This C.C. is coming on before us for hearing in the presence of Sri. G. Brahmaiah, Advocate for complainant; and of Sri. A. Sarath Chander, Advocate for opposite parties No.1 to 3; upon perusing the material papers on record; upon hearing and having stood over for consideration, this Forum passed the following:-
O R D E R
(Per Sri R. Kiran Kumar, FAC President)
This complaint is filed u/s.12-A of Consumer Protection Act, 1986.
2. The averments made in the complaint are that the complainant has joined in Jeevan Anand Policy (with profits) (with accident benefits) and critical illness rider plus premium waiver benefit which was introduced by the opposite party corporation. The complainant submitted that he obtained insurance policy on 05-02-2008 from the opposite party No.1 branch, for a sum assured amount of Rs.2,00,000/-, payable by the complainant in half yearly installments for a period of 16 years and the agreed half yearly premium is Rs.10,013/- vide policy bearing No.688224456 dt.06-02-2008. The complainant submitted that he is paying the premium by way of deductions from his salary through his drawing officer, as the complainant is working as Railway Guard in South Central Railway, Kazipet and there is no default in payment of premiums to the opposite party No.1 at any point of time. The complainant further submitted that suddenly he was sick and admitted in Sri Raksha Hospital, Khammam on 16-10-2012 due to paralysis stroke and discharged from the said hospital on 22-10-2012, for the above admission for paralysis stroke the complainant spent huge amounts an amount of Rs.70,138/- towards medical expenses. The complainant further submitted that as per the policy issued by the opposite party No.1 they have to reimburse the amount spent by the complainant, but they did not choose to pay the above said amount, in these circumstances, on 13-02-2013 complainant submitted an application to the opposite party for payment of medical expenses. After receiving the said application, the opposite party No.3 sent a evasive reply to the complainant stating that the complainant was suffered with paralysis stroke within six months from the date of revival of the policy by the complainant, as such they refused to pay the medical expenses. The complainant further submitted that the policy was renewed on 14-09-2012 and the opposite parties accepted the premium through salary attachment the opposite parties are not entitled to plead such ground, it is a bounded duty of the opposite parties to pay the medical expenses which were incurred by the complainant on 16-10-2012 onwards. As the opposite parties failed to pay the medical expenses which were incurred by the complainant for his paralysis disease, for that the complainant approached the Forum.
3. On behalf of the complainant, the following documents were filed and marked as Exs.A-1 to A-4.
Ex.A-1:- Photocopy of Policy bearing No.688224456.
Ex.A-2:- Medical Certificate issued by Sri Raksha Hospital, Dr. G. Venkateswarlu, Khammam, dt. 02-02-2013.
Ex.A-3:- Medical Bills (Nos.96) worth of Rs.60,641/-.
Ex.A-4:- Medical Bills (Nos.30)
4. On receipt of notice, opposite parties corporation appeared through their counsel and filed counter. In their counter, opposite parties admitted the issuance of Insurance Policy bearing No.688224456, commencing from 06-02-2008 for sum assured amount of Rs.2,00,000/- and the said policy was issued with critical illness rider benefit (CIRB) along with premium waiver benefit, as the same was opted by the life assured in his proposal for insurance dt. 05-02-2008. The opposite parties submitted that as per the policy, “critical illness benefit – definition and terms and conditions” -
A) Waiting period:- A waiting period of 6 months will apply from the date of commencement of risk or revival of the policy, as the case may be to be first diagnosis of the critical illness under consideration. This would mean that the benefit of the policy schedule is not applicable if any of the contingencies mentioned in condition (D) below occurs (i) at any time on or after the date on which the risk under the policy as commenced but before the expiry of 6 months reckoned from the date or (ii) before the expiry of 6 months from the date of revival. However, this condition will not apply to conditions arising directly out of accident.
The opposite parties further submitted that as per the said stipulated terms and conditions of the policy under “Critical illness rider benefit”, if any of the contingencies mentioned in the condition (D) of the policy occurs before the expiry of 6 months from the date of revival, benefit of the policy schedule will be not applicable. The opposite parties further submitted that the life assured had submitted an application to the opposite parties corporation for payment under critical illness rider benefit on 03-02-2013. The opposite parties also submitted that the said policy had lapsed for non receipt of eight (8) half yearly installments of premiums by the opposite parties corporation, viz.., the premium due from 02/2009 to 08/2012 was not received. The opposite parties further submitted that basing on the personal statement regarding his health, dated 14-09-2012, signed and furnished by the life assured, the said policy was revived. As the said policy was revived on 14-09-2012, the waiting period of 6 months will be completing on 13-03-2013 and hence critical illness rider benefit cannot be considered. The opposite parties further submitted that basing on the request dated 14-09-2012 from the life assured, they moved under the above said policy was assured to salary savings scheme w.e.f. 02/2013, the said policy was lapsed for non-payment of premiums from 02/2009 to 08/2012 and the opposite parties revived the policy of the life assured on the basis of the personal statement regarding health signed by him. The opposite parties further submitted that the complainant has filed only a one page medical certificate dt. 02-02-2013 from Sri Raksha Hospital, Khammam, certifying that the complainant has been suffering from CVA-ischaemic Stroke and that he was admitted on 16-10-2012 and discharged on 22-10-2012, the said certificate does not contain any admission No. or any registration of the patient, and neither the case sheet showing the day to day treatment details: nor the discharge summary are produced by the complainant in proof of his treatment. The opposite parties further submitted that the Ayurvedic Medical Bills produced do not contain any corresponding medical prescriptions and mere affixing of rubber stamp of Dr. D.S. Charyulu, Assistant Prof., on the Medical bills cannot be a substitute for Medical prescriptions. The opposite parties further submitted that Medical prescriptions contain data related vital health parameters, such as BP, Pulse Rate, Clinical Examination / Laboratory Test Results: symptoms: O/E, i.e., “on examination” details and details as to the diagnosis / prognosis of the disease. The opposite parties also submitted that the letter dated 03-02-2013 addressed to opposite party No.3 intimating the claim for Critical illness riders benefit, the complainant averred that “on 16-10-2012 admitted in ICU ward was given treatment”, whereas, the detailed case sheet of ICU showing the hourly readings of vital parameters, such as B.P., Pulse, Temperature and other clinical and pathological investigations data, case history, present symptoms, details of surgical or non-surgical procedures carried out, details of medicines administered are not produced by the complainant. And also not clear as to how an alleged treatment under the care of Sri Raksha Hospitals, Khammam, and an Allopathic Hospital is connected or followed up with Ayurvedic medical bills sourced from Warangal and the complainant not produced even a single medical prescription for the alleged Ayurvedic treatment. The opposite parties further submitted that for a Critical Illness of CEREBRO VACULAR ACCIDENT (i.e. CVA), a single phase medical certificate issued by Sri Raksha Hospitals, Khammam is produced and no medical record/ case sheet / discharge summary / ICU treatment record for either allopathic or Ayurvedic treatment is produced by the complainant. And also submitted that the 46 medical bills for Ayurvedic Medicines contain different dates ranging from 20-10-2012 to 18-03-2014. The opposite parties further submitted that the total amount of medical bills enclosed to the complaint is only Rs.28,822.99/- whereas, an amount of Rs.70,138/- is claimed by the complainant and the complainant had not submitted any proof for the alleged claim of Rs.41,242.01/-, in view of the aforesaid submissions and in view of the CIRB claim arising within the stipulated waiting period of 6 months from the date of revival, the opposite parties are not liable to pay the claim amount and prayed to dismiss the complaint.
5. On behalf of the opposite parties the following documents were filed and marked as Exs.B-1 to B-4.
Ex.B-1:- Original Consumer Complaint including the Annexures and Postal Envelop.
Ex.B-2:- Original Proposal for Insurance dt. 05-02-2008.
Ex.B-3:- Original Office of copy of the policy bond bearing No.688224456 including the Annexure attached where Critical Illness Rider benefit is opted for.
Ex.B-4:- Original personal Statement regarding health dt.14-09-2012.
6. Counsel for complainant filed written arguments.
7. Heard Oral Arguments from both sides.
8. Upon perusing the material papers on record and upon hearing the arguments, now the point that arose for consideration is,
Whether the complainant is entitled for the medical reimbursement, under the policy?
Point:-
In this case the complainant obtained insurance policy bearing No.688224456 from opposite parties and as per the policy the opposite parties agreed to pay Critical Illness Rider plus Premium waiver benefit to the policy holder. During the period from 2/2009 to 8/2012 the complainant failed to pay the premium amount. On 14/09/2012 the complainant approached the opposite parties and submitted personal statement regarding his health and basing on his statement the said policy was revived. That on 16-10-2012 the complainant was sick and admitted in Sri Raksha Hospital, Khammam due to paralysis stroke and he was discharged from the hospital on 22-10-2012. Subsequently on 13-02-2013 the complainant submitted claim to the opposite party No.3 for payment of medical expenses which are spent for paralysis stroke. After receiving the said application, the opposite party No.3 had given a reply to the complainant stating that the complainant was suffered with paralysis stroke within 6 months from the date of revival of the policy, as per the policy terms and conditions “a waiting period of 6 months will apply from the date of commencement of risk or revival of the policy” and they refused to pay the medical expenses, for that the complainant approached the Forum.
It is an undisputed fact that the complainant has taken policy on 06-2-2008 and the same was revived on 14-09-2012. After revival of the policy on 16-10-2012 i.e. within two months from the date of revival of the policy the complainant joined in Sri Raksha Hospitals, Khammam due to suffering from CVA – Ischaemic Stroke and discharged on 22-10-2012. The complainant admitted in hospital for CVA – Ischaemic stroke within six months from the date of revival. As per the policy, Critical Illness Benefit – Definitions and terms and conditions.
Waiting Period:- A waiting period of 6 months will apply from the date of commencement of risk or revival of the policy, as the case may be to be first diagnosis of the critical illness under consideration. This would mean that the benefit of the policy schedule is not applicable if any of the contingencies mentioned in condition (D) below occurs (i) at any time on or after the date on which the risk under the policy as commenced but before the expiry of 6 months reckoned from the date or (ii) before the expiry of 6 months from the date of revival. However, this condition will not apply to conditions arising directly out of accident.
From the above terms and conditions of Critical Illness Benefit in the policy, we are of the opinion that the waiting period clause is directly applicable to this case. The complainant admitted in the hospital for treatment for his critical illness i.e. CVA – Ischaemic Stroke within the period of 6 months from the date of revival as such the complainant is not entitled for medical reimbursement. Hence, this point is answered accordingly against the complainant.
9. In the result, the complaint is dismissed. There is no order as to costs.
Typed to dictation, corrected and pronounced by us, in the open forum on this the 25th day of April, 2017.
FAC PRESIDENT MEMBER
DISTRICT CONSUEMR FORUM,
KHAMMAM.
