DISTRICT CONSUMER DISPUTES REDRESSAL FORUM PALAKKAD
Dated this the 26th day of March 2013
Present : Smt.Seena H, President
: Smt. Preetha.G. Nair, Member
: Smt. Bhanumathi.A.K, Member Date of filing: 07/11/2012
(C.C.No.201/2012)
K.A.Sureshkumar,
Kunnath House, Poriyani,
Mundur, Palakkad Taluk
Palakkad - Complainant
(By Adv.K.Balachandran)
V/s
The Branch Manager,
LIC of India, Main Road,
Pazheri Plaza,
Kodathipadi, Mannarkkad - Opposite party
(By Adv.T.P.George)
O R D E R
By Smt.SEENA.H, PRESIDENT
Complaint in brief.
Complainant availed a health insurance policy of opposite party vide policy No.776446862 on 15/4/2008. Under the policy, complainant, his wife and son are the beneficiaries. Premium payable is Rs.15,000/- per year and the sum assured for the complainant is Rs.4 lakhs and for wife and children Rs.1 lakh each. Complainant’s son was admitted in cardiac care centre, Chennai on 9/5/2012 for a heart surgery and was discharged on 22/5/2012. When the expense was claimed opposite party rejected the claim. Complainant requested for reconsideration of the claim by the Divisional Manager, but the Divisional Manager also repudiated the claim of the complainant under the head pre-existing congenital defect. According to the complainant his son was not suffering from any ailments at the time of availing the policy in the year 2008. Opposite party after verification of medical records was satisfied with the same and has issued the policy. Heart problem which was there at the time of birth was cured by surgery on 09/1/2002. The present treatment for which claim has been made is not to correct any birth defects or congenital anomalies and also not for correction or replacement of any material that was implanted. So the reason for rejection is incorrect. Hence the complaint. Complainant prays for an order directing the opposite party to sanction the amount along with compensation and cost.
Opposite party filed version contending the following:
Opposite party admits the policy. According to opposite party as per policy condition the complainant and his spouse are entitled to all the benefits under the policy from the date of commencement of policy itself. But the child is entitled to the Major Surgical Benefits (MSB) only from the policy anniversary on which the age last birthday is 18 years. i.e. from 15/4/2015. This is specifically mentioned in the policy. Conditions and privileges attached to the policy document also clearly mentions in Clause 3 (11)(viii) that till that age child is not covered for this benefit. However the minor insured member is eligible to be covered for Hospital Cash benefit subject to the conditions and privileges of the policy.
As per the policy conditions, Hospital cash benefit is not payable for pre existing diseases. This is specifically stated in Clause 6(1) and (ii) of conditions and privileges of the policy. The treatment records shows that the child was a cardiac patient and it was diagnosed when the child was just 3 months of age. At that time it was diagnosed as Transposition of great vessels, VSD and severe sub pulmonic stenosis and a left modified shunt to reduce the pulmonary blood flow was done in 1996 October. When the child was 2 years and 9 months he had repeated cyanosis and a right modified shunt was inserted in April 2000. Again a heart surgery was done in 28/02/2002. Again in May 2012 he has developed severe conduit stenosis, moderate tricuspid regurgitation, mild RV dysfunction with proximal stenosis and again heart surgery was done under high risk. All the treatments and operations were done for correction of birth defects and congenital anomalies.
Pre-existing medical conditions are excluded and no benefits are available and no payment will be made by the opposite party. This is a clear case of pre-existing disease. The complainant / Principal Insured have willfully suppressed the material information and took the policy by violating the terms of the policy.
Hence the opposite party has rightly rejected the claim of the complainant.
The evidence adduced by the parties consists of their respective chief affidavit. Ext.A1 to A9 and Ext.B1 to B5 marked on the side of the complainant and opposite party respectively. DW1 cross examined.
Issues that arise for consideration are
1. Whether there is any deficiency in the service on the part of opposite party ?
2. If so, what is the relief entitled to the complainant ?
Issue No.1 & 2
Heard both parties and has gone through the entire evidence on record. The limited question that arise for our consideration is whether complainant’s son who has undergone heart surgery is entitled for major surgical benefits and Hospital Cash benefits.
According to the opposite party, the child is entitled to Major Surgical Benefits only when he attains 18 years of age i.e. from 15/4/2015 onwards. At the time of the surgery child was only 15 years old. On the other hand complainant argues for the position that children is entitled for the Major Surgical Benefits as he is the insured and not the child included in the policy as per Clause 13 of the policy. According to the complainant, ‘insured’ and ‘insured child’ are under different footing. A child included in the policy is a child who is not in existence at the time of availing the policy and after birth and during the period of the policy is included in the policy.
For the sake of clarity the disputed provision are reproduced below:
1.Definition
Cl.15: Insured : Insured means the person covered for the benefits under this policy and shall include the Principal Insured, the Insured Spouse (if included by the Principal Insured) and the Insured Children (if included by the Principal Insured) whose names are specified in the Schedule or in a valid endorsement made by the corporation to the schedule.
Cl.16 Insured Child : means the named person(s) labeled as such in the Schedule being a surviving legitimate child of the Principal Insured and of the Insured Spouse.
Cl.17 Insured Spouse : means the named person labeled as such in the Schedule being the surviving legal spouse of the Principal insured.
On going through the provisions we do not find any ambiguity in the terms of the policy as contented by the complainant. If the contention of the complainant that insured child and insured are two categories is accepted, then what would be the definition of insured spouse would mean ?
In Ext.B1 it is specifically stated that the date of commencement of major surgical benefit for the insured child is on 15/4/2015. So we find that as per the terms and conditions of the policy complainant’ son is not entitled for the major surgical benefits.
Next question is with regard to Hospital cash benefits. According to opposite party, it is not payable since the surgery was for correction of birth defects and congenital anomalies of the child which was a pre existing condition which is specifically excluded under clause 6(1)(i) & (ix) of the policy. It is an admitted case of the complainant that his son has congenital heart problem. It find a place in Ext.B2 also. Complainant has undergone ‘Rastelli Operation’ in the year 2002 (evident from Ext.A7). In the year 2012, Redo Conduct repair was done by surgery which we understand as a reoperartive cardiac surgery. Ext.A2 also confirm the same. In Ext.A2 in the column Nature of surgery performed it is stated ‘Redo Rastelly (high risk) open heart’. No expert evidence adduced to prove that these two operations are totally different and is not a reoperative surgery. Hence we find that complainant is not entitled for Hospital Cash Benefits under clause 6(1)(i) & (ix)
In view of the above discussions we are not in a position to attribute any deficiency in service on the part of opposite party.
In the result, complaint dismissed.
Pronounced in the open court on this the 26th day of March 2013.
Sd/-
Seena H
President
Sd/-
Preetha G Nair
Member
Sd/-
Bhanumathi.A.K.
Member
APPENDIX
Exhibits marked on the side of the complainant
Ext.A1 – Copy of the policy No.776446862 dated 15/4/2008
Ext.A2 series – Claim form, Claim intimation etc. with discharge summary
dtd.29/5/12
Ext.A3 – Copy of Discharge summary
Ext.A4 – Copy of letter rejecting claim dated 15/6/12
Ext.A5 -Copy of appeal dated 9/7/12
Ext.A6 – Copy of letter of rejecting appeal
Ext.A7– Copy of Discharge summary from Cardiac Care Center.
Ext.A8 – Copy of discharge summary from 22/9/96 to 9/10/96 of Cardiac Care
Center dated
Ext.A9 – Copy of discharge summary alongwith treatment details for the period
from 22/4/99 to 5/5/99.
Exhibits marked on the side of the opposite party
Ext.B1 – Copy of policy document.
Ext.B2 – Policy copy conditions and privileges referred in the policy document.
Ext.B3 – Discharge summary from Sriramachandra Medical college and
Research centre, Chennai
Ext.B4 – Discharge summary from Fortis Malar Hospital, Chennai
Ext.B5 – Claim intimation form by the complainant.
Witness examined on the side of the complainant
Nil
Witness examined on the side of the opposite party
DW1 – Augustin Thomas Manager (Legal)
Cost
No cost allowed.
