Icici Prudential Life Insurance Company Ltd vs Preeti Prasad

THIS revision petition has been filed by the petitioner against the order dated 3.9.2013 passed by the Jharkhand State Consumer Disputes Redressal Commission, Ranchi (in short, ''the State Commission'') in Appeal No. 26 of 2013 M/s. ICICI Prudential Life Insurance Co. Ltd. Vs. Smt. Preeti Prasad by which, while dismissing appeal, order of District Forum allowing complaint was upheld.

BRIEF facts of the case are that Complainant/respondent obtained medi -claim policy from OP/petitioner for a sum of Rs.3,00,000/ - "Crisis Cover Insurance Policy" from 17.1.2008 which was renewed in the year 2009 and 2010, respectively. On 14.3.2010, complainant was admitted at Raj Hospital where she remained hospitalized till 30.3.3010 and on that date she was shifted to Apollo Hospital where she was kept on ventilator till 7.4.2010 and was discharged on 8.4.2010. Complainant incurred expenses around Rs.4,00,000/ - and submitted claim to OP which was repudiated on the ground that certain criteria under this disease has not been fulfilled. Alleging deficiency on the part of OP, complainant filed complaint before District Forum. OP resisted complaint and submitted that as under mentioned criteria "a) Requiring permanent oxygen therapy as a result of a consistent FEV1 test value of less than one litre (Forced Expiratory Volume during the first second of a forced exhalation).

b) Arterial Blook Gas analysis with partial oxygen pressure of 55 m.m. Hg or less.

c) Dyspnoea of rest. This diagnosis must be confirmed by a chest physician".

was not fulfilled, Claim was rightly repudiated and prayed for dismissal of complaint. Learned District Forum after hearing both the parties allowed complaint and directed OP to pay Rs.3,00,000/ - as per terms of policy and Rs.1,00,000/ - as compensation for harassment and Rs.10,000/ - as cost of litigation. Appeal filed by OP was dismissed by learned State Commission vide impugned order against which this revision petition has been filed.

HEARD learned counsel for the parties and perused record. Learned Counsel for the petitioner submitted that inspite of proof from medical record that complainant''s treatment was not covered under the criteria laid down in terms of conditions of policy documents, learned District Forum committed error in allowing complaint and learned State Commission further committed error in dismissing appeal; hence, revision petition be allowed and impugned order be set aside. On the other hand, learned Counsel for the respondent submitted that order passed by learned State Commission is in accordance with law; hence, revision petition be dismissed.

LEARNED Counsel for the petitioner submitted that as per policy document sent along with policy certificate complainant''s treatment for chronic lung disease does not fall within purview of criteria mentioned in the terms and conditions. Learned Counsel for the respondent submitted that this policy document was never sent to the complainant and he was given only Crisis Cover which does not include aforesaid criteria; hence, reliance cannot be placed on policy document. Learned Counsel for the petitioner has drawn my attention towards last note of Crisis Cover in which it has been mentioned that it is sales literature indicative of terms, conditions, warranties and exceptions, but in the event of conflict between the terms and conditions contained in sales literature and contained in policy documents, the terms and condition contained in policy documents shall prevail.

LEARNED Counsel for the petitioner could not place any document on record to substantiate that this policy document was sent to complainant and was received by him. In such circumstances, there was no question of availing free look period of 15 days and complaint cannot be bound by terms of policy document.

AS per last note of alleged sales literature this literature nowhere contains any criteria for chronic lung disease and in such circumstances, merely because certain criteria have been laid down in alleged policy document in chronic lung disease, complainant cannot be denied benefit of treatment taken for chronic lung disease.

EVEN if it is presumed that criteria mentioned in policy document is applicable, OP has not adduced any evidence to prove that complainant did not make criteria for coverage under chronic lung disease. Learned Counsel for the petitioner submitted that in different reports dated 20.3.2010, complainants PCO2 and PO2 were not as per criteria given in Clause ''B'' of chronic lung disease in policy document. During course of arguments, learned Counsel for the petitioner was unable to give full name of PCO2 and PO2 and in such circumstances, it cannot be concluded that complainant''s case did not fall under this criteria. Not only this, complainant examined Dr. Shyam Lal Sarka who deposed that on account of chronic lung disease, complainant suffered respiratory failure and she was kept under ventilator support from 15.3.2010 to 30.3.2010 and on 30.3.3010 referred to Apollo Hospital. He has specifically stated that he was Chest Physician in Raj Hospital even then he was not cross -examined by Counsel for OP before District Forum who could have apprised whether complainant''s case was covered or not covered under the criteria mentioned in the policy document. In absence of any cross -examination, learned District Forum has not committed any error in allowing complaint to the extent of grant of Rs.3,00,000/ - as sum assured.

LEARNED District Forum also allowed Rs.1,00,000/ - as compensation. There was no justification for allowing huge compensation of Rs.1,00,000/ - while allowing assured amount of Rs.3,00,000/ - particularly when OP''s defence was that policy document was sent along with policy certificate which contained necessary requisites for availing benefits pertaining to chronic lung disease. In such circumstances, it would be appropriate to allow only Rs.25,000/ - as compensation instead of Rs.1,00,000/ - and to this extent, order of District Forum is modified.

CONSEQUENTLY , revision petition filed by the petitioner is partly allowed and impugned order dated 3.9.2013 passed by the State Commission in Appeal No. 26 of 2013 M/s. ICICI Prudential Life Insurance Co. Ltd. Vs. Smt. Preeti Prasad and order of District Forum in Complaint No.227/2010 Smt. Preeti Prasad Vs. M/s. ICICI Prudential Life Insurance Co. Ltd. is modified and compensation of Rs.25,000/ - is substituted instead of Rs.1,00,000/ - allowed by District Forum. Petitoner is directed to make payment of aforesaid amount to respondent within four weeks failing which; petitioner would be liable to pay interest @ 9% p.a. from 28.12.2012 till payment.