PBEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM.
Dated this the 29th day of October 2011
Filed on :11/05/2010
Present :
Shri. A Rajesh, President.
Shri. Paul Gomez, Member. Member.
Smt. C.K. Lekhamma, Member
C.C. No. 287/2010
Between
Sony C.A. : Complainant
S/o. Andrecos, (By Adv. K.P. Paulose
Chakkinattu house, Murimattam,
Karingachira, Irumpanam, Aiswarya Building,
Ernakulam. 109, Valanjambalam
Ernakulam)
And
Bajaj Allianze Life Insurance co. Ltd., : Opposite party
40/8800 C, 2nd Floor, (By Adv. Jasmine V.H.,
DEVAS, MG Road, Vattoly complex, Kompara
Near Padma Jn Junction, Cochin-18)
Ernakulam, Pin-682 035.
O R D E R
A Rajesh, President.
The case of the complainant is as follows:
On 27-06-2009 the complainant availed himself of a family life insurance policy of the opposite party. The complainant, his wife and their two children were insured for Rs. 1 lakh each, policy was covering hospitalization expenses as well. On 16-08-2009 the complainant and his family members met with an accident. His wife Reji succumbed to the injuries. The complainant and his son Andrew were injured and taken to Lakeshore Hospital, Ernakulam. The complainant duly submitted application for insurance benefits, but the opposite party rejected the same. The complainant is entitled to get an insurance claim of Rs. 1 lakh for the death of his wife and Rs. 25,000/- towards medical expenses of the complainant together with compensation of Rs. 1 lakh and Rs. 25,000/- as legal expenses. This complaint hence.
2. Version of the opposite party.
The policy is a medi/health care policy and not a life insurance policy. As per the terms and conditions of the policy no death benefit will be payable in case of death of any member. As per clause 6 (K) of the policy terms and conditions one would be eligible for insurance claim only if there is hospitalization upon the advice of a doctor at least for 24 hours continuously. The complainant and his son have not been hospitalized for the above period. The opposite party has rightly rejected the claim of the complainant and there is no deficiency in service on their part.
3. The complainant was examined as PW1 and Exts. A1 to A3 were marked on his side. The witness for the opposite party was examined as DW1. Ext. B1 to B22 were marked on their side. Heard the counsel for the parties.
4. The points that arose for consideration are
i. Whether the complainant is entitled to get insurance claim of
Rs. 1 lakh for the death of his wife?
ii. Whether the complainant is entitled to get Insurance claim of
Rs. 25,000/- for the injuries sustained by him?.
iii. Whether the complainant is entitled to get a compensation of
Rs. 1 lakh from the opposite party?
iv. Whether the complainant is entitled to get Rs. 25,000/- by
way of legal expenses of the complainant?
5. Point No. i. The following points are not disputed by the parties.
i. On 25-06-2009 the complainant submitted Ext. B22 proposal
form for health plan.
ii. On the basis of Ext. B22 the opposite party issued Ext. A3
Family care first policy for the complainant, his wife and 2
children with sum assured of Rs. 1,00,000/- each for the
period from 26-06-2009 to 26-06-2012.
iii.During the currency of the policy on 16-08-2009 the
complainant’s family met with a road traffic accident .
iv. The complainant’s wife Raji breathed her last on the way to
the hospital
v. The complainant and his son Andrew had sustained injuries
due to the impart of the accident.
vi. The complainant submitted Ext. B3 insurance claim
application dated 22-03-2010 before the opposite party
claiming insurance claim for the death of his wife.
vii. Ext. B3 was rejected by the opposite party stating that
death benefit will not be payable in case of death of any
member.
6. We have carefully gone through the terms and conditions in
Ext. A3 policy, clause 4 reads as follows:
“No death benefit will be payable in case of death of
any member. In case of death of any member, subject to clause 25, the policy will continue with rest of the members”.
It is well settled law that parties to the insurance contract are bound by the terms and conditions in it. As per clause 4 of terms and conditions the opposite party is necessary not liable to pay the insurance claim for the death of the complainant’s wife. Arguments to the contrary rejected hence.
7. Point No. ii. The complainant himself submitted Ext. B9 claim application for the injuries sustained by him due to the accident. Ext. B9 claim application was repudiated by the opposite party as per Ext. A1 letter dated 06-04-2010 issued by the opposite party which is as follows:
“As per D/S member was admitted with contention injury over limb’s due to RTA which was treated with analgesics and bed rest. Admission primarily for evaluation, investigation, active line of management could not be discerned. Hence as per policy clause 6 K, claim is not admissible or payable”
Clause 6 K in ext. A3 reads as follows:
“Hospitalization primarily for diagnosis, X-ray examinations general physical or medical check up not followed by active treatment during the Hospitalization period”.
Ext. B11 is the discharge summary of the complainant issued from Lakeshore hospital, Ernakulam. As per Ext. B11 the final diagnosis is contusion injury right forearm, right hip and right knee. After the clinical examination and the investigation the doctor who treated the complainant prescribed the following medicines to him.
i. Omeprazole (Omez 20mg cap)
ii. Tramadol + Paracetamol (Ultra tab) and
iii. The medicines in Ext. B17 Medical bill.
The test have been conducted by the doctor to diagnose the actual state of affairs and to decide the mode of treatment to be adopted on the patient. Therefore the rejection of the claim of the complainant as per Ext. A3 is unsustainable. The complainant is entitled to get insurance claim from the opposite party.
8. Points Nos. iii&iv. Compensation can be granted if a consumer has been wronged . In this cxae thre is nothing as such. No order as to compensation since. In spite of mental agony and other inconveniences the complainant has had to undergo litigation expenses, we fix the costs at Rs. 2,000/-.
9. In view of the above we are closing the proceedings in this complaint with a direction to the opposite party to pay the insurance claim of the complainant for the treatment expenses together with interest @ 12% p.a. from the date of this
complaint till realization on production of necessary documents to the same. Costs of Rs. 2,000/- is awarded.
The above said order shall be complied with within a period of one month from the date of receipt of a copy of this order.
Pronounced in the open Forum on this the 29th day of October 2011
Sd/- A Rajesh, President.
Sd/- Paul Gomez, Member
Sd/- C.K. Lekhamma, Member.
Forwarded/By Order,
Senior Superintendent.
Appendix
Complainant’s Exhibits :
Ext. A1 : copy of letter dt. 06-04-2010
A2 : copy of letter dt. 21-09-2009
A3 : brochure
Opposite party’s Exhibits :
Ext. B1 : True copy of letter dt. 06-04-2010
B2 : Letter dt. 10-07-2010
B3 : Copyof care first claim form
B4 : Addoc/No claim letter details
dt.06-04-2010
B5 : “” “” dt. 26/11/2009
B6 : copy of letter dt. 21-09-2009
B7 : Copy of letter dt. 21-09-2009
B8 : copy of identity card of Mr. Sony C.a.
B9 : Copy of care first claim form
B10 : Letter dt. 14-09-2009
B11 : Discharge summary dt. 17—08-2009
B12 : Lab resultl from 16/08/2009
to 17/08/2009
B13 : Plain and contrast CT Imaging of Brain
B14 : Bill dt. 19-09-2009
B15 : Bill dt. 16/08/2009
B16 : Inpatient settlement receipt
B17 : Discharge bill dt. 17/08/2009
B18 : Wound certificate cum accident register
B19 : Wound certificate cum accident register
B20 : Copy of FIR
B21 : Charge sheet
B22 : copy of Proposal form for health plan
Depositions:
PW1 : Sony C.A.
DW1 : Midhin Raj M.O.
