ORDER
By Jayasree Kallat, Member
The petition was filed on 18.11.08. The complainant has subscribed to a Health Care Policy of the opposite parties with effect from 28.08.06 with a total premium of Rs.1640/- for a basic sum assured of Rs.10,000/-. The policy No. being 0026347566. The date of coverage of risk commence from 28.09.2006. The complainant had undergone surgical procedure and hospitalization at Malabar Hospital Urology center Eranjipalam from 14.05.07 to 19.05.2007. Complainant had submitted the original bills amounting to Rs.30,894/- for claiming the benefits as per the policy conditions. The opposite parties had paid only Rs.600/- without giving any reason for reducing the claim. The action of the opposite parties of not paying the entire claim amount is against the policy condition which amounts to deficiency of service on the part of the opposite parties. Hence complainant has filed this petition seeking relief from the opposite parties.
The opposite parties have filed a version denying the allegations and averments in the complaint except those that are specifically admitted. The complainant has concealed the true facts of the case. Opposite parties admit that the complainant had subscribed to a Health care policy of the opposite parties with effect from 28.08.06 with premium of Rs.1640/- for a basic sum assured for Rs.10,000/-. The date of coverage of risk commences from 28.09.06. The complainant is eligible for reimbursement of expenditure incurred by the complainant as per the condition in the policy document. Opposite parties had paid an amount of Rs.600/- to the complainant as hospital cash. The complainant is not eligible for surgical benefit because the complainant’s surgery is within the waiting period as the policy is not run for more than six months. The petitioner’s illness was diagnosed within the waiting period. So as per the terms and conditions in the policy the petitioner is not entitled to receive any amount as claimed in the petition. Opposite parties are not having any liability to pay any further amount. Opposite party prays to dismiss the petition.
Points for consideration.
Whether the complainant is entitled for any relief. If so what is the amount.
The complainant was examined as PW1 and Exts.A1 to A7 were marked on complainant’s side.Ext.B1 was marked on opposite parties side.
The case of complainant is that she had taken a Health Care Policy of the opposite parties w.e.f. 8.08.06 with a total premium of Rs1640/- for a basic sum assured of Rs.10,000/-. The date of coverage of risk commences from 28.09.06 as per Ext.A4. The complainant had undergone surgical procedure and hospitalization at Malabar Hospital, Eranhipalam from 14.05.07 to 17.05.07. The operation TOT sling done under SAB for stress urinary incontinence undergone on 16.05.2007 after the complainant admission on 14.05.2007. The diagnosis of the disease was done on 14.05.2007. The opposite parties had taken a contention that the complainant is not eligible for surgical benefit because the complainant’s illness was diagnosed within the waiting period. The primary condition of the policy according to the opposite party is that the policy will start to run only after one month of the joining date. The surgical benefit will be provided to the life assured in case of a surgery done by qualified surgeon for surgical operation and performed at a hospital as inpatient due to the covered injury of sickness for surgical procedure advised by a qualified doctor or surgeon and the policy is in full force. Opposite parties contention is that there is a waiting period of 180 days to claim for the surgical benefit and the policy document is dtd. 28.08.06 and the illness were diagnosed according to opposite party on 15.12.06 as per Ext.A1. A perusal of Ext.A1 shows that the complainant was admitted on 14.05.07 for an operation TOT sling done under SAB on 16.05.07. Ext.A1 also shows that USG was done on 15.12.06 a simple cyst in left ovary. This does not explain that the complainant had undergone operation due to the diagnoses done on 15.12.06. The complainant’s case is that she was admitted on 14.05.07 ie. far beyond 180 days. Hence she is eligible to claim under surgical benefits.Ext.A4 document would go to show that date of risk commences from 28.09.06. The policy schedule Ext.A4 also shows that basic sum assured for the complainant is Rs.10,000/-. After hearing both sides and perusal of documents we are of the opinion that the complainant is entitled for the basic sum assured Rs.10,000/- as per the policy schedule Ext.A4. Whatever the contention taken by the opposite parties the complainant is eligible for the basic sum assured Rs.10,000/-. Ext.A3 and A4 confirms of this fact. Hence we are of the opinion that complainant is entitled for Rs.10,000/- along with compensation.
In the result petition is allowed and opposite parties are directed to pay an amount of Rs.10,000/-along with a compensation of Rs.5,000/- and a cost of Rs.500/- within one month on receiving the copy of the order.
Pronounced in the open court this the 24th day of May 2011.
Date of filing:18.11.08
SD/- PRESIDENT SD/- MEMBER SD/- MEMBER.
APPENDIX
Documents exhibited for the complainant:
A1. Discharge summery of Malabar Hospitals dt.19.05.07.
A2.Details of medicines & bills (13 Nos.)
A3.Premium intimation dtd.15.06.2007.
A4.Bajaj Allianz Life Insurance Policy Schedule.
A5. Original cheque for Rs.600/- dt.27.06.07.
A6. Claim under Policy of the complainant.
A7. Letter submitted for the claim for documents.
Documents exhibited for the opposite party:
B1.Guaranteed benefits of Bajaj Allianz Health care schedule.
Witness examined for the complainant:
PW1. Kanakam.K(Complainant)
Witness examined for the opposite party:
None
Sd/-President
//True copy//
(Forwarded/By Order)
SENIOR SUPERINTENDENT
