Delhi

New Delhi

CC/560/2010

Sudhakar Singh Jadon - Complainant(s)

Versus

M/S. Aviva Life Insurance Company Ltd. - Opp.Party(s)

21 May 2016

ORDER

CONSUMER DISPUTES REDRESSAL FORUM-VI

(DISTT. NEW DELHI),

 ‘M’ BLOCK, 1^STFLOOR, VIKAS BHAWAN, I.P.ESTATE,

 NEW DELHI-110001

 

 

Case No.C.C./556/2010                                                                                                   Dated:

In the matter of:

BRIJLAL BANSAL,

C-14, Block-C,First Floor,

Anand Vihar,

Delhi-110092

        ……..COMPLAINANT

 

VERSUS

1.     Branch Manager

        Royal Sunderam Alliance Insurance Co. Ltd.

        13^th Floor, Ambadeep Building,

        K.G. Marg,

        New Delhi-110001

 

2.     Manager/CEO,

        Royal Sunderam Alliance Insurance Co. Ltd.,

        Corporate Claims Department,

        Sudram Towers, 45 &46, Whites Road,

        Chennai-600014 (Tamilnadu)

                                       

               .... OPPOSITE PARTIES

 

ORDER

PRESIDENT: S.K. SARVARIA

 

        This complaint under the provisions of Consumer Protection Act, 1986 (in short ‘Act’) is filed by the complainant alleging, in brief, that on telephonic call of the representative regarding insurance policy explaining about the  ‘Hospital Cash Insurance’ policy and ensuring that if the complainant got admitted in hospital then after getting the above policy the complainant will receive Rs.3000/- per day for hospitalization for the bed rest and days for restricted activities of the complainant after any illness or any insured person subject to maximum 180 days,  the complainant got ready for himself and his wife and asked the representative to proceed further for issuance of the policy. Thereafter the complainant received a letter dated 21/05/2009 in which the OP clarified that voice consent has been taken and premium of the policy will be collected by the Credit Card of the S.B.I. Accordingly the complainant consented to pay Rs.6387/- for the above medical policy for the period 22/5/2009 to 21/5/2010 and OP issued the policy vide Master Policy No. HCSBIL0012 and Policy No. CSE0003564000100.  This policy was taken by the complainant only on the basis of the assurance that complainant received Rs.3000/- per day for hospitalization, for the bed rest and days for restricted activities of the complainant after any illness or any insured person subject to maximum 180 days.

        The complainant had pain in his shoulder and some other body parts so he was admitted in Deepak Memorial Hospital on 10/9/2009 and remained admitted there up to 16/9/2009.  The medical expanses of the complainant incurred in the hospital were Rs.32,417/-.  The complainant deposited the expanses of the hospital and sent all relevant documents of the same to the office of OPs vide Hospital Cash Claim Form dated 4/12/09 for Rs. 2,55,000/- but the complainant did not receive any medical claim amount.  The medical claim of the complainant was not processed despite requests of the complainant.  There is no question of any pre-existing ailment because the complainant took the treatment of D.V.T. which cannot be considered pre-existing disease.  The complainant has prayed for the following relief:-

1. Rs. 2,55,000/- towards the cash insurance for 85 days @ Rs.3000/- per day as per the terms of the policy.
2. Interest @ 24% p.a. on the above sum from the date of sickness till date of payment.
3. Rs.50,000/- towards damages for harassment, tension and agony undergone by the complainant at hands of the OP.
4. Rs. 25,500/- Costs of present complaint and its proceedings.

                The notice of the complaint was issued to OP who contested the complaint and filed reply. According to OP the complainant had availed Hospital Cash Policy No. CSC0003564000100 from the OP valid from 22/5/2009 to 21/5/2010 under terms provided that daily benefit of Rs.3000/- for every 24 hrs. of hospitalization. The OP has provided the said covers subject to terms and conditions as stipulated in the policy, which governs the instant claim.  According to OP the complainant was admitted for Coronary Heart Disease alongwith diabetes at Deepak Memorial Hospital from 10/9/2009 to 16/9/2009 for treatment.  He lodged a claim in respect of said treatment.  Upon perusal of the medial records it was found that the complainant was admitted for Coronary Artery disease alongwith the pre-existing diabetes and OP has submitted that all heart ailments are excluded from the terms and conditions of the policy issued to the complainant during first year of policy inception.  OP has submitted that as per the policy there is one year waiting period for treatment of the heart ailment.  Hence, the claim was not admissible and not payable.

        OP has submitted that the insurance is a contract between the insurer and insured and the insured in this instant policy has agreed for the contract of the insurance and therefore terms and conditions are binding on the respective party to this instant contract. OP has denied other facts stated in the complaint.

        In the rejoinder the complainant has denied the facts stated in the reply of OP and has reaffirmed the facts stating in the complaint.

        In support of his case the complaint has filed affidavit in evidence and on behalf of OP affidavit in evidence of Sh. G. Vinay Prakash an officer and authorized representative of the OP is filed.  Both the parties have filed written arguments.

        On behalf of parties the written arguments are filed by both the parties are relied upon instead of addressing oral arguments.

We have gone through the written arguments filed on behalf of parties, record of the case and relevant provisions of law. The basic facts in this case are not disputed.  Admittedly, the complainant was issued the Hospital Cash Policy No.CSC0003564000100 from the OP valid from 22/5/2009 to 21/5/2010 with the term provided that daily benefit of Rs.3000/- for every 24 hrs. of hospitalization. It is also admitted that the complainant was admitted for medical treatment in Deepak Memorial Hospital from 10/9/09 to 16/9/09.  Undisputedly the complainant lodged a claim in respect of said treatment which was repudiated by the OP Insurance Company.

There are written policy terms in the Hospital Cash Plan of the OP Insurance Company taken by the complainant from the OP for himself and his wife.  In the face of written terms and conditions which are part of the record, the oral assurance by representative or office bearer of insurance company in question has got no meaning and latter should give way to the former.  Admittedly the complainant was admitted for treatment in the Deepak Memorial Hospital on 10/9/2009 and was discharged on 16/9/09.  The discharge summary with heading Case Summary shows that the complainant was known case of DM and CAD. In other words he was known case of diabetes and Coronary Artery disease or heart problem.  The condition No. 3 of the hospital cash plan indicates several diseases which are excluded in the first year of the Hospital Cash Plan in question.  Heart disease is amongst the diseases excluded in the first year of this the Hospital Cash Plan obtained by the complainant from the OP.  Therefore, in the light of the Case Summary when the complainant was a known case of Coronary Artery Disease and his treatment was done as per consultation of the Cardiologist during his stay in the hospital as per the discharge summary, the complainant, in our view, is not entitled to claim medical reimbursement or compensation in the present complaint.

        In view of the above discussion the complaint is dismissed.  Keeping in view over all facts and circumstances of this complaint case the parties are left to bear their own cost of litigation. Copy of the order be sent by registered post to the parties free of cost. This order be sent to server www.confonet.nic.in

File be consigned to record room.

Announced in open Forum on 16/05/2016.

 

 

(S K SARVARIA)

PRESIDENT

 

                                                 (RITU GARODIA)                                             (H M VYAS)

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