was discharged on 16.11.07 and he paid to St. Stephen Hospital, New Delhi Rs. 1,91,437/- for his treatment which he claimed to be reimbursed from the OP insurance company on basis of his policy, but the OP company on 28.11.07 repudiated his claim informing that the illness for which he lodged Reimbursement Claim was not covered by the Critical Illness Benefit Rider provided in the insurance policy.
4. We have heard Sri S.K. Chaddha, counsel for the appellants and Ms. Babita Sharma, counsel for the respondent in this appeal.
5. As will appear from discharge summary Report issued by St. Stephen Hospital of the complainant, the complainant had a severe Chest Pain and the doctor attending him diagnosed Coronary Artery Disease (Unstable Angina III B), and placed an Stent inside his Right Coronary Artery (2.75 x 23 mm axxion) on 12.11.07, and his was a case of known type II Diabetes Mellitus and Hypertension.
6. The OP declined to pay, saying that the said nature of disease is not included in the definition of Heart Attack given in the policy. The discharge summary Report of the complainant shows that the complainant suffered with Unstable Angina, which means a condition where there is reduced blood supply to the Heart, while in Myocardial Infaraction which in common parlance is called as Heart Attack, there is complete cessation of blood supply, to the Heart. Thus the two conditions of the Heart are distinct to each other while in former there is reduced blood supply while in later there is no blood supply to the Heart and therefore Unstable Angina will not be covered under the meaning of the Heart Attack contained in the Policy.
Besides, it appears from the discharge summary, the ECG of the complainant was normal, the two tests which are diagnostic for heart attack viz. CPK & CK-MB tests relating to Cardiac Enzymes were also reported normal while according to the Policy in case of Heart Attack, the ECG must have changes in the ECG and Elevation of Cardiac Enzymes.
7. The District Consumer Forum repelled the contention of the OP company and passed an award as above in favour of the complainant respondent
8. The respondent suffered a heart ailment. It was found that he was suffering from Unstable Angina and a Stent was placed in his heart veins, in order to regularize the blood flow.
9. The Insurance Company refused payment of the insurance amount on the ground that the disease suffered by the respondent did not correspond to the symptoms laid down in their Insurance Cover. The Insurance Cover provides for payment of compensation for Critical Illness and one of them is Heart Attack. The definition given of the Heart Attach in the Cover-Note is as follows ;
Heart Attack : The death of a portion of heart muscle as a result of inadequate blood supply as evidenced by an episode of typical chest pain, new ectrocardiographic changes and by elevation of the cardiac enzymes. Diagnosis must be confirmed by a consultant physician.
10. The respondent company refused to pay the compensation on the ground that the disease suffered by the respondent did not fulfill the conditions as mentioned in the Insurance Cover Note.
11. It was pointed out from the side of appellant Insurance Company that no muscle of the Heart had become dead and no elevation of enzymes as noted above were found, and no changes were found in the ECG.
12. This Commission is wholly in disagreement with the view, that because of non fulfillment of aforesaid condition the complainant will not be entitled for compensation from the Insurance Company. It is manifest that the respondent suffered a serious Heart Ailment and an arterie was found blocked and a stent was placed. It was a very serious condition and if such a Heart Ailment is not compensatable, what other disease, will be required for grant of reimbursement. It is not open to the Insurance Company to place conditions which are unlikely to be fulfilled with a view to create a device to escape payment of compensation. It amounts to defrauding and cheating the customer. It is not open to Insurance Company to provide such particulars and details of the disease which quite often do not appear and which may provide a ground to the Insurance Company to avoid Payment of Compensation Symptoms appearing in all kinds of Heart Ailment cannot always be the same, and merely because all symptoms are not 100% the same, the Insurance Company cannot avoid compensation. The ailment suffered by the respondent was highly serious and life threatening and the spirit and purport of the agreement must be assumed to be such, as to provide for such serious disease of Heart.
13. Counsel for OP Insurance Co. argued that the agreement was duly signed by the respondent and that the complainant is an educated person, he should be presumed to know, what he is signing about, and the ethics of law provides that the parties should be made to abide by the agreement made by him. The counsel did not cite the new Supreme Court case of Grasim Industries Ltd. Vs M/s. Agarwala Steel 2010(1) S.C.J. 351 where this aspect has been emphasized, but we must be mindful of the same.
14. Judicial ethics becomes obliterated where there is fraud and deception. The obsequious insertion of such detail which may not get noticed, and be glossed over, and put in place with a view to act as an embargo when a demand for compensation is made, is not ethical in itself and the cry of ethics must rebound and hit back the Insurance Company itself.
15. The Insurance Company should not therefore be allowed to withhold reimbursement of treatment charges and the compensation on the grounds enumerated in the Cover Note and the appeal must therefore fail.
16. Appeal dismissed.
17. Bank Guarantee/FDR, if any furnished by the appellant, be returned forthwith.
18. A copy of this order as per the statutory requirements be forwarded to the parties free of charge and also to the concerned District Forum and thereafter the file be consigned to Record room.
19. Announced on 1st day of February, 2010.
(Justice Barkat Ali Zaidi) President (M.L. Sahni) Member ysc