DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BATHINDA

CC.No.261 of 07-06-2011

Decided on 16-09-2011

Pritam Singh son of Kartar Singh, R/o H.No.14145, Street No.07-A, Ganesa Basti, Near Durga Mander, aged about 57

 years, Bathinda, District Bathinda.

.......Complainant

Versus

1. Reliance Life Insurance Company Limited, Regd. No.121, Regd. Office H-Block Ist Floor, Dhirubhai Ambani

   Knowledge City, Navi Mumbai, Maharashtra-400710, through its M.D.

    

2. Reliance Life Insurance Company Limited, Hazi Rattan Chowk, Bathinda, through its Branch Manager.

    

3. The Medi Assist. India T.P.A. Pvt. Limited Team Reliance Wealth + Health Shipla Vidya, IIIrd Floor, 49, 1st Main

   Road Sarakki Indi. Layout, 34th Stage, J.P. Nagar Bangalor-560078, through its M.D.

......Opposite parties

Complaint under Section 12 of the Consumer Protection Act, 1986.

QUORUM

Smt. Vikramjit Kaur Soni, President

Sh.Amarjeet Paul, Member

Smt. Sukhwinder Kaur, Member

Present:-

For the Complainant: Sh. H.S.Dhanoa, counsel for the complainant.

For Opposite parties: Sh. Sanjay Goyal, counsel for opposite party Nos.1&2

Opposite party No.3 exparte

ORDER

Vikramjit Kaur Soni, President:-

1. The present complaint has been filed by the complainant under Section 12 of the Consumer Protection Act, 1986 as amended up-to-date (Here-in-after referred to as an 'Act'). The brief facts of the complaint are that the complainant had purchased Wealth + Health Policy from the opposite party No.2. According to the terms and conditions of the policy, any person who obtain the said policy, is entitled to avail the reimbursement of medical expenses in case of any illness when he is admitted in any hospital on the basis of daily hospital cash benefit to the tune of Rs.600/- per day. So after assurance of the opposite parties, the complainant purchased the above said policy bearing policy No.2564738 w.e.f. 11.09.2008 to 11.09.2018. The complainant has been regularly paying the premium of the said policy to the opposite party No.2. On 12.08.2009, the complainant met with an accident while he was going on a motorcycle with a car and sustained multiple grievous injuries on his person and the right leg of the complainant was fractured from 4-5 places but no FIR was got registered as the matter was got compromised between the complainant and the driver of the car. The complainant had sustained multiple injuries in the said accident and as such, he was got admitted in Civil Hospital, Bathinda but thereafter, the complainant was shifted to DMC Hospital, Ludhiana and intimation regarding the said accident was also given to the opposite party No.2 through agent. Thereafter, the complainant remained admitted in D.M.C. Hospital, Ludhiana w.e.f. 12.08.2009 to 27.09.2009 and was discharged from the hospital on 27.09.2009. The complainant covered under the scheme of the policy Wealth + Health, claimed Rs.600/- per day for the above said period of 12.08.2009 to 27.09.2009. The claim filed to the opposite party No.2. The claim of the complainant was lodged vide reimbursement claim No.RLIC-2180-Pritam Singh. The complainant was discharged from D.M.C. Hospital, Ludhiana on 27.09.2009 but he was again got admitted in D.M.C. Hospital, Ludhiana and was operated upon and remained hospitalized from 11.10.2009 to 11.11.2009. Thereafter, he remained admitted in Amandeep Hospital, Amritsar from 27.02.2010 to 12.03.2010 and the insurance claim for the above said period from 11.10.2009 to 11.11.2009 and 27.07.2010 to 12.03.2010 was submitted by the complainant on 09.11.2010 in the office of the opposite party No.2 alongwith the above said claim Form, the complainant has supplied all the requisite formalities to honour his lawful claim for the above said period as per Rs.600/- per day. So the complainant became entitled to reimbursement the total amount of Rs.53,400/- i.e. for 89 days but the complainant was surprised, when the opposite parties have honored his claim only to the tune of Rs.7,800/- and with held his remaining claim. Thereafter, the opposite party No.3 issued a letter to the complainant on 24.11.2010 regarding that the premium due against the complainant upto 11.09.2009 but the same has not been deposited by him even after availing the grace period and as such, the complainant is not entitled to the medical insurance claim. The claim of the complainant has been rejected by the opposite parties as the complainant has purchased the policy on 11.09.2008 on the basis of half yearly installment, the next installment was on 13.03.2009 which was got deposit on the fixed date and the third installment was due on 11.09.2009 which was got deposit on 15.09.2009 after four days and the delay was due to the reason that the complainant was admitted in the hospital and unable to pay the premium. The complainant has alleged that he has been regularly paying the amount of premium but after the accident, he remained under treatment with D.M.C. Hospital, Ludhiana and remained confined to bed and was not in a position to deposit the amount of premium within period. Thereafter, the complainant approached the opposite party No.2 and told his reasons for not depositing the premium within period but the opposite parties have been postponing the matter on one or the other pretext. The complainant also served a legal notice dated 13.04.2011 to the opposite parties but no reply has been given by the opposite parties. Hence, the complainant has filed the present complaint for seeking directions of this Forum to pay the claim of Rs.53,400/- for 89 days alongwith cost and compensation.

2. Notice has been issued to the opposite parties. The opposite party Nos.1&2 after appearing before this Forum, have filed their joint written statement and pleaded in preliminary submissions that the complainant had submitted an application for Reliance Life Insurance Wealth + Health Plan insurance bearing No.3835608 dated 11.09.2008 in his own name, the premium was to be paid half yearly to the tune of Rs.6,000/-. The complainant was given the detailed description about the features of the said plan including the premium amount to be paid, all the charges, that would be levied on the same and was also apprised with its terms and conditions before signing the said application Form. It was only after being completely satisfying himself with the features of the plan and terms of the plan including premium amount to be paid annually towards the said plan and after having understood and agreed to the terms and conditions, the complainant applied and signed the said Application Form on his free will and consent. The plan was a health wealth plus which takes care of the hospitalization expenses which include, daily hospitalization expenses, intensive care unit expenses and post hospitalization expenses in the form of recuperation benefits. It is also a condition of the policy that the maximum number of days that can be spent in the hospital (including days spent in ICU) by the Principal insured are restricted to 180 days. In this particular case, the Daily hospitalization cash benefit payable was 5% of the annual premium which comes out to be Rs.600/- per day and this was payable for maximum 180 days during the whole policy which was 10 years. The Policy holder is entitled for the amount of daily hospitalization cash benefit only if the terms and conditions of the policy are satisfied. The policy also pays for recuperation benefit which is in addition to daily hospitalization cash benefit. The amount of recuperation benefit for the principal insured will be equal to twice the amount of daily cash benefit in a ward other then ICU. The complainant got admitted to the hospital 3 times for which he had lodged claim release request. First claim for admission in hospital from 12.08.2009 to 27.09.2009. The complainant was got admitted with Fracture of Femur & Tibia. Even with Open Reduction & Internal Fixation (ORIF) the hospitalization would not exceed 10 days as there is no treatment except administration of antibiotics. The healing process takes a longer duration after which the patient is required to get it reviewed in OP/X-ray taken to see the result/condition followed by Physiotherapy – especially after 3 or 4 weeks – depending on the condition of the fractured bone. Physiotherapy is again an OP procedure and does not warrant admission. The admission is on 12.08.2009 and the Discharge is said to have been on 27.09.2009 – which was an unreasonable long period of time considering the illness and the subsequent surgery for which the complainant got admitted. The opposite parties had asked for the clarification for the unduly long duration, copy of the treatment chart issued by the hospital and certificate form the hospital certifying the time of admission and time of discharge for which various letters were sent 1st letter sent on 12.02.2010, reminder letter sent on 22.02.2010, 2nd reminder letter was sent on 02.03.2010, closure notice was sent on 10.03.2010 and finally closure letter was sent on 14.03.2010. The second claim for admission in hospital from 11.10.2009 to 11.11.2009, the admission was also for an unusual long duration and during the stay only few tablets have been prescribed but the claim had been repudiated as per conditions No.8.5.1 of the policy.

The half year premium was due on 11.09.2009. It has not been remitted even during the Grace period. So, the policy got discontinued. As per record of the opposite parties, the policy has been reinstated w.e.f. 24.10.2009 and the hospitalization was on 11.10.2009. At the time of admission to the hospital, the policy was in lapsed status due to non-payment of premium and so no benefits arising under the policy could be paid. The third claim for admission in hospital from 27.02.2010 to 12.03.2010, the Daily hospitalization cash benefit amounting to Rs.6,000/- (Rs.600 per day for 11 days of admission in Hospital) and recuperation benefits of Rs.1,200/- was also paid as per the terms and conditions of the policy. The opposite parties have denied that the complainant has been paying the premium regularly and it is stated that the half yearly premium was due on 11.09.2009 but it was not paid even during the grace period and the policy got discontinued and the same was reinstated only w.e.f. 24.10.2009. The complainant lodged a claim with the opposite parties for release of the claim amount on daily hospitalization cash benefit for hospitalization from 12.08.2009 to 27.09.2009. The complainant has not explained the hospitalization for an unreasonably long period and has not provided copy of the treatment chart issued by the hospital and certificate from the hospital certifying the time of admission and time of discharge and it is denied that the complainant was admitted from 12.08.2009 to 27.09.2009. The claim release request for hospitalization from 11.10.2009 to 11.11.2009 was lodged with the opposite parties but the same was denied due to the reasons mentioned above. The claim release request for hospitalization from 27.02.2010 to 12.03.2010 was lodged with the opposite parties for the same, the payment of Rs.7,800/- was duly made to the complainant vide HDFC Bank cheque No.321585 dated 30.11.2010. The complainant became entitled for claim of Rs.53,400/- for 89 days and the claim was only payable for 13 days for which the same was paid without any delay. The third half yearly payment of premium was due on 11.09.2009 and the same was not paid either on due date and not within the grace period, therefore, all the benefits under the policy were withdrawn and the policy was reinstated only on 24.10.2009.

3. The opposite party No.3 despite service of notice/summon, has failed appear before this Forum. Hence, exparte proceedings are taken against opposite party No.3.

4. Parties have led their evidence in support of their respective pleadings.

5. Arguments heard. Record alongwith written submissions submitted by the parties perused.

6. The learned counsel for the complainant has submitted that the complainant had purchased medi-claim Policy vide Ex.C-1 bearing No.2564738 valid from 11.09.2008 to 11.09.2018 and the mode of payment was half yearly premium. This policy was under the name of Wealth + Health Policy. According to the terms of the policy, a person who obtains the said policy, is entitled to avail the reimbursement of medical expenses if in case he admits in any hospital on the basis of daily hospital cash benefit (DHCB) to the tune of Rs.600/- per day. On 12.08.2009, the complainant met with an accident and sustained multiple grievous injuries on his person and the right leg of the complainant was fractured from 4-5 places; no FIR was got registered as the matter was got compromised between the complainant and the driver of the car. The complainant was got admitted in Civil Hospital, Bathinda but later on, he was shifted to DMC Hospital, Ludhiana and intimation regarding the said accident was also given to the opposite party No.2 through agent. The complainant remained admitted in D.M.C. Hospital, Ludhiana w.e.f. 12.08.2009 to 27.09.2009 and was discharged from the hospital on 27.09.2009. The complainant under the scheme of the policy Wealth + Health, lodged the claim @ Rs.600/- per day for the above said period of 12.08.2009 to 27.09.2009 to the opposite party No.2 vide reimbursement claim No.RLIC-2180. The complainant was again admitted in D.M.C. Hospital, Ludhiana from 11.10.2009 to 11.11.2009 and thereafter, he remained admitted in Amandeep Hospital, Amritsar from 27.02.2010 to 12.03.2010. The insurance claim with regard to the above mentioned 2 periods was withheld which was submitted by the complainant on 09.11.2010 in the office of the opposite party No.2. The complainant has supplied all the requisite formalities to honor his lawful claim for the above said period @ Rs.600/- per day. His total claim amount is Rs.53,400/- for 89 days but the opposite parties have honored the claim of Rs.7,800/- only and have with held the remaining claim of the complainant. The opposite party No.3 issued a letter to the complainant on 24.11.2010 that the premium was due against the complainant upto 11.09.2009 but the same has not been deposited by the complainant even after availing the grace period, as such he is not entitled to the medical insurance claim. The complainant has purchased the policy on 11.09.2008 on the basis of half yearly installment, the next installment was payable on 13.03.2009 which was got deposit on the fixed date and the third installment was due on 11.09.2009 which was got deposit on 15.09.2009 after four days, the delay was due to the reasons that the complainant was admitted in the hospital. The complainant also served a legal notice dated 13.04.2011 to the opposite parties.

7. The learned counsel for opposite parties has submitted that the complainant had submitted an application for Reliance Life Insurance Wealth + Health Plan insurance bearing No.3835608 dated 11.09.2008 for half yearly premium of Rs.6,000/-. The Proposal Form bearing No.3835608 dated 22.06.2011 was submitted. The plan so taken by the complainant, was Wealth + Health plan which takes care of the hospitalization expenses which included, Daily Hospitalization Expenses, Intensive Care Unit Expenses and Post Hospitalization Expenses in the form of recuperation benefits. It is also a condition of the policy that the maximum number of days that can be spent in the hospital (including days spent in ICU) by the Principal insured are restricted to 180 days. In this particular case, the Daily Hospitalization Cash Benefit was payable 5% of the annual premium which comes out to be Rs.600/- per day and this was payable for maximum 180 days during the whole policy which was for 10 years. The Policy holder is entitled for the amount of daily hospitalization cash benefit, if he satisfies the terms and conditions of the policy. The complainant had got admitted to the hospital 3 times, for which he had lodged claim release request.

1. The first claim for admission in hospital from 12.08.2009 to 27.09.2009. The complainant was got admitted with Fracture of Femur & Tibia. Even with Open Reduction & Internal Fixation (ORIF), the hospitalization would not exceed 10 days as there is no treatment except administration of antibiotics. The healing process takes a longer duration after which the patient is required to get it reviewed in OP/X-ray taken to see the result/condition followed by Physiotherapy – especially after 3 or 4 weeks – depending on the condition of the fractured bone. Physiotherapy is again an OP procedure and does not require admission. The admission is on 12.08.2009 and the Discharge is said to have been on 27.09.2009 which was an unreasonable long period of time considering the illness and subsequent surgery for which the complainant got admitted. The opposite parties had asked for the clarification for the unduly long duration, a copy of the treatment chart issued by the hospital and certificate form the hospital certifying the time of admission and time of discharge for which various letters were sent i.e. the first letter sent on 12.02.2010, reminder sent on 22.02.2010, second reminder was sent on 02.03.2010, closure notice was sent on 10.03.2010 and finally closure letter was sent on 14.05.2010.

2. The second claim for admission in hospital from 11.10.2009 to 11.11.2009, the admission was also for an unusual long duration and during the stay only few tablets have been prescribed but the claim had been repudiated as per the following terms and conditions of the policy: 8.5.1 Discontinuance of Premiums due within three years from the date of commencement of the-policy:- 'If Premiums have not been paid for at least three consecutive years from the inception the health insurance benefits and rider benefits if any will cease immediately.'

   The half yearly premium was due on 11.09.2009, it has not been remitted even during the grace period and the policy got discontinued. According to the record of the opposite parties, the policy has been reinstated w.e.f. 24.10.2009 and the hospitalization was on 11.10.2009. At the time of admission to the hospital, the policy was in lapsed status due to non-payment of premium and so no benefits arising under the policy could be paid.

3. The third claim for admission in hospital from 27.02.2010 to 12.03.2010. The Daily Hospitalization Cash Benefit amounting to Rs.6,600/- (Rs.600 per day for 11 days of admission in Hospital) and recuperation benefits of Rs.1,200/- was also paid as per the terms and conditions of the policy.

8. The complainant had failed to pay the half yearly premium which was due in September 2009 and it was also not paid even during the grace period and as such, the policy was discontinued and the same was reinstated only w.e.f. 24.10.2009. The benefits for hospitalization from 12.08.2009 to 27.09.2009, were not paid as the complainant till date, has not explained the hospitalization for unreasonably long period and has not provided the copy of the treatment chart issued by the hospital and certificate from the hospital certifying the time of admission and time of discharge. On this ground, the claim of the complainant 12.08.2009 to 27.09.2009 was not admitted. The claim release request for hospitalization from 11.10.2009 to 11.11.2009 was also denied due to the reasons that the policy stands lapsed during that period. Another reasons for hospitalization from 27.02.2010 to 12.03.2010 was lodged with the opposite parties and the payment of Rs.7,800/- for the same, was made to the complainant through HDFC Bank cheque No.321585 dated 30.11.2010. The complainant asked for claim of Rs.53,400/- for 89 days for three admissions in the hospital.

9. As per the first claim, the complainant has failed to give any explanation for hospitalization for such a long time and his second claim was not paid as the policy was ineffective during that period and the claim for 13 days has already been paid to the complainant.

10. A perusal of Ex.C-2 shows that the complainant had failed to pay the premium which was due on 11.09.2009 and even after the expiry of grace period, he has failed to remit the premium to the opposite parties. According to Ex.C-2, the policy was lapsed as the complainant has failed to pay the premium even during the grace period. The relevant portion of Ex.C-2 is reproduced as under:-

“8.5.1-Discontinuance of Premiums due within three years from the date of commencement of the Policy:

If Premiums have not been paid for at least three consecutive years from the inception the health insurance benefits and rider benefits if any will cease immediately

The half year premium was due on 11.09.2009. 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. 24.10.2009. The Hospitalization is on 11.10.2009 – that is during the policy grace period.”

11. The opposite parties have rejected two claims of the complainant out of 3 claims and paid the third claim vide Ex.C-5 as under:-

The complainant had received the payment of Rs.7,800/- vide Ex.C-6.

12. With regard to the claim for the hospitalization for the period from 12.08.2009 to 27.09.2009, the opposite parties has written a letter dated 10.04.2010 vide Ex.C-8 to the complainant for submitting the following documents:-

“1) We note that Date and Admission is 12.08.2009 and the Discharge Summary is 27.09.2009. Kindly let us have clarification from the Hospital. And reason for unduly long duration of Hospitalization.

2) We also would like to have a copy of treatment chart issued by the Hospitalization, we await your compliance as above.

3) Certificate required from the hospital Certifying Time of Admission and Time of Discharge.”

Before that, the opposite parties have mentioned in their letter Ex.C-8 that they have already sent 4 letters in this regard and also conveyed the complainant that if he would not submit the papers as mentioned above, his claim would be denied for want of requisite documents.

13. The opposite parties have again sent a reminder dated 29.04.2010 to the complainant vide Ex.C-9 and asked him to deposit the documents mentioned in Ex.C-8. Thereafter, the second reminder was sent vide Ex.C-10 and Closure Advice was sent vide Ex.C-11 dated 20.06.2010 to the complainant by the opposite parties. The relevant portion of Closure Advice is reproduced as under:-

“What your have submitted is only a Discharge Summary which has already been filed with us. Further, it may please be noted that you have not submitted any Indoor Case Paper other than the Hospital Bill and the Pharmacy Bills. Your attention is drawn to clause No.-VI under Annexure-2 of the policy where it is the responsibility of the insured to submit the documents/information for processing the claim. We cannot arrange for the claim documents.

Since you have failed to comply with our requirement inspite of closure advice as well as original letters prior to this we have closed the claim for non-submission of required claim documents.”

14. The medi-claim policy was obtained by the complainant, the mode of premium of this policy was half yearly premium. The half yearly premium was due on 11.09.2009 against the complainant but the complainant has failed to pay the premium during grace period and therefore, the policy was got discontinued, the premium had been paid by the complainant after lapse of grace period and the policy was discontinued and the same was reinstated only w.e.f. 24.10.2009. The policy remained lapsed from 11.09.2009 to 23.11.2009. Any hospitalization during this period is not covered under the Health + Wealth policy. The hospitalization for the period from 12.08.2009 to 27.09.2009, the complainant had been repeatedly asked by the opposite parties to submit the documents and seek clarifications from the complainant that why he remained admitted as indoor patient for such a long period and has also issued reminder letters but the complainant has failed to reply to the said letters of the opposite parties. The complainant has specifically mentioned that he has paid the premium vide receipt dated 15.09.2009. The opposite parties had requested for production of this receipt but the complainant has failed to produce the said receipt dated 15.09.2009. The hospitalization of 13 days for the period from 27.02.2010 to 12.03.2010 has already been paid to the complainant which includes Daily Hospitalization Cash Benefit amounting to Rs.6,600/- (Rs.600 per day for 11 days of admission in Hospital) and recuperation benefits of Rs.1,200/- was also paid as per the terms and conditions of the policy.

15. Therefore, in view of what has been discussed above, this Forum is of the considered view that there is no deficiency in service on the part of the opposite parties. Hence, this complaint is dismissed without any order as to cost.

A copy of this order be sent to the parties concerned free of cost and file be consigned for record. '

Pronounced in open Forum

16-09-2011

(Vikramjit Kaur Soni)

President

(Amarjeet Paul)

Member

(Sukhwinder Kaur)

Member