State Consumer Disputes Redressal Commission
Icici Prudential Lic vs Devendra K.Jain on 29 July, 2021
M.P.STATE CONSUMER DISPUTES REDRESSAL COMMISSION
PLOT NO. 76, ARERA HILLS, BHOPAL (M.P.)
APPEAL NO. 957/2013
1. ICICI Prudential Life Insurance Co.
Branch Office : Gujrati Bazar,
Opposite Delux Petrol Pump,
Sagar, Tahasil and District Sagar (M.P.),
Through Branch Manager, Sagar.
2. Ruchi Jain,
Agent,ICICI Prudential Life Insurance Co.
Branch Office : Gujrati Bazar,
Opposite Delux Petrol Pump,
Sagar, Tahasil and Branch Sagar (M.P.). ... Appellants
Vs.
Devendra Kumar Jain,
Aged about 64 years
S/o Late Laxmichand Jain,
Resident of Bhagwanganj, Sagar,
Tahasil and District Sagar (M.P.). ... Respondent
BEFORE;
HON'BLE DR. MONIKA MALIK, PRESIDING MEMBER.
HON'BLE SHRI S.S. BANSAL, MEMBER.
COUNSEL FOR THE PARTIES:
SHRI ARPIT SAXENA, LEARNED COUNSEL FOR APPELLANTS.
NONE FOR RESPONDENT.
: 2 :
ORDER
( 29.07.2021 ) The following order of the Bench was delivered by Dr. Monika Malik, Member.
This appeal, by the opposite parties/appellants, is directed against the order dated 7.3.2013, passed by the District Consumer Disputes Redressal Commission, Sagar (for short 'the District Commission'), in complaint case No.13/12, whereby the District Commission has partly allowed the complaint filed by the complainant/respondent and the opposite parties have been directed to give the insurance claim amount to the complainant, within a period of two months along with Rs.5,000/- as compensation, on account of deficiency in service with Rs.1,000/-, as costs.
2. Briefly put the facts of the case, as narrated by the complainant, are that the complainant had obtained an insurance policy from the opposite parties after giving requisite premium in this regard. The complainant had obtained aforesaid policy in August, 2010. In the night of 10.1 2011, the complainant fell from his bed and suffered injuries in his knee. After initial treatment at home, he visited a doctor on 13.1.2010, who advised him knee replacement. Subsequently, the complainant got admitted in the hospital from 10.3.2011 to 19.3.2011 and underwent surgery for total knee replacement on 11.3.2011. The complainant alleged that he had timely intimated the Insurance Co. regarding his treatment but was : 3 : denied insurance claim. Therefore, alleging deficiency in service on part of the opposite party, he filed a complaint seeking relief, before the District Commission.
3. The opposite party resisted the complaint stating that the complainant's treatment regarding knee replacement is not covered under clause 8.4.18 of the policy conditions. The complainant did not dispute the policy conditions within the free look period of 15 days and therefore, they are binding on him. Rs.6,000/- has already been given to the complainant, as treatment expenses but his insurance claim in entirety is not payable, as per the terms and conditions of the policy. Hence, this appeal.
4. Heard. Perused the record.
5. Learned counsel for the opposite party/appellant vehemently argued that, as per clause 8.4.18 of the policy terms and conditions, any expense incurred during first two years of the policy issuance date is not payable regarding joint replacements, except due to an accident. He drew out attention to various prescriptions and treatment sheets, including the discharge summary and submitted that the complainant was suffering from 'Osteoarthritis'. The total knee replacement (TKR) carried out in complainant's case is as a result of 'Osteoarthritis', as underlying cause. The complainant's case is not such that he suffered injuries due to an accident, because of which knee replacement was carried out. Therefore, the impugned order deserves to be set aside.
: 4 :6. Condition 8.4.18 of the policy, which is annexed as Annexure 'C', in the record of the District Commission, reads thus:-
"8. Exclusions: The Company shall not be liable to make any payments under this policy in respect of any expenses whatsoever incurred by any insured (person(s) in connection with or in respect of any of the following.
4) Any expense incurred during the first 2 years from policy issuance date or revival date in case the revival is after 60 days from the date of first unpaid premium shall not be payable for the following disease/surgeries & any complications arising out of them.
(18) Joint Replacements except due to an accident (one Knee or one Hip Replacement in a Policy year)."
7. In order to decide the question involved in the matter reference of certain documents, available in the record of the District Commission, is pivotal:
Page No.32, is the discharge summary of Sancheti Joint Replacement Centre. Here the diagnosis of the complainant is mentioned as: 'osteoarthritis both knee of right < left without distal neurovascular compromise'. Further the discharge summary also mentions 'No H/O Trauma' in the clinical findings.
Page 47 is a certificate from the same Centre. It, however, does mention that there is fall from bed at night on 10.1.2011 but the X-ray report at page 43 dated 13.1.2011, i.e. : 5 : just three days after fall, mentions opinion as 'Osteoarthritis seen'.
We further observe that page 44 is the prescription by Dr. Rajneesh Mishra, which mentions the patient's condition as, 'Extensive B/L Osteoarthritis', who 'Needs B/L TKR'.
8. Aforesaid documents leads us to conclude that Osteoarthritis was the reason for knee replacement and it is not possible that fall from bed on 10.1.2011 could lead to Osteoarthritis in three days time.
9. In view of the foregoing discussion, it is established that the complainant went for the knee replacement surgery on account of Osteoarthritis, which is not covered under the policy's terms and conditions. It is not a case, where the complainant met with an accident and was advised knee replacement surgery, which could then fall in the scope of insurance policy, issued by the appellant.
10. Therefore, in wake of the above discussion, we are of the considered opinion that the impugned order, which suffers from material irregularity, deserves to be and is hereby set aside. Consequently, the complaint is dismissed. The appeal filed by the appellants is allowed. However, no order as to costs of this appeal.
(DR. MONIKA MALIK) (S.S. BANSAL)
PRESIDING MEMBER MEMBER
Mercy