IMPORTANT POINT
Insurance Company must clearly inform insured about terms and conditions of policy.

Prem Narain, Presiding Member—The present first appeal has been filed by the appellants A. Hyma and another against the impugned order dated 2.5.2012 of the State Consumer Disputes Redressal Commission, Kerala, Thiruvanthapuram (hereinafter referred as the ‘State Commission’) passed in Consumer Complaint No.18/2009.

2. The brief facts as recapitulated from the complaint are that the first complainant is the wife of one deceased P.N. Pradeep Kumar and the second complainant is the son of the deceased Pradeep Kumar who are the legal heirs and that the said Pradeep Kumar was insured by the opposite parties. It is the case of the complainants that the deceased Pradeep Kumar had taken an insurance policy from the first opposite party in the year 2006 and that he had renewed the policy in the subsequent year and also that the insured when faced with a critical illness inclusive of coronary artery decease had applied for a sum of Rs. 3,90,000/- for the treatment as assured by the opposite parties as per the policy conditions. It is alleged that though the insured had produced necessary certificates for the treatment, the opposite parties did not pay the sum consequent to which the surgery was prolonged and finally on 4.9.2008 the insured was taken to Malabar Institute of Medical Science Ltd, Kozhikode and though the surgery was fixed to be done on 5.9.08 by 6 A.M., the insured succumbed to his illness. The very case of the complainants is that if the opposite parties had disbursed Rs. 3,90,000/- at the appropriate time, the surgery could have been done and the complainant’s life could have been saved.

3. The complainants then filed the consumer complaint no.18/2009. The OP resisted the complaint. The State Commission after hearing both the parties allowed the complaint vide its order dated 2.5.2012 as under:

“It is found that the opposite parties had committed deficiency in service in not paying the death claim amount of Rs. 2lakhs even though they were aware of the fact that the insured had passed away on 15.9.2008. We also hold that since no separate compensation for deficiency in service is ordered, the complainant is entitled for the payment of Rs. 2lakhs with 12% interest from the date of complaint till payment. The complainants are also eligible for payment of Rs. 5,000/- towards costs of the proceedings."

4. The complainants have filed the present appeal against the above order of the State Commission.

5. Heard the learned counsel for both the parties and perused the record.

6. The learned counsel for the appellants stated that though he State Commission has allowed the death claim of Rs.2 lakhs as per the policy condition, however, the claim in respect of the Critical Illness Benefit has not been awarded by the State Commission for which the complainants are entitled.

7. The learned counsel mentioned that insured suffered Chest Pain on 30.3.2008. Though he was relieved after one day but he was advised Bye Pass Surgery by the treating doctor. Accordingly, he filed the claim with OP insurance company under the heading of Critical Illness Benefit. The OP did not allow the claim under the head of Critical Illness Benefit on the ground that the disease of the insured cannot be treated as heart attack as defined in the policy. However, the bye pass surgery could not take place and ultimately the insured died on 5.9.2008. The learned counsel argued that first of all the insured had suffered heart attack as was diagnosed by the doctors in the common parlance and he was advised to go for bye pass surgery. Critical illness of heart attack is covered in the list of critical illnesses in the policy. Under the heading of Critical Illness Benefit, the learned counsel drew attention to Critical Illness Benefits as given in the policy which states as under:

“Critical Illness Benefit - In the event of the Assured’s survival for a period of at least thirty (30) days following a first diagnosis of Critical Illness or first performance