National Consumer Disputes Redressal
Karuna Sharma vs Icici Lombard General Insurance ... on 28 March, 2016
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI REVISION PETITION NO. 618 OF 2016 (Against the Order dated 01/12/2015 in Appeal No. 10/2014 of the State Commission Rajasthan) 1. KARUNA SHARMA W/O LATE PIYUSH KANT SHARMA, PLOT NO. 402, J.D. TOWERS, BDI APARTMENT, SUNSHINE CITY ALWAR BY PASS ROAD,BHIWADI ALWAR RAJASTHAN ...........Petitioner(s) Versus 1. ICICI LOMBARD GENERAL INSURANCE COMPANY LIMITED & ANR. ZENITH HOUSE, KESHAVRAO KHADYA MARG, MAHALAXMI MUMBAI-40003 MAHARASHTRA 2. ICICI BANK RIICO CHOWK, BHIWADI DISTRICT-ALWAR RAJASTHAN ...........Respondent(s)
BEFORE: HON'BLE MR. JUSTICE V.K. JAIN, PRESIDING MEMBER HON'BLE DR. B.C. GUPTA, MEMBER For the Petitioner : Mr. Nityanand Singh, Advocate For the Respondent :
Dated : 28 Mar 2016 ORDER JUDGMENT JUSTICE V.K.JAIN, PRESIDING MEMBER (ORAL)
Late Sh. Piyush Kant Sharma, husband of the petitioner, took a home loan of Rs. 13,25,650/- from the respondent no. 2, ICICI Bank. The deceased also took an insurance policy issued by the respondent no. 1, ICICI Lombard General Insurance Co. Ltd., known as Home Safe - Secure Mind Policy. Under the said policy, the insured was covered to the extent of Rs. 13,50,000/-, in the event of his suffering from any of the following illnesses:-
"a) Cancer, End Stage Renal Failure, Multiple Sclerosis b) Undergoing of the following surgical procedures:
Major Organ Transplant, Heart Valve Replacement or Coronary Artery Bypass Graft.
c) Occurrence of the following medical events: Stroke, Paralysis and Myocardial Infarction"
2. The husband of the petitioner/complainant expired on 08.04.2012. He was suffering from Chronic Liver Disease/Leptospira Infection and was diagnosed as a case of Hepatic Encephalopathy and Hemolysis. He also took treatment in Indraprastha Apollo Hospital from where he was discharged on 17.02.2012. He was advised transplant of liver, but he expired before the said transplant could be carried out. On death of her husband, the petitioner/complainant submitted a claim for payment in terms of the policy taken by the deceased.
3. The claim was rejected by the insurer vide letter dated 25.07.2012, which, to the extent it is relevant, reads as under:-
"On examination and verification of the claim documents it is understood "On examination and verification of the claim documents it is understood that the inspired was a known case of Chronic Liver Disease/Leptospira infection and was diagnosed as a case of Hepatic Encephalopathy and Hemolysis which is evident from the Discharge Summary of Indraprastha Apollo Hospitals dated 17th Feb 2012. Further, it is also noted that the insured a known case of Chronic Liver Disease - Ethanol induced (Alcohol related) which is evident from the consultation records of Dr. Amitabha Dutta and the indoor case papers of Indraprastha Apollo Hospitals & Institute of Liver & Biliary Sciences.
There has been no loss suffered by the insured as per the 9 major medical illnesses and procedures defined and covered under the Policy. The claim falls outside the purview of the nine major medical illnesses and procedures defined and covered under the Policy.
Amongst other grounds of exclusion and non-applicability of the policy, the loss suffered by the insured falls under 3. General Exclusions Applicable to the Policy, Part II of the Schedule which is stated hereunder:-
"The Company shall not be liable for any loss or damage under this Policy:
5. Directly or indirectly caused by or contributed to by or arising out of usage, consumption or abuse of alcohol and/or drugs.
In view of the above reason and inter-alia stated we regret our inability to pay your claim."
4. Being aggrieved from the rejection of the claim, the complainant approached the concerned District Forum by way of a complaint. The complaint was resisted by the insurer primarily on the same ground on which the claim had been repudiated. The District Forum, vide its order dated 12.11.2013, allowed the complaint. Being aggrieved from the order passed by the District Forum, the respondent no. 1 approached the concerned State Commission by way of an appeal. Vide impugned order dated 01.12.2015, the appeal filed by the respondent no. 1 was dismissed. Being aggrieved, the petitioner/complainant is before us by way of this revision petition.
5. It is evident from a perusal of the insurance policy taken by the deceased that the said policy covered the life of the insured only in the event he suffered from any of the diseases specified in the said policy. Chronic liver disease/Leptospira Infection and Hepatic Encephalopathy and Hemolysis are not amongst the diseases covered under the policy taken by the deceased. Therefore, even if the deceased was not suffering from the diseases resulting in his death, at the time of taking the policy, he having died on account of having contracted disease not covered by the insurance policy, the petitioner/complainant is not entitled to any payment from the insurer. The learned counsel for the petitioner/complainant submits that no documents were supplied to the deceased and therefore, he was not aware of the terms and conditions of the policy. In our opinion, the complainant/petitioner can have no personal knowledge as to which documents were made available by the insurer to the deceased. This is a matter which could be in the knowledge either of the insurer or of the insured. No communication was ever sent by the insured to the insurer alleging therein that the documents relevant to the policy had not been supplied to him. Had the requisite documents not been supplied to him, the least the deceased would have done was to right a letter to the insurer expressing such a grievance. That having not been done, the inevitable inference is that all the documents had been supplied to him and that is why no such grievance was expressed by him to the insurer.
6. More importantly, as far as this case is concerned, the illnesses covered under the policy are given in the policy itself. Here they are not indicated in some other documents such as an annexure to the policy or the terms and conditions applicable to the policy. Therefore, from a bare perusal of the insurance policy itself, it would have been known that the said policy covered only the diseases specified in Section 1 of the policy.
7. For the reasons stated hereinabove, we find no ground to interfere with the view taken by the State Commission. The revision petition is accordingly dismissed, with no order as to costs.
......................J V.K. JAIN PRESIDING MEMBER ...................... DR. B.C. GUPTA MEMBER