Order No. 16 dt. 16/06/2017
The case of the complainant in brief is that the complainant is the holder of Happy Family Floater Policy being no.31500/48/2013/7102 and the sum assured amount of Rs.8 lakhs and the policy was valid from 11.12.12 to 10.12.13 and the complainant paid the premium of Rs.21,090/- to o.p. insurance company. The o.p. no.1 provided the policy and the said policy covers the two dependants of the complainant. The complainant on 28.9.13 admitted at B.M. Birla Heart Research Centre and he was diagnosed as triple vessel disease with type II diabetes mellitus and he had the problem of coronary angiography. After necessary tests the complainant underwent elective coronary angiography to assess coronary arteries. Such coronary angiography revealed that the complainant suffered from triple vessel disease and he was discharged on 2.10.13. The complainant paid a sum of Rs.75,766/-. Again the complainant felt pain and admitted to Apollo Gleneagles Hospital on 15.10.13 and he incurred the medical expenditure of rs.34,609/- which was settled at Rs.24,009/-. The complainant thereafter was admitted to Lilabati Hospital, Mumbai for treatment and he was treated under Dr. Samuel Mathew and he incurred the expenses of Rs.9,49,635/-. After recovery the complainant submitted bills and o.p. no.2 settled the claim amount of Rs.5 lakhs not even considering the sum assured amount of the settled policy which was Rs.8 lakhs. On the basis of the said fact the complainant filed this case praying for direction upon the o.p. insurance company for release of the fund ofRs.3 lakhs along with compensation and cost.
The o.ps. contested this case by filing w/v and denied all the material allegations of the complaint. O.p. no.1 stated that the complainant was admitted thrice in different hospitals like B.M. Birla Heart Research Centre against which the complainant raised the claim of Rs.75,792/- and settled to the extent of Rs.72.766/-; Apollo Gleneagles Hospital against which the complainant raised the claim of Rs.34,609/- and settled to the extent of Rs.24,009/-; and last of all Lilabati Hospital against which the complainant raised the claim of Rs.9,43,679/- and settled to the extent of Rs.4,03,225/-. It was further stated that during the said month the complainant raised the bill of Rs.10,54,080/- and out of which o.ps. settled the claim of Rs.5 lakhs as per policy condition. It was also stated that the patient has a pre existing disease of hypertension and diabetes mellitus type II which the complainant suppressed the said fact at the time of taking the policy during the period from 11.12.12 to 10.12.13 with a sum assured of Rs.8 lakhs. It is an admitted fact that the complainant took the policy from 11.12.1999 and from 2007-08, 2008-09, 2009-10 and 2010-11 with a sum insured upto Rs.5 lakhs for each year and for the period from 2011-12 took sum insured upto Rs.7 lakhs and 2012-13 took sum insured upto Rs.8 lakhs. The o.p. no.1 stated that as per clause 4.1, 4.2 and 4.3 of the proposal form are the guidelines laid down for the exclusions of expenses if the insured are holding a pre existing health condition or ailment or injuries. In clause 4.1 of the proposal form defines pre existing health condition of the insured and as per the terms and conditions of the policy the amount was settled with the complainant. There was no deficiency in service on the part of o.p. no.1. In view of the said fact o.p. no.1 prayed for dismissal of the case.
In their w/v o.p. no.2 stated that the patient was suffering from diabetes since last three years and for that reason the sum was restricted in 2008-09 for Rs.5 lakhs and the sum of Rs.4,03,225/- was paid to the complainant. In the year 2008-09 the sum assured was Rs.5 lakhs and the patient was admitted to the hospital three times and he was paid the amount of Rs.5 lakhs. There was no deficiency in service on the part of o.p. no.2 and the case is to be dismissed.
On the basis of the pleadings of parties the following points are to be decided:
- Whether the complainant had the policy with o.p. no.1 and the policy was valid at the relevant point of time?
- Whether there was any deficiency in serviced on the part of o.ps.?
- Whether the complainant will be entitled to get the relief as prayed for?
Decision with reasons:
All the points are taken up together for the sake of brevity and avoidance of repetition of facts.
Ld. lawyer for the complainant argued that the complainant had the policy of sum assured of Rs.8 lakhs and he paid the premium and the policy was valid from 11.12.12 to 10.12.13. During the said period the complainant suffered heart ailment for which he was treated at different hospitals viz. B.M. Birla Heart Research Centre, Apollo Gleneagles Hospital and Lilabati Hospital and after recovery he submitted a claim of Rs.9,49,635.68 and the complainant was paid only Rs.5 lakhs though the sum assured of Rs.8 lakh. In view of the said fact the complainant prayed for balance amount of Rs.3 lakhs along with other reliefs.
Ld. lawyer for the o.ps. argued that the complainant from time to time enhanced the sum assured of the policy and lastly as per the policy on the basis of which the complainant claimed the amount though the assured sum of Rs.8 lakhs, but during the said period the complainant was admitted to hospital thrice and he was treated in different hospitals. Ld. lawyer for o.ps. argued that from the documents filed by the complainant it is crystal clear that the patient had pre existing disease of hypertension and diabetes mellitus type II which the complainant suppressed the material fact at the time of taking the policy during the period 11.12.12 to 10.12.13. From the documents filed by the complainant it appears that each and every attending doctors of that hospital diagnosed the patient was suffering hypertension and diabetes mellitus type II along with other disease. The complainant was suffering from the said disease for a long time and there were pre existing diseases of the patient which the complainant suppressed at the time of taking policy in the year 2012-13. As per the policy in clause 4.1 it was specifically stated that pre existing health condition or disease or ailment or injuries any ailment / disease / injuries / health which are pre existing (treated / untreated, declared / not declared in the proposal form). In case of any of the insured person of the family when the cover incepts for the first time, are excluded for such insured person upto 4 years of those policy being inforce continuously. On the basis of the said fact and as per the terms and conditions of the policy the complainant was provided with the amount of Rs.5 lakhs. The complainant being aware of the terms and conditions under the policies about the suppression of material facts and being aware that he will not get assured benefits because of terms and conditions of exclusions laid down in clause 4.1 to 4.3 of the policy has filed the present complaint. In view of the said fact o.ps. prayed for dismissal of the case.
Considering the submissions of the respective parties it is an admitted fact that the complainant is the holder of Happy Family Floater Policy and the sum assured was Rs.8 lakhs and the policy was valid at the relevant point of time. The o.ps. also admitted the said fact. From the documents filed by the complainant it appears that he was suffering from hypertension and diabetes mellitus type II diseases previously and as per the terms and conditions of the policy, the policy holder will have to wait for two years to enjoy the medical benefits and as the policy holder was continuing his policy from 2007-08, 2008-09, 2009-10, 2010-11 with a sum assured of Rs.5 lakhs each year and accordingly he was entitled to enjoy the medical benefit to the extent of sum assured of Rs.5 lakhs only. It is also an admitted fact that the complainant was admitted to the hospital during the same year on three occasions and he submitted bills. The o.p. no.1 after verifying the medical bills of the complainant and as per the terms and conditions of the policy and even relaxation was given as per the clause 4.1 to 4.3 of the said policy the complainant was provided with the amount of Rs.5 lakhs. The complainant received the said amount and after accepting the said amount the chapter of further claimed becomes closed. But the complainant in order to have the claim filed this case for experimental sake if the false claim is made against the insurance company but from the materials on record it appears that the complainant suppressed his pre existing disease of diabetes mellitus type II which was the root cause of all the troubles faced by the complainant. The o.ps. for the sake of the continuation of the policy by the complainant since the year 2007 considered the case of the complainant sympathetically and accepted the bills incurred by the complainant as per the terms and conditions of the policy and the sum assured upto Rs.5 lakhs was paid to the complainant. Accordingly, the claim made by the complainant has got no basis and there is no deficiency in service on the part of o.ps. thereby the complainant will not be entitled to get any relief as prayed for. Thus all the points are disposed of accordingly.
Hence, ordered,
That the CC No.600/2014 is dismissed on contest without cost against the o.ps.
Supply certified copy of this order to the parties free of cost.
