State Consumer Disputes Redressal Commission
Icici Prudential Life Insurance ... vs Vivek Jain on 4 March, 2021
FIRSTADDITIONAL BENCH
STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
PUNJAB, CHANDIGARH.
First Appeal No.786 of 2019
Date of Institution : 29.11.2019
Date of Reserve : 03.02.2021
Date of Decision : 04.03.2021
1. M/s. ICICI Prudential Life Insurance Company Ltd,
Registered Officer, ICICI Pru Life Towers, 1089,
Appasaheb Marathe Marg, Prabhadevi, Mumbai-400025.
2. ICICI Prudential Life Insurance Co. Ltd., Branch Office at
Bathinda through its Branch Manager.
.......Appellants/Opposite Parties
Versus
1. Vivek Jain S/o Balwant Jain, House No.5146, Cozy Home
Street No.6, Nai Basti, Bathinda, Punjab.
2. Rimpy Jain W/o Vivek Jain, House No.5146, Cozy Home
Street No.6, Nai Basti, Bathinda, Punjab.
.......Respondents/Complainants.
First Appeal against order dated
10.10.2019 passed by District
Forum (now Commission),
Bathinda.
Quorum:-
Mr. Rajinder Kumar Goyal, Presiding Member.
Ms. Kiran Sibal, Member.
Present:-
For the appellants : Sh. U.K. Kanwar, Advocate For the respondents : Sh. Nitish Garg, Advocate ..................................................................................F.A. No.786 of 2019 2
KIRAN SIBAL, MEMBER:-
This appeal has been preferred by the appellants against order dated 10.10.2019 passed by District Consumer Disputes Redressal Forum, Bathinda (in short, "the District Commission"), whereby the complaint filed by respondents/complainants, was partly accepted and District Commission passed the following order:-
"For the reasons recorded above, the complaint is partly accepted with Rs.5,000/- as cost and compensation against opposite parties. Opposite parties are directed to settle the claim of the complainants as per terms and conditions of the policy and pay amount found payable to the complainants. The compliance of this order be made within 45 days from the date of receipt of copy of this order".
It would be apposite to mention that hereinafter the parties will be referred, as have been arrayed before the District Commission.
Facts of the Complaint
2. Brief facts, as averred in the complaint, are that complainant No.1-Vivek Jain purchased medical Insurance Policy of 'ICICI Prudential Life Insurance Co. Ltd.' in his name under 'Pru Health Saver' from opposite parties at Bathinda in the month of January 2013. As per oral assurance of OP No.2, complainant No.1 and his family including complainant No.2 F.A. No.786 of 2019 3 were covered under this medical insurance policy. The officials of OPs assured them to provide best services regarding insurance policy and he was required to deposit a sum of Rs.44,000/- per annum with OPs for the same. OPs assured the complainants that after completion of two years from the date of purchase of the policy, complainant No.1 and his family including complainant No.2 shall be entitled for the cashless hospitalization for any type of disease from the Network Hospitals of OPs. It was alleged that the signatures of the complainants were obtained by the officials/insurance advisers of OP No.2 on various blank printed forms, without explaining their contents. After few days, OP No.2 informed the complainant No.1 that his policy is issued bearing No.17357812, but the complainants never received any policy containing its detailed terms and conditions from OPs till date. As such, the complainants were totally unaware of terms and conditions of the policy. Complainant No.1 continued depositing the premiums amount of Rs.44,000/- per annum with OPs i.e. Rs.44,000/- for the first year on 11.01.2013, Rs.44,000/- on 30.06.2014 and Rs.44,000/- on 03.03.2015. It was further alleged that at the time of deposit of second premium, OP No.1 had ensured the complainant No.1 that the delay premium would not be effected on the policy benefits. Unluckily, the complainant No.2-Rimpy Jain fell ill in the last week of March 2016. On 01.04.2016, complainant No.1 took complainant No.2 F.A. No.786 of 2019 4 to Dr. Rupinder Kaur Nagpal, but there was no improvement in the health of complainant No.2. On 20.05.2016, she had undergone Ultra Sono Graphy from Nagpal Super Specialty Hospital, Bathinda. She was diagnosed to be a case of Adenomyosis with Sub mucous seedling Fibroid Uterus with PID. As such, she was got admitted in Delhi Nursing Home, Bathinda on 21.05.2016 and remained admitted in this hospital upto 23.05.2016. She underwent for surgery of Hysterectomy and was discharged on 23.05.2016. She was treated for the ailment and doctor concerned charged a sum of Rs.32,000/- from complainant No.1 for treatment including admission fee, operation fee, OT charges, Anesthesia fee, room charges, doctor visit fee and nursing case fee and the same was paid by complainant No.1 on 23.05.2016, vide receipt No.519. Complainant No.1 also purchased medicines from R.S. Medical Agencies, The Mall, Bathinda against proper bills and spent Rs.32,000/. In this way, he spent approx. Rs.64,000/- for treatment of complainant No.2. It was further submitted that the complainant No.1 applied for reimbursement of amount spent by him for the treatment of complainant No.2 and supplied copies of the bills issued by the doctors as well as bills issued by M/s R.S. Medicos, Bathinda and all the requisite documents including treatment record of complainant No.2, but OPs failed to honour the claim of the complainants. OPs repudiated the F.A. No.786 of 2019 5 claim vide their letter dated 30.05.201.6 on the following grounds:-
" (a) Any expense incurred during the first two years from policy commencement 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 diseases or surgeries and any complications arising out of them and
(b) Hysterectomy for Fibroids, Menorrhagia, Dysfunction all Utering Bleedings, Utering Prolapse".
It was further submitted that the claim had been illegally and arbitrarily repudiated by OPs on the basis of total false ground as the policy was never elapsed, rather it was continuing since the date of purchase. The complainants were never informed by OPs that Hysterectomy for Fibroids, Menorrhagia, Dysfunctional Uterine Bleeding, Uterine Prolapse are not covered under the policy. It was rather assured that after completion of two years from the date of purchase, every problem shall be covered under the policy. Complainants alleged deficiency in service and unfair trade practice on the part of OPs and prayed that OPs be directed to reimburse the medical claim of Rs.64,000/- and further be directed to pay Rs.50,000/- as compensation and Rs.5500/- as litigation expenses.
F.A. No.786 of 2019 6Defence of the Opposite Parties
3. Upon notice, opposite parties appeared and filed joint written reply, by raising preliminary objections that complaint is false frivolous, and vexatious. This Forum had no jurisdiction to entertain the complaint. It was alleged that OPs received duly filled up and signed proposal form. On the basis of information given by the complainants in the proposal form, the policy in question was issued as per their consent and they were explained terms and conditions. Being satisfied with terms and conditions, they signed the proposal form and declaration in the proposal form thereof that they had read the proposal form and after fully understanding the contents thereof and terms and conditions of the plan, have applied for same. Thereafter, OPs issued the policy to the complainants. It was further revealed that the complainants made several claims during the period 2014-2016 and OPs had duly made the payment in accordance with terms of the policy contract. The complainants never approached OPs for non- receipt of policy documents. It was further mentioned that the renewal premium under the policy which was due on 27.02.2014 was paid by the complainants on 30.06.2014. The complainants failed to pay the renewal premium on the due date and even within the grace period. Accordingly, the policy moved to lapsed status, as per terms of the policy contract. Thereafter, the complainants approached OPs for re-instatement of the policy alongwith the F.A. No.786 of 2019 7 Personal Health Declaration Form and also paid the renewal premium amount of Rs.44,000/- on 30.06.2014. OPs sent letter dated 04.07.2014 asking the complainants to submit the medical reports and they submitted the medical reports on 30.07.2014 and policy was reinstated on 04.08.2014. The policy was in the lapsed status from 27.02.2014 to 04.08.2014, i.e. for a period of 6 months. OPs had reproduced some relevant clauses of the policy contract, reproduction of which are not necessary for the sake of brevity. It was further alleged that after reinstatement of the policy, the complainants had submitted various claims under the policy and OPs had duly paid the claim amount in accordance with terms of the policy contract. The details of the previous claims are also revealed, but reference of which was not necessary. It was further revealed that OPs received claim intimation from the complainants on 27.05.2016, wherein it was mentioned that Complainant No.2 was diagnosed with Uterine Fibroid and was admitted on 21.05.2016 and was discharged on 23.05.2016 and whereby the complainants claimed the hospitalization expenses. On receipt of the claim, OPs evaluated the claim and it was revealed that the illness for which the complainant No.2 was diagnosed and admitted, falls within the 'Exclusion Clause' of the policy contract. As such, nothing was payable to the complainants. Accordingly, OPs repudiated the claim vide letter dated 30.05.2016 in accordance with terms and conditions F.A. No.786 of 2019 8 of policy contract. On merits also, similar averments were made as already mentioned as preliminary objection in the written reply by OPs and prayed for the dismissal of the complaint. Evidence of the parties
4. In support of their claim, the complainants tendered in evidence as Ex.C-1 to Ex.C-21 alongwith affidavit of Complainant No.1-Vivek Jain as Ex.C-22.
5. To rebut the aforesaid evidence, OPs tendered in evidence affidavit of Reema Makhija, Senior Manager-Legal as Ex.OP1/1 along with documents i.e. Ex.OP1/2 to Ex.OP1/4. Findings of the District Forum
6. The District Commission, after going through the record and hearing learned counsel on their behalf, partly accepted the complaint of the complainants, vide impugned order. Hence, this appeal.
Contentions of the Parties
7. We have heard learned counsel for the parties and have carefully gone through the record of the case as well as their written arguments.
8. Learned counsel for the appellants has vehemently argued that Vivek Jain-respondent after completely understanding and satisfying himself of the terms and condition of the product "Health Saver, U56" had submitted the duly F.A. No.786 of 2019 9 signed Proposal Form dated 11.01.2013. The contents of the Proposal Form were explained to the respondent and he had also given a Declaration stating that the respondent had furnished the information after fully understanding the contents thereof and also after understanding the terms and conditions of the plan that the respondent had applied for and had made true and accurate disclosure of all the facts and had not withheld any information. It was further argued that upon receipt of the duly filled up Proposal Form and believing the information provided by the respondent to be true and correct, along with the initial Premium, the appellant evaluated and processed the Proposal Form on the basis of the information furnished by respondent and issued Policy bearing No.17357812 on 27.02.2013 stipulating for an annual premium of Rs.44,000/- annually. The said policy was issued by the appellants relying upon the information provided in the Proposal Form, regarding the various aspects including the personal, professional and other details. It was submitted that appellants had never raised the issue of non receipt of policy documents but had approached the Respondent-Company for several claims from the period 2014-2019 and that the appellants had duly made the payments in accordance with the terms of the policy contract which clearly establishes the fact that the respondent had duly received the policy bond and was aware of the terms and conditions. It was relevant to mention herein that the F.A. No.786 of 2019 10 renewal premium under the said policy was due on 27.02.2014 but he failed to pay the renewal premium even in the grace period, therefore, the policy lapsed. Respondent after several reminders paid the policy premium on 30.06.2014 along with the PHD form dated 01.07.2014 (form for reviving the policy). Respondent approached the appellants for re-instatement of the policy along with the Personal Health Declaration Form and also paid the renewal premium amounting to Rs.44,000/- on 30.06.2014 which was approximately after four months from the due date of policy. Appellants had sent a letter dated 04.07.2014 asking the respondents to submit the medical reports and respondent submitted the medical reports on 30.07.2014. The policy revival was equivalent to issuing a fresh policy contract and therefore, there are some rules as per the underwriting guidelines of the company. The last requirement raised by the company was submitted only on 30.07.2014. Accordingly, the policy was re-instated on 04.08.2014. It was submitted that the policy was in the lapsed status from 27.02.2014 to 04.08.2014, i.e. for a period of six months. Averring on similar lines as stated in the appeal, learned counsel for the appellants prayed for allowing the appeal.
9. Learned counsel for the respondents had vehemently argued that District Forum had rightly allowed the complaint of respondent No.1. It was further argued that there is nothing on record to prove the fact that the policy had been F.A. No.786 of 2019 11 obtained by fraud and there was any suppression of material facts. A perusal of Ex.C-21 of the record reveals that the next date of renewal is 27.02.2017 and therefore, it was to be inferred that the appellant used to receive the premiums from 27th February of every year. It was submitted that the policy had never been elapsed as they had renewed the policy from the back date as it would be clear from the receipt Ex.C-21, therefore, the exclusion clause was not applicable to the respondents. It was settled law that on the revival, the policy relates back to the date on which it was issued. The premium paid on 30.06.2014 relates back to the date 27.02.2014 and therefore, the exclusion was not applicable to the respondents. Learned counsel for the respondents has also relied upon judgment passed by the Hon'ble National Consumer Disputes Redressal Commission in Revision Petition No.3234 of 2018 titled as "Sunita Devi Vs. Branch Manager, Life Insurance Corporation of India & Anr" in support of his contentions. Averring on similar lines as stated in written reply, learned counsel for the respondents prayed for dismissal of the appeal. Consideration of Contentions
10. We have given our thoughtful consideration to the contentions raised by the parties and have carefully gone through the record of the case as well as their written arguments.
F.A. No.786 of 2019 12
11. The admitted facts of the case are that respondent/complainant purchased medical Insurance Policy of 'ICICI Prudential Life Insurance Co. Ltd.' in his name under 'Pru Health Saver' from opposite parties at Bathinda in the month of January 2013. Complainant No.1 and his family including complainant No.2 are covered under the said medical insurance policy and annual premium of policy was Rs.44,000/-. Respondent No.2 was admitted to the hospital on 21.05.2016 due to the Uterine Fibroid which was within two years from the date of re-instatement of the policy after the lapsed status. When the claim for reimbursement was lodged with the appellants the same was repudiated (Ex.C-1) on the ground that there is waiting period of two years from the date of re- instatement i.e. 04.08.2014, as per clause 8(8) of the policy contract.
12. The main grievance of the appellants/OPs is that the District Commission failed to appreciate the fact that the claim of the respondents/complainants was rightly repudiated by it on the ground of the "Exclusion clause" of the policy contract. It has been submitted that the policy was reinstated on 04.08.2014 after receipt of premium from complainant on 30.06.2014. The renewal premium under the said policy was due on 27.02.2014 but the respondent after several reminders have paid the policy premium only on 30.06.2014 i.e. after a gap of four months. The case of the appellants/OPs is that F.A. No.786 of 2019 13 respondent failed to pay the renewal premium on the scheduled due date and even within the grace period, accordingly, the policy moved to lapsed status for a period of six months i.e. from 27.02.2014 to 04.08.2014 as per the terms of the policy contract. Thereafter, the policy was reinstated on 04.08.2014 by the appellants/OPs who also took the Personal Health Declaration Form (Ex.C-4).
13. On the other hand, the case of the respondents is that respondent No.2 was admitted to the hospital on 21.05.2016 due to the Uterine Fibroid which was within two years from the date of re-instatement of policy after the lapsed status. When the claim for reimbursement was lodged with the appellants the same was repudiated on the ground that the waiting period of two years from the date of re-instatement i.e. 04.08.2014, as per clause 8(8) of the policy contract has lapsed. But the District Commission had partly allowed the complaint of the complainants/respondents due to which the present appeal has been filed.
14. At the onset, to determine the present controversy, it would be relevant here to discuss the exclusion clause of the policy under which the claim has been repudiated. As per exclusion clause 8(8) of the Insurance Policy Contract it is stated as under:-
F.A. No.786 of 2019 14
"8. (a) Any expense incurred during the first two years from Policy Commencement 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 diseases or surgeries and any complications arising out of them and
(b) Hysterectomy for Fibroids, Menorrhagia, Dysfunctional Uterine Bleeding, Uterine Prolapse".
We have also carefully perused the condition No.9 which deals with revival (Re-instatement) of Lapsed Policy and the relevant portion of the policy is reproduced as under:-
" A Policy, which has lapsed for non-payment of premium within the days of grace, may be revived subject to the following conditions:-
a. The application for revival is made within 2 years from the due date of the first unpaid premium and before the Cover Cessation Date. Revival will be based on the then applicable revival norms of the Company.
b. The revival of the Policy may be on terms different from those applicable to the Policy before it lapsed.
c. In case of Family Floater Cover, the application for revival should be made for all Insured Person(s).
d. No Waiting Period will be applicable for any revival within 60 days from the due date of the first unpaid premium.
e. There shall be a Waiting Period of 30 days from the date of revival applicable for all Insured Person(s) where the Policy was lapsed for a period of more than 60 days from the date of first F.A. No.786 of 2019 15 unpaid premium. Also, all exclusions applicable at the Policy Commencement Date shall once again become applicable.
f. The Company may subject all the Insured Person(s) to medical examination before taking a decision on the revival of the Policy. The Policyholder shall have to furnish, at his own expense, satisfactory evidence of health as required by the Company.
g. No benefit is payable for an Event which occurred or symptoms of which first occurred or were first diagnosed during the period when Policy was in lapsed condition.
h. The revival will take effect only on its being specifically communicated by the Company to the Insured Person(s)".
In the instant case, the patient was operated for hospital for Hysterectomy for Fibroids which is not covered under the policy contract as stated in exclusion clause 8.8 of the policy contract as reproduced above.
15. It has been contended by the counsel for the appellants that the policy revival is equivalent to issuing a fresh policy contract and, therefore, there are some rules as per under written guidelines of the company. The fact that the policy was lying in a lapsed status from 27.02.2014 to 04.08.2014 i.e. for almost a period of six months is not disputed by any of the parties. Admittedly, the policy was re-instated on 04.08.2014 whereas the respondent/complainant No.2 was admitted in the hospital on 21.05.2016 (1 year 9 months from revival) due to F.A. No.786 of 2019 16 uterine fibroid which was within two years from the date of re- instatement of the policy contract.
16. In the present case, the unpaid premium was paid after a gap of four months. The Insurance Policy has clearly specified in clause 9(d) that no waiting period will be applicable for any revival within 60 days from the due date of the first unpaid premium. Further in the instant case, admittedly premium has been paid after four months only. Therefore, the revival will be passed on the then applicable, revival norms of the company. The re-instatement happened only on 04.08.2014, therefore all the exclusions are applicable once again as if they were at the time of policy commencement date. Therefore, in view of the waiting period of two years from the date of re-instatement i.e. 04.08.2014, as per clause 8(8) of the Insurance Policy, the complainant is not entitled to any insurance claim for the said treatment. Therefore, the claim of the complainant has been rightly repudiated by the Insurance Company. The District Commission has committed irregularity by not relying upon the evidence adduced by the appellants wherein the said disease was exempted under the exclusion clause and specific terms and conditions of the policy and has overlooked the same while passing the said order and is liable to be set aside.
17. It has also been observed by us, that on one hand the respondents/complainants is challenging the terms and F.A. No.786 of 2019 17 conditions and non receipt of the policy documents but on the contrary, he has also claimed for all health related benefits under the policy and even during the pendency of this appeal. The respondents have made several claims during the period 2014-2019 and the learned counsel for the appellants has stated in the written argument that they have reimbursed approximately Rs.2,87,027/- till date to the respondents for various claims raised with them strictly as per the terms and conditions, the details of the said claims are stated as below:-
Decision Claim paid as per T& C Date & Mode of
Payment
Paid Rs.5,000/- 13.11.2014-NEFT
Paid Rs.22,506/- 05.10.2015-NEFT
Paid Rs.5,000/- 14.05.2016-NEFT
Paid Rs.24,139/- 11.12.2017-NEFT
Paid Rs.2,938/- 29.05.2018-NEFT
Paid Rs.71,331/- 02.07.2018-NEFT
Paid Rs.5,000/- 29.11.2018-NEFT
Paid Rs.48,273/- 20.02.2019-NEFT
Paid Rs.1,02,840/- 29.08.2019-NEFT
The respondents have not rebutted the above said averments made by the appellants in the written submissions as well as during the course of arguments before us. Therefore, we are of the opinion that the appellants have been able to prove that the claims are paid in accordance with the terms and conditions of the policy and there is no deficiency on their part.
18. Sequel to the above discussion, we find merit in the appeal. Accordingly, the same is allowed and the order passed by the District Commission is set aside. The complaint filed by F.A. No.786 of 2019 18 the complainants before the District Commission is also dismissed.
19. The appellants had deposited a sum of Rs.25,000/- at the time of filing of the appeal. It further deposited an amount of Rs.25,000/- in compliance of order dated 04.12.2019 of this Commission. These amounts alongwith interest, which has accrued thereon, if any, shall be remitted by the registry to the appellants, whosoever deposited, after the expiry of 45 days of the sending of certified copy of the order to them in accordance with law.
20. The appeal could not be decided within the statutory period due to heavy pendency of work and less staff.
(RAJINDER KUMAR GOYAL) PRESIDING MEMBER (KIRAN SIBAL) MEMBER March 04, 2021.
SK