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 :

O R D E R

( 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 pa

Click Here to Read the rest of this document