Order No.  17  dt.  24/03/2017

       The case of the complainant in brief is that the complainant purchased a policy named as Well Insurance Family from o.p. no.1 bearing policy no.WF 001000002457 wherein the complainant and his wife were insured covering the period from 29.4.12 to 28.4.13 and selected the Classic Plan after paying premium of Rs.28,730/- per annum. On 14.8.12 the complainant fell ill and was admitted to Kothari Medical Centre. Under the said policy the complainant is entitled to get ICU benefit @ Rs.3000/- per day, 17 days in total sum of Rs.51,000/-. The complainant is entitled to get Rs.2 lakhs for the treatment of heart attack and also for kidney failure of Rs.2 lakhs totaling Rs.4 lakhs. After recovery the complainant submitted a bill ofRs.5,51,699/- but o.p. insurance company disbursed only Rs.46,500/-. The complainant claimed the balance amount of Rs.4,46,500/- and compensation of Rs.1 lakh and litigation cost of Rs.10,000/-.

            The o.ps. contested this case by filing w/v and denied all the material allegations of the complaint. It was stated that the complainant subscribed as Well Insurance Family Classis Insurance Plan and a policy was issued to that effect. It was stated that at the time of obtaining policy proposer Has to fill up proposal form containing several questionnaires relating to the health of the proposed insured and insurance policy is issued on good faith and the information given by proposer are true and correct. During the policy period the insured was firstly hospitalized on 14.8.12 and during the said hospitalization period he had been diagnosed with gum infection followed by sepsis and multi organ failure. The claim was reported under the covered in hospital benefit for sickness. Accordingly the claim was processed as per the terms and conditions of the policy for an amount of Rs.46,500/- (no. of days in hospitalization i.e. 6 days daily benefit @ Rs.2000 = 6x2000 = Rs.12,000/-)  after deducting one day deductable as per the policy; 11 days in ICU @ Rs.3000 =11x3000 = Rs.33,000/- plus convalescence benefit of rs.1500/-.

            During the 2^nd hospitalization the insured had been diagnosed with mandibular abscess with septicemia with multi organ failure. The insured had a medical history of type 2 diabetes mellitus, cirrhoses lever and other ailments. The insured’s past medical history was not disclosed by the hospital during the 1^st hospitalization, though he was admitted in the same hospital the claim was processed and the complainant’s claim was settled to Rs.61,500/- as per the terms and conditions of the contract and there is no further due and payable to the complainant. It was further stated that the complainant did not file any document or adduced any evidence that he suffered from heart attack or kidney failure, hence the claim under critical illness i.e. heart attack and kidney failure as claimed by the complainant was not accepted. In view of such fact o.ps. prayed for dismissal of the case.

            On the basis of the pleadings of parties the following points are to be decided:

1. Whether the complainant has suffered from heart attack and kidney failure for which he was treated in the hospital.
2. Whether the complainant was paid the entitled amount by the insurance company.
3. Whether there was any deficiency in service on the part of o.ps.
4. 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 in spite of having the policy the complainant was not provided with the claim of the amount towards the reimbursement of the medical bills which the complainant was entitled to get from o.ps. In support of the said contention the complainant adduced evidence as well as filed other documents. The o.p. no.2 without considering those documents rejected the claim of the complainant holding that the complainant failed to establish the claim that he had the critical illness for which he was entitled to get the full reimbursement of the medical expenses. In view of such fact ld. lawyer emphasized that the complainant will be entitled to get the relief as prayed for.

            Ld. lawyer for the o.ps. argued that as per terms and conditions of the policy and the non disclosure of the disease suffered by the complainant prior to the purchase of the policy the complainant suppressed the material fact, but in spite of the said fact the complainant was provided with the benefit as he was entitled to get and since the complainant failed to file any document relating to his heart attack and kidney failure and therefore the claim under the critical illness was not entertained. As per the terms and conditions of the policy the amount which the complainant was entitled to get was paid by o.ps.

            Considering the submissions of the respective parties it is admitted fact that the complainant at the relevant point of the time was the holder of insurance policy under o.p. no.1. It is an admitted fact that the complainant became ill and he was admitted to the Kothari Medical Centre. So far as the treatment rendered by the hospital it appears that the complainant initially was treated in the said hospital for gum infection followed by sepsis and multi organ failure and as per the terms and conditions of the policy the amount was determined in favour of the complainant. Subsequently the complainant further hospitalized in the said hospital and as per the diagnosed made by the hospital and the benefits the complainant will be entitled to get was considered and the amount of Rs.61,500/- was paid. Since the complainant failed to prove that he was falling within the category of treatment of critical illness i.e. heart attack or kidney failure did not arise under the said policy, therefore o.p. no.1 rightly allowed the part claim of the complainant after considering of the relevant documents including medical papers, bills, vouchers, etc. On perusal of the materials on record we do not find any illegality was committed by the o.p. insurance company and the claim of the complainant was partly allowed after considering the terms and conditions of the policy which the complainant was entitled to get. Therefore we hold that there was no deficiency in service on the part of o.ps. and as such, 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.372/2014 is dismissed on contest without cost against the o.ps.  

            Supply certified copy of this order to the parties free of cost.