ADV. RAVI SUSHA, MEMBER The complainant had availed Ashadeep policy from the opp.party bearing No.781547082 and other policy bearing No.781084865 and 78073302. The Ashadeep Policy bearing No.781547082 was proposed on 25.2.1998 and the policy was granted on 28.7.2008 for a sum of Rs.50,000/- to be matured on 28.7.2013. The premiuym was fixed at Rs.2,714/- half yearly. The complainant had undergone renal transplantation on 7.4.2003 as he happened to be directed as a chronic patient of ‘Renal failure”. Expenses for the surgery and treatment and continued use of medicine exceeded Rs.4 Lakhs and the complainant is entitled to medical benefits to the tune of double the sum of insurance and accordingly he placed a claim before the opp.party. The opp.party changed the Asheep claim benefit [B] policy one of endorsement type plan 14-15 from 28.7.2003 onwards and demanded the certificate for further endorsement. The change was without the knowledge and consent of the complainant and the rate of premium was also changed accordingly The change was advised to the benefit of the complainant suggesting disability of policy conditions, against his demands for medical imbursement on 25.3.2003. The complainant had suffered mental agony which is estimated to Rs.25,000/- which is to be compensated by the opp.parties. Hence the complaint. The opp.parties filed a version contending, interalia, that the complaint is not maintainable either in law on or facts. The opp.parties issued Life Insurance Policy No.781547082 [Asha Deep Policy] to the complainant viz. L. Uthaman. Uner this plan [121-15] either of the two benefits mentioned A & B below are payable. AThe sum assured with vested bonuses is payable either on the date of maturity Or on earlier death B. However if the Life assured, during the term of the policy a. Undergone cornary Artory By-ass surgery b. Undergoes regular Heemo –Dialysis of Kidney Transplant. c. Is afflicated with cancer [Malignant d. Suffers a paralytic stroke causing total permanent disability of two or more limbs persisting for 3 months after suffering the stroke and produces evidence there to satisfactory to the Corporation, then the following payments will be made. 1. Immediate payment of 50% of the sum assured 2. Payment of the balance 50% of the sum assured along with vested bonus on full Sum assured payable either on the date of maturity or on earlier death 3. An amount equal to 10% of the sum assured will be paid every year commencing From the policy anniversary falling on or after the date of eligibility till maturity Or death whichever is earlier. 4. The premiums [including accident premium] will be waived, subject to recovery of unpaid premiums till the next anniversary after the date of eligibility. A lien in respect of the benefits mentioned in para 2 [B] above will be operative commencing from the date of risk and ending one year from the date of the policy. These benefits are not payable if contingency occurs during the lien period and in such event, the policy will be altered to a corresponding Endowment Assurance with profit plan [Table 14] from the first policy anniversary The life assured underwent Kidney Transplantation on 7.4.2003 and put forth a claim for benefits B mentioned above. But the life assured is not eligible for benefit B since the contingency occurred within one year from the date of revival of the policy. In this caselien is operative for a period of one year from the date of revival and since the occurrence of the contingency is within this lien period, the plan of assurance has been altered from Asha Deep to Endowment Assurance Plan with consequent change in instalment premium. There is no illegality or impropriety in altering the plan and denying benefit ‘B’ of the policy. The life assured becomes eligible for benefit B of the policy only when the conditions given under 11 [A] is satisfied. In this particular case the lapsed policy was revived on 27.2.2003 and the contingency occurred which is within on year from the date of revival. Hence benefit B is not payable in this case. The medical claim of the complainant cannot be entertained as the policy conditions are not satisfied as mentioned above. There is no lack of service or deficiency of service on the part of the opp.parties vide letter dt. 30.7.2003 the 2nd opp.party informed the complainant that his claim under benefit B is disallowed for reasons stated thereunder and vide letter dt. 6.8.2003 the original policy was returned to the complainant after changing the Asha Deep Policy to Endowment Assurance Plan with profits. Hence no relief is admissible against the opp.parties. Points that would arise for consideration are: 1. Whether there is deficiency in service or unfair trade practice on the part of the opp.parties 2. Reliefs and costs. For the complainant PW.1 is examined. Ext.P1 to P5 are marked. For the opp.parties DW.1 is examined. Ext. D1 is marked. Points 1 and 2 The complainant filed this complaint against the repudiation of his claim in connection with the policy taken by him. The contention of the opp.party is that the renal transplantation was done within one year of the revival of policy. Opp.party has also then converted the said policy into an ordinary Endowment Assurance Policy with effect from 28.7.2003. According to them the complainant has revived his lapsed policy on 27.2.2003 and the contingency occurred within one year from the date of revival. Hence 11 B benefit is not payable to the complainant and therefore the policy claim was repudiated and as per Administrative condition opp.party has converted the policy into an ordinary Endowment Assurance Policy. The definite contention of the complaint is that the complainant had paid premium of Rs.2174/- from 28.7.1998 upto 2002. On 28.1.2003 the opp.party has asked the complainant to pay the entire arrear with interest and late fee through Ext.P2 letter for Renewing the policy. On the basis of Ext.P2, the complainant paid the entire arrears including the interest and late fee and opp.party issued Ext.P3 Renewal Premium Receipt. According to the complainant after collecting the arrears, with interest and late fee, the opp.party cannot contend that the policy is starting a fresh on revival. On verifying Ext.P3, it can be seen that the opp.party had received the entire arrears with interest and also late fee and issued Renewal Premium Receipt and also it is seen that Ext.P2 letter was issued by opp.party themselves and not on the request of the complainant asked to pay the entire dues with interest and with late fee for renewing the policy. The complainant had paid the amount on the basis of Ext.P2. After P3 renewal of policy, the denial of Benefits B of Edt.P1 Policy on the ground of contingency occurred within one year from the date of revival is not legal. In these circumstances were of the view that the repudiation of the complainant’s claim is not proper and there is deficiency in service on the side of the opp.party. Point found accordingly. The complainant is entitled to get 11 B benefit in the policy The next point to be decided is that whether the conversion of policy from Ashadeep to an Endowment Assurance Policy is legal and proper. According to the complainant, the said conversion was done without issuing any letters to the complainant or without his knowledge. Opp.party contend that they have power to convert such policy as per Administrative condition. By converting into ordinary Endowment Assurance Policy the features of the medical reimbursement was taken away. In this case the complainant has paid the outstands arrears with late fee on 27..2.2003. The renal transplantation was done on 7.4.2003. The opp..party has no case that the complainant has suppressed his existing renal diseases at the time of revival of policy. In these circumstances without giving the above said conditions to the complainant along with Ext.P1, the opp.party cannot convert the policy unilaterally by which the features of the medical reimbursement was taken away. Hence the act of opp.party of converting the policy amount to unfair trade practice. In the result the complaint is allowed, directing the opp.parties to pay the complainant Rs.25,000/-[50% of the assured amount] with interest at the rate of 12% per annum from12..9..2003 till payment and also 10% of the assured amount on every succeeding year along with waiver of future premiums. Opp.parties 1 to 3 are also to pay Rs.25,000/- towards compensation for unfair trade practice. The order is to be complied with within one month from the date of this order. Dated this the 30TH day of March, 2009. I n d e x List of witnesses for the complainant PW.1. – Uthaman List of documents for the complainant P1. – Policy certificate P2. – Revival quotation P3. – Revival premium receipt P4. – Discharge summary from PVS Hospital, Ernakulam P5. – Bills from PVS Hospital. List of witnesses of the opp.parties DW.1. – K. Sundaresan List of documents for the opp.partis D1. – Affidavit
......................K. VIJAYAKUMARAN : President
......................RAVI SUSHA : Member | | 
