BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM,

ERNAKULAM.

Date of filing : 16/11/2010

Date of Order : 27/10/2012

Present :-

Shri. A. Rajesh, President.

Shri. Paul Gomez, Member.

Smt. C.K. Lekhamma, Member.

C.C. No. 602/2010

Between

And

O R D E R

A. Rajesh, President.

1. Briefly stated, the case of the complainant is as follows :-

The complainant is the holder of the Reliance Life Insurance Wealth + Health Plan Policy. While so, he was admitted at Nirmala Medical Centre with fever on 22-06-2010. The disease was diagnosed as paratyphoid fever. He was treated there as inpatient for 14 days. As per the policy conditions, the complainant is eligible for Rs. 1,000/- per day for inpatient treatment and ex-gratia amount of Rs. 2,000/-. But the claim submitted by the complainant was repudiated by the 2^nd opposite party by their letter dated 03-09-2010 stating that the hospitalisation within 90 days from the date of reinstatement is not admissible. The reason given for repudiation is not correct and hence unsustainable. The complainant submitted the cheque towards the premium on 25-03-2010 and hence he is entitled for the hospitalisation benefit from 23-06-2010 onwards. The denial of his claim on flimsy grounds amounts to deficiency in service. The complainant is entitled to get Rs. 15,000/- along with interest at the rate of 12% p.a. from the date of complaint till realisation. He is also entitled for Rs. 3,000/- as compensation for mental agony and hardships caused to him by the denial of the claim. This complaint hence.

2. The version of the 1^st opposite party is as follows :-

The complainant had proposed for a reliance Wealth + Wealth Plan (Regular) Policy for him and his wife by paying an annual premium of Rs. 20,000/- with effect from 31-03-2008. As per the terms and conditions of the policy, there is a waiting period of 90 days from the date of payment of the premium. No claim would be entertained in this period unless the hospitalisation has occurred due to accident. The complainant paid the premium amount by cheque. Only after realisation of funds, the policy would be re-instated and the policy of the complainant re-instated with effect from 28-03-2010. The complainant is not entitled to get the insurance claim as per the terms and conditions of the policy.

3. Despite service of notice from this Forum, the 2^nd opposite party did not respond to the same for their own reasons. The complainant was examined as PW1 and Exts. A1 and A2 were marked. The witness of the 1^st opposite party was examined as DW1 and Ext. B1 was marked. Heard the counsel for the parties.

4. The points that came up for consideration are as follows :-

1. Whether the complainant is entitled to get the insurance claim from the opposite parties?

2. Whether the opposite parties are liable to pay compensation and costs of the proceedings to the complainant?

5. Point No. i. :- The claim for insurance of the complainant was repudiated by the 2^nd opposite party vide Ext. A1 letter dated 03-09-2010, which reads as follows :

“On a scrutiny of the CLAIM PAPERS submitted by you in the above connection vide your letter dated 20-08-2010. We find that the claim is not admissible in terms of the policy under the following clause of the policy:

Page No. 13 Clause 5 – Exclusion – 2 : Hospitalisation due to illness within the 1^st 90 days from the date of cover commencement or 90 days from the date of revival if reinstated after discontinuance of the cover.

The Annual Premium was due on 01-04-2020. It has not been remitted even during the Grace Period. Hence, the policy got discontinued. As per our records the policy has been reinstated w.e.f 22-06-2010. The hospitalisation is within 90 days from the date of reinstatement, hence, not admissible under the policy.

We, therefore, regret to inform you that the claim stands denied.”

6. The complainant underwent treatment at Medical Trust Hospital from 10-08-2010 to 17-08-2010 evidenced by Ext. A2 medical certificate. Admittedly, the premium of the policy had been remitted on 25-03-2010. As per the terms and conditions of the policy, the complainant is not entitled to get insurance coverage of 90 days with effect from 25-03-2010. Even according to DW1, the witness for the 1^st opposite party the period of 90 days expired on 23-06-2010. As per Ext. A2 medical certificate, the period of treatment of the complainant is from 10-08-2010 to 17-08-2010.

7. The conditions of the policy categorically states that the policy holder is not entitled to any benefits before 90 days of any claim which shows that the dead line is 23-06-2010. The claim of the complainant is after that for the treatment covering from 10-08-2010 to 17-08-2010. So, the contention of the 1^st opposite party fails. The 1^st opposite party also contents that the complainant had not remitted the premium in time, but DW1 goes to depose that the same is not true and the amount had been paid in time, which the 1^st opposite party had not been able to disprove. Hence again they failed. The point goes against them.

8. In a materialistic and competitive spheres of life, it may not be out of place to win a battle at any costs, but humanity subsists only when it is and has to be upheld. The frivolous and imatured arguments are not well grounded for rejection of a legal cause, which we feel has a semblance in this case. The adage “Fiat justitia ruat caelum” is undisputed.

9. In the above circumstances, we have no hesitation to hold that the complainant is entitled to get the insurance claim for his treatment as per Ext. A2 medical certificate. Since, the complainant has not produced any evidence to substantiate in quantum of expense, we think that the ends of justice would be met by giving a direction to 1^st opposite party to disburse the insurance claim of the complainant in view of the above observations.

The order shall be complied with, within a period of one month from the date of receipt of a copy of this order, failing which the amount shall carry interest @ 12% p.a till payment.

Pronounced in the open Forum on this the 27^th day of October 2012

Sd/- A. Rajesh, President.

Sd/- Paul Gomez, Member.

Sd/-C.K. Lekhamma, Member.

Forwarded/By Order,

Senior Superintendent.

A P P E N D I X

Complainant's Exhibits :-

Opposite party's Exhibits :-

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