O R D E R<br /> <br /> <br /> <br /> SRI.D. KRISHNAPPA, PRESIDENT:<br /> <br /> The grievance of the complainant against the Op in brief is, that he had availed a mediclaim policy from the Op which covers life insurance, critical illness benefit, accidental cover death and accidental total permanent disability partial permanent disability and cash benefit cover. That after obtaining a policy, later on as he was suffering from right central disc herniation L 4-5 Fenestration discetomy Foraminotomy under general Anesthesia and underwent surgery by spending Rs.65,936.70. That after he was discharged from the hospital he sent a claim with all medical bills to Op on 09/08/2008 to reimburse the expenditure but the Op has not reimbursed it. When the Op has issued a policy to him, is bound to pay the amount and therefore has failed to render service and thereby has caused deficiency in his service.<br /> <br /> Op has appeared through his advocate and filed version denying to have issued a mediclaim policy as alleged by the complainant and that policy issued by them covers critical illness benefits, accidental death total and partial disability etc., and the Op terming all these allegations of the complainant are false stated to had issued a policy called new family gain policy and stated that the complainant has not opted any rider in the proposal form therefore denying that the complainant is entitle for reimbursement of medical expenditure has further stated that unit link insurance policy called family gain policy was issued in favour of the complainant which do not cover benefits like mediclaim critical illness benefits etc., and the claim of the complainant in that regard is false and narrated that the complainant has only opted a policy which cover the risk of his death. As the complainant has not opted for mediclaim benefits is not entitle for any other benefits and stating that they are bound by the terms and conditions of the policy and their liability under the policy is to pay the death benefits and nothing else and thus has prayed for the dismissal of the complaint.<br /> <br /> In the course of enquiry into the complaint, the complainant and one Ravi Kumar for Op have filed their affidavit evidence re-asserting what they have stated in their respective complaint and version. The complainant along with the complaint has produced a copy of policy issued in his favour, premium paid receipt and copy of terms and conditions of the policy, besides producing copies of medical bills and a legal notice he got issued to the Ops. Op has produced the proposal form submitted to the complainant on which they issued a new family gain policy. Counsel for the complainant has filed written arguments. We have heard the counsel for the Op and perused the records including written arguments of the complainant’s counsel. <br /> <br /> On consideration of the above materials, following points for determination arise.<br /> <br /> 1. Whether the complainant proves that he is under the policy obtained, entitle for reimbursement of medical expenditure and the Op has caused deficiency in his service in not reimbursing it?<br /> 2. To what relief the complainant is entitled to?<br /> <br /> Our findings are as under:<br /> <br /> Point No.1 : In the negative<br /> Point No.2 : See the final order<br /> <br /> REASONS<br /> <br /> Answer on point No.1: On going through the rival contentions of the parties we do not find any disputes between the parties except a limited point whether the policy obtained by the complainant from the Op covers illness and other contingencies other than the death benefit and whether the complainant is entitle for reimbursement of medical expenditure. The complainant in his complaint claims to have taken a mediclaim policy from the Op, where as the Op has denied that the policy issued in favour of the complainant contain medical reimbursement facility besides denying that it is a mediclaim policy and stated it is only a new family gain policy without any rider, as the complainant has not opted for rider benefits and stated that the policy issued to the complainant is only to cover death benefit + fund value. With this we shall examine the nature of the policy availed by the complainant and issued by the Op.<br /> <br /> The Op has produced the original proposal form submitted by the complainant. In which we see the product name i.e the policy name is described as new family gain with sum assured Rs.1.00 lakh and under that heading there are columns under the sub-heading ‘riders –sum assured’. The learned counsel appearing for the opponents submitted. That the words riders-sum assured are the columns provided to the choice of the complainant to avail other benefits like critical illness, accidental benefits, total permanent and partial disability policy etc., but the complainant has not opted any such benefits except death benefits and therefore submitted the policy issued is not a mediclaim policy but only a death benefit policy. The learned counsel appearing for the opponent also invited our attention to the contents of the policy obtained by the complainant. On perusal of the contents of the policy, we find that 5/6/2008 is the commencing date of the policy. The duration of the policy is shown as 14 years with Rs.1.00 lakh as sum assured and the benefit of the policy is shown as death benefit - Rs.1.00 lakh fund value. Maturity benefit to the policy holder is shown as fund value only and nothing else. The counsel for the complainant has not denied the proposal form the complainant had submitted and the contents of the policy issued and the arguments submitted by the learned counsel for the opponent. The contents of the policy clearly go to show that after the completion of the term of 14 years under the policy, the complainant would be entitle for the death benefit + fund value. Death benefit under the conditions of the policy is defined as the amount payable on death. Fund value is defined Under Section 3.1 below.<br /> <br /> “Fund value is defined as equal to the numbers of units under this policy multiplied by unit price and that unit price is further defined which goes to show calculation of the price in accordance with the formula given therein. These uncontroverted facts would go to show that the complainant only opted for policy which confirms a benefit of certain amounts of insurance on his death or on maturity.<br /> <br /> The learned counsel for the complainant invited our attention to the conditions of the policy which contain insurance covers means life insurance cover, critical illness, benefit cover, accidental cover etc., Though the condition of the policy contain such extra benefit, the counsel for Op argued that complainant since did not opt for such benefit under the head riders in the proposal form he would not be entitled for benefit of reimbursement for critical illness or for treatment. The policy term themselves disclose that the insured is entitle for death benefits only and nothing more. Therefore, we find that policy availed by the complainant and issued by the Op cover the death risk to the amount that would be payable on maturity and it do not contain any assurance covering illness.<br /> <br /> Learned counsel for the Op without prejudice to the first contention also submitted that the complainant has suppressed his ailment while submitting the proposal form and he by relying upon the hospital records produced by the complainant himself stated that the complainant had pre-existing disease but in the proposal form he has mentioned as if he did not have any ailment and therefore submitted that the complainant having had suppressed the material facts of his pre-existing disease is not entitle for reimbursement. We find that the complainant in the proposal form has made tick marks by showing as if he was not having any ailment as on the date of submitting of his proposal form for issue of a policy. This proposal form is submitted on 03/06/2008. The Op after accepting the proposal issued the policy with effect from 05/06/2008. The hospital records submitted by the complainant issued by the resident doctor of Agadi hospital, Bangalore reveal that the complainant himself gave his health history on 27/07/2008. That he was having low back ache radiating the low limit since 6 months and when investigated that MRI shows right Para Central herniation and he underwent surgery for L-4-5 Fenestration discetomy Foraminotomy under General Anesthesia. Therefore, on the history given by the complainant himself as on 27/07/2008 he was having this disease 6 months earlier to the date of the admission. That means the complainant admittedly had this ailment and it was in his knowledge prior to giving the proposal form and thereby the complainant in our view suppressed, the fact of his ailment and obtained the policy and therefore on that ground also the complainant is not entitle for reimbursement. As such the complainant in either way is not entitled for the relief and accordingly, we answer point No.1 in the negative and pass the following order.<br /> <br /> O R D E R<br /> <br /> Complaint is dismissed. Parties to bear their own cost.<br /> <br /> Dictated to the Stenographer. Got it transcribed and corrected. Pronounced in the Open forum on this the 12th July 2010.<br /> <br /> <br /> <br /> MEMBER MEMBER PRESIDENT<br /> <br /> <br /> <br />