DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BATHINDA.
CC.No.542 of 31-10-2012
Decided on 19-03-2013
Madan Lal Jindal aged about 57 years S/o Ralla Ram R/o House No.20062, near Easyday, St.No.9/2, Jujhar Singh Nagar, Bathinda.
........Complainant
Versus
1.Bajaj Allianz Life Insurance Company Ltd., regd. And Head Office at GE Plaza, Airport Road, Yarwada, Pune-471 006, through its Chairman/Managing Director.
2.The Branch Manager,Bajaj Allianz Life Insurance Company Ltd.,, The Mall, Bathinda.
.......Opposite parties
Complaint under Section 12 of the Consumer Protection Act, 1986.
QUORUM
Smt. Vikramjit Kaur Soni, President.
Sh.Amarjeet Paul, Member.
Smt.Sukhwinder Kaur, Member.
Present:-
For the Complainant: Sh.Sandeep Bansal, counsel for complainant.
For Opposite parties: Sh.M.L Bansal, counsel for opposite parties.
ORDER
VIKRAMJIT KAUR SONI, PRESIDENT:-
1. The complainant has filed the present complaint under section 12 of the Consumer Protection Act, 1986 as amended upto date (Here-in-after referred to as an 'Act'). The brief facts of the complaint are that the complainant is having life insurance policy bearing No.0235155690, which covers risk of his family also and has paid the insurance premium to the opposite parties. The adviser/agent of the opposite parties met the complainant and his family members and influenced that his company i.e. the opposite party No.1 is the best company to cover the life risk, hospitalization and illness including his family and to make the payment of the hospitalization and medical expenses and also to give the good benefits and returns on the amount given to the opposite parties as premium by the consumer. On the allurement of the adviser/agent of the opposite party No.1, the complainant has purchased the said policy on dated 9.11.2011, which covers risk of his family also and has paid the insurance premium to the opposite parties, which is valid from 8.11.2011 and they gave Rs.4 lacs risk cover on the said policy to him and his family members. The opposite parties issued the health cards in favour of the complainant and his wife Pushpa Jindal and regular premium of Rs.21,114/- has been paid to them. The wife of the complainant namely Pushpa Jindal became ill in the month of April, 2012 due to the heart problem and she was diagnosed as Rheumatic heart disease and she was got admitted in Post Graduate Institute of Medical Education and Research, Chandigarh on 16.4.2012 for her treatment and has undergone the various medical tests and thereafter she has undergone valve replacement surgery and was medically treated and more than 6 lacs on her treatment, medicines, special diet, conveyance and transportation has been spent/incurred by the complainant and she was discharged on 22.5.2012 from PGI, Chandigarh. The complainant had applied for the mediclaim with the opposite parties vide claim No.AZBJ/00115464, but his claim was repudiated on the ground that the same is inadmissible and the claim does not fall under the purview of the policy for the reason that verification of the claim document reveal that the patient is diagnosed of Rheumatic heart disease and undergone for valve replacement surgery. As per policy terms & conditions, the expenses related to the valve replacement have waiting period in the said policy. Hence the claim is not payable and the opposite parties repudiated his claim vide their repudiation letter dated 10.7.2012. The complainant alleged that his claim has been rejected against the law and facts and without any basis. Hence the complainant has filed the present complaint alleging unfair trade practice on the part of the opposite parties to seek the directions to them to pay the insurance amount of Rs.4 lacs alongwith interest, cost and compensation.
2. Notice was sent to the opposite parties. The opposite parties after appearing before this Forum have filed their joint written statement and pleaded that no cause of action has arisen in favour of the complainant as the claim for reimbursement of medical expenses incurred for treatment of his wife, lodged by him is neither covered not admissible as per the terms & conditions of the said policy. The wife of the complainant namely Smt.Pushpa, was admitted in PGI, Chandigarh on 16.4.2012 i.e. within just 4 months of the policy commencement date (8.11.2011) for the treatment of Rheumatic Heart Disease and undergone Valve Replacement but the above diseases have a waiting period of 3 years from the date of commencement of the said policy. The treatment taken for the diseases suffered by the wife of the complainant are covered from the first renewal date i.e. 3 years after the commencement of the said policy and the claims arising out of the said diseases if suffered after 3 years from the date of commencement are liable to be paid only after the first renewal date or date of revival whichever is later. The first renewal date under the policy is 8.11.2014 whereas the complainant lodged the claim for reimbursement of medical expenses incurred for admission of his wife on 16.4.2012 i.e. within just 4 months of the commencement of the said policy. The claim is legally and rightly rejected by the insurance company vide letter dated 10.7.2012 as per the terms & conditions. As per the terms & conditions of the said policy, the claim was repudiated on waiting Clause 8 read with Exclusion Clause 6b. The said policy was issued to the complainant and the claim, if any, was/is payable as per the terms & conditions of the said policy. The complainant after fully understanding the terms & conditions & exclusion clauses, himself out of his free will opted for the Family Care First Policy and the said policy was issued to him in accordance with the proposal made by him. The complainant received the original policy bond containing the express terms & conditions of the said policy as approved by the statutory body namely I.R.D.A. The complainant himself approached the opposite parties for taking the medical insurance policy and all the terms & conditions of the policy including the exclusion clauses were conveyed to him in detail and he after hearing, understanding and while admitting the same to be accepted, filled and signed the proposal form and accordingly the policy documents containing complete policy schedule, terms & conditions, exclusion clause and also free look letter was issued to him, whereby he has right to reconsider his policy within the period of 15 days but he has not availed the free look period, which clearly shows that he was well aware about the terms & conditions of the said policy as well as exclusion clause thereof and has accepted the same. The complainant has never raised any protest or objection against the terms & conditions of the said policy and no complaint was ever lodged by him that the promises made to him at the time of solicitation of the insurance business are not part of the express terms & conditions of the policy document. Since the claim for reimbursement lodged by the complainant related to diseases suffered during the waiting period, thus the claim is not tenable and admissible and the same was repudiated.
3. The parties have led their evidence in support of their respective pleadings.
4. Arguments heard. The record alongwith written submissions submitted by the parties perused.
5. Admitted facts of the parties are that the complainant has purchased the insurance policy bearing No.0235155690 on dated 9.11.2011 and the opposite parties paid the regular premium of Rs.21,114/- and risk cover of Rs.4 lacs to him. The said policy was valid upto 8.11.2011. The wife of the complainant namely Pushpa Jindal became ill in the month of April, 2012 due to the Rheumatic heart disease and she was got admitted in Post Graduate Institute of Medical Education and Research, Chandigarh on 16.4.2012 and has undergone the various medical tests and thereafter she has undergone valve replacement surgery and was discharged on 22.5.2012 from PGI, Chandigarh. The complainant has lodged the claim vide claim No.AZBJ/00115464 to the opposite parties but they have rejected his claim vide letter dated 10.7.2012.
6. The disputed facts between the parties are that the complainant alleged that he has paid the premium and the risk is covered for upto 4 lacs and he is entitled to get the amount spent on the treatment of his wife but the opposite parties have rejected his claim vide letter dated 10.7.2012 on the ground that as per policy terms & conditions, the expenses related to the valve replacement have waiting period in the said policy. The said policy commencement date was 8.11.2011 and the wife of the complainant was admitted in PGI, Chandigarh on 16.4.2012 i.e. within the policy commencement date for the treatment of Rheumatic Heart Disease and undergone Valve Replacement but the above diseases have a waiting period of 3 years from the date of commencement of the said policy. The treatment taken for the diseases suffered by the wife of the complainant are covered from the first renewal date i.e. 3 years after the commencement of the said policy and the claims arising out of the said diseases if suffered after 3 years from the date of commencement are liable to be paid only after the first renewal date or date of revival. The first renewal date under the policy is 8.11.2014 whereas the complainant lodged the claim for reimbursement of medical expenses incurred for admission of his wife on 16.4.2012 i.e. within just 4 months of the commencement of the said policy.
7. The claim has been rejected by the insurance company vide letter dated 10.7.2012 as per the Exclusion Clause 6b. The relevant portion of Ex.R3 i.e the repudiation letter dated 10.7.2012 is reproduced hereunder:-
“On detailed scrutiny of the same, we find that the claim does not fall under the purview for reasons given below:-
Verification of the claim document reveal that the patient is diagnosed of Rheumatic heart disease and undergone for valve replacement surgery. As per policy terms & conditions, the expenses related to the valve replacement have waiting period in the policy. Hence the claim is not payable.
Exclusion 6b
The Company shall not be liable to make any payment if Hospitalization or Medical expenses or claims are attributable to, or based on, or arise out of, or are directly or indirectly connected to any of the following: Hospitalization and/or treatment within the Waiting Period and Hospitalization and/or treatment following the diagnosis within the Waiting Period; |
Illness covered only after first Renewal 8:
The Company shall not be liable to make payment for the following illness only from the first Renewal Date or date of Revival, whichever is later, provided these illness are diagnosed or Hospitalization or Medical Expenses incurred after the first Renewal Date or date of Revival, whichever is later; Any heart related disease, Tympanoplasty, Valve Replacement, Valvotomy, Cerebral Hemorrhage; Angiographies, Angioplasty ( with or without stent) Coronary Artery Bypass Graft unless post Accident. The first Renewal will be due after three years from the Policy Commencement Date. |
Hence we regret to inform you that the claim is inadmissible and thus repudiated, we have retained the claim docket for future reference.”
Further page 10 of 18 of the policy document Ex.R2 shows the 'Illness covered only after first Renewal'. The relevant portion of this is reproduced:-
“ Illness covered only after first Renewal
8) The Company shall be liable to make payment for the following illness only from the first Renewal Date or date of Revival, whichever is later, provided these illness are diagnosed or Hospitalization or Medical Expenses incurred after the first Renewal Date or date of Revival, whichever is later.
Any heart related disease, Tympanoplasty, Valve Replacement, Valvotomy, Cerebral Hemorrhage; Angiographies, Angioplasty ( with or without stent) Coronary Artery Bypass Graft unless post Accident.
The first Renewal will be due after three years from the Policy Commencement Date.”
The complainant has nowhere averred in his complaint that the policy documents are not supplied to him. The complainant after fully understanding all the terms & conditions, schedules, benefits and exclusions etc. of the said policy has purchased the same with his own free will. Thus the terms & conditions of the said policy are binding on the complainant as well as the opposite parties as the insurance is a contract.
8. Therefore in view of what has been discussed above, the opposite parties have rightly repudiated/rejected the claim of the complainant. Hence we find no merits in the complaint and this complaint is hereby dismissed without any order as to cost.
9. A copy of this order be sent to the parties concerned free of cost and file be consigned to the record room.
Pronounced in open Forum:-
19-03-2013
Vikramjit Kaur Soni
President
Amarjeet Paul
Member
Sukhwinder Kaur
Member
