IN THE CONSUMER DISPUTES REDRESSAL FORUM, ALAPPUZHA
Tuesday the 30th day of August, 2016
Filed on 11.02.2015
Present
1.Smt. Elizabeth George (President)
2.Sri. Antony Xavier (Member)
3.Smt.Jasmine.D. (Member)
in
C.C.No.44/2015
between
Complainant:- Opposite Party-
Sri. C.G. Sivadas The Branch Manager
Siva Bhavan Life Insurance Corporation
M.O. Ward of India, Branch Office No.1
Alappuzha – 60999 Vellakkinar, P.B. No. 444
(By Adv. P.V. Satheesh) Alappuzha
(By Adv. S. Devalal)
O R D E R
SMT. ELIZABETH GEORGE (PRESIDENT)
The case of the complainant is as follows:-
On 10.10.2008 the complainant took a Health Plus Policy uder LIC’s Health Plus Plan (Table 901) for yearly premium of Rs.15,000/- valid to 10.10.2020. As per the policy the complainant is entitled to get various benefits offered under the policy like Hospital Cash Benefit, Major Surgical Benefit and Domiciliary Treatment Benefit. On 20.11.2013 complainant was admitted as inpatient in Medical Trust Hospital, Ernakulam due to Visual Disturbances facial deviation and slurring of speech and treated in the hospital up to 25.11.2013 and continued the follow up treatment. He had spent Rs.28,873/- for his treatment. The complainant lodged a claim before the opposite party, for obtaining the hospital benefits along with hospital records and bills. But it was rejected on the ground of self inflicted injuries or conditions of misuse of drugs or alcohol. The rejection of the claim of the complainant is absolutely baseless and the opposite party committed deficiency in service. Hence the complaint is filed.
2. The version of the opposite party is as follows:-
The policy of the complainant is a unit linked health insurance plan which provides for health risk cover in the form of hospital cash benefits, major surgical benefits etc. subject to terms and conditions, daily hospital cash benefits rejected by the opposite party as per the findings of the TPA. The in-house investigator of TPA has submitted his investigation report. As per his report he had history of Diabetes Mellitus since 4 years, HTN since 2 years and a chronic smoker and alcoholic. Afterwards, TPA rejected the claim as indoor case paper shows that the policy holder is a chronic alcoholic and smoker and the present ailment is attributed to chronic alcoholism. The TPA rejected the claim under rejection code H12 (Exclusions Clause 6) which states that misuse of any drugs or alcohol will result in rejection of claim. The opposite party has rightly rejected the claim according the terms and conditions stipulated in the “Conditions and Privileges” which has been part and parcel of the policy document. There is no defect or deficiency in service or unfair trade practice from the part of the opposite party.
3. The complainant was examined as PW1. The documents produced were marked as Exts.A1 to A3. Opposite parties produced documents which marked as Exts.B1 to B6.
4. The points that arose for consideration are as follows:-
1) Whether there is any deficiency in service on the side of the opposite party?
2) If so the reliefs and costs?
5. It is an admitted fact that complainant is a Health Plus policy holder of the opposite party. According to the complainant, he was hospitalized on 20.11.2013 to 25.11.2013 due to Visual Disturbances facial deviation and slurring of speech. He continued follow up treatment and had spent Rs.28,873/- for his treatment. According to the complainant, he is entitled to get benefits like hospital cash benefits, major surgical benefits and domiciliary treatment benefits. So he lodged a claim before the opposite party for obtaining the assured benefits, but his claim was rejected by a letter dated 11.11.2014 from the opposite party stating that the disease for which had had undergone the treatment was the result of chronic diabetes and alcoholism. In order to substantiate the allegation of the complainant, the complainant has produced the policy copy which marked as Ext.A1 and copy of the discharge summary which marked as Ext.A2. The opposite parties filed version stating that the complainant is not entitled to claim any amount as per the policy because according to the medical authority the disease for which he had undergone the treatment was a result of chronic diabetes and alcoholism. The opposite party has produced six documents which marked as Exts.B1 to B6. The point to be considered is whether the treatment undergone by the complainant was the result of chronic diabetes and alcoholism. On verifying Ext.A2 the discharge summary under the title clinical history it is stated that, “No history of headache, vomiting loss of consciousness of seizure. No history of stroke or TIA in the past. Initially he was evaluated at Medical College Hospital, Alappuzha. CT head done was normal. Had alleged history of fall 2 days ago.” During the cross examination of the complainant, he stated that he never drink alcohol. Even though opposite party produced Ext.B5 the investigation report which shows the complainant was a chronic smoker and chronic alcoholic it was not proved by examining any witness. Hence the contention of the opposite party that the complainant was not entitled to get the policy benefits as the disease is caused due to alcoholism is not sustainable. According to the complainant, as per Ext.A1 policy, the complainant is entitled to get various benefits like hospital cash benefits, major surgical benefits and domiciliary treatment benefits. The daily hospital cash benefit opted by the insured was Rs.1000/- with an increase of 5% per year up to a maximum of 1.5 times of the initial DHB. The complainant was hospitalized on 20.11.2013 and was discharged on 25.1.2013. Hence the eligible No. of days as per the policy is only 3 days and total eligible cash benefit is Rs.3,750/-. Then the next question is whether the complainant is entitled to get major surgical benefit and domiciliary benefit. The complainant has no case that he has undergone any surgery. Hence he is not entitled to get any surgical benefits under the policy, according to the complainant, he had expended Rs.28,873/-/- for his treatment and he is entitled to get it towards domiciliary treatment benefit. As per Ext.B6, the complainant claimed Rs.28,873/- towards the expenses for the treatment. The opposite party totally denies the domiciliary treatment benefit. On verifying Ext.B1 policy under the head domiciliary treatment benefit it is stated that, “If at least 3 years’ premiums have been paid, an amount can be claimed which will be made out of the Policy Fund, by cancellation of appropriate number of units, equal to actual amount spent to meet any domiciliary treatment expenses or any other medical expenses over and above those paid through hospital cash/surgical benefits incurred in respect of Principal Insured or any of the other Insured lives at any time, subject to all of the conditions mentioned in clause 3(iii) being satisfied for each payment.” As per Ext.B1 which envisages 3 kinds of benefit such as Hospital cash benefit, major surgical benefit and domiciliary benefit. There is no records to show that the complainant was advised to undergo domiciliary treatment, but on going through clause 2 (iii) of the conditions in the policy, describing domiciliary treatment benefit, it is stated that, “or any other medical expenses over and above those paid through hospital cash benefit / surgical benefit incurred.” The only limitation is that the amount claimed under the medical expenses will be paid by the LIC by cancellation of appropriate number of units equal to actual amount spent for medical expenses. Hence we are of opinion that complainant is entitled to get hospital cash benefit as well as the other medical expenses as stand under the domiciliary benefit by the cancellation of an appropriate number of units.
In the result, complaint is allowed partly. The opposite parties are directed to process the claim application of the complainant and pay the hospital cash benefit and domiciliary treatment benefit as per the norms of the policy with interest @ 9% per annum from the date of complaint till realization to the complainant. The opposite parties are further directed to pay an amount of Rs.2,000/- (Rupees two thousand only) towards costs of the proceedings to the complainant. The order shall be complied within one month from the date of receipt of this order.
Dictated to the Confidential Assistant transcribed by me and pronounced in open Forum on this the 30th August 2016.
Sd/- Smt.Elizabeth George (President) :
Sd/-Sri. Antony Xavier (Member) :
Sd/- Smt.Jasmine.D. (Member) :
Appendix:-
Evidence of the complainant:-
PW1 - C.G. Sivadas (Witness)
Ext.A1 - Policy copy with conditions
Ext.A2 - Copy of discharge summary
Ext.A3 - Copy of rejection letter
Evidence of the opposite parties:-
Ext.B1 - Copy of the policy with conditions
Ext.B2 - Copy of the proposal form
Ext.B3 - Copy of the form to be filled in by the Member (Beneficiary) in case the
Member is not a Minor
Ext.B4 - Copy of the discharge summary
Ext.B5 - Copy of the investigation report
Ext.B6 - Copy of the rejection letter dated 11.11.2014
// True Copy //
By Order
Senior Superintendent
To
Complainant/Opposite parties/S.F.
Typed by:- pr/-
Compared by:-
