BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM.
Dated this the 13th day of January 2016
Filed on : 27-10-2014
PRESENT:
Shri. Cherian K. Kuriakose, President.
Shri. Sheen Jose, Member.
Smt. Beena Kumari V.K. Member.
CC.No.801/2014
Between
Lizy K. Vaidyan, : Complainant
W/o. K.Kuriakose Vaidyan, (party-in-person)
Asok Qtr No. 8,
Asok Textiles Ltd.,
Ashoskapuram,
Aluva-683 101.
Present Address
Padinjare Veedu,
Edathala P.O.,
Ernakulam-683 561.
And
1. The General Manager, : Opposite parties
Bajaj Allianz Life Insurance (By Adv. Jeswin P. Varghese,
Co. Ltd., GE Plaza, Vattoly Complex, 2nd floor, Kompara
Airport Road, Yerewada, Junction, Ernakulam, Cochin-18)
Pune -411 006.
2.The Manager,
Bajaj Allianz Life Insurance
Co. Ltd., 2nd floor,
Yasoram Victoria Towers,
Banerjee Road, Kachripady,
Kochi-682 018.
O R D E R
Cherian K. Kuriakose, President.
1. Complainant's case
2. The complainant is the holder of policy No. 0002736524 of Bajaj Alliance Life Insurance Company Ltd. with effect from 28-08-2013 and it is supposed to be matured on 28-08-2018. The agreed premium instalment was Rs. 2,842/- and the policy amount was Rs. 50,000/-. The complainant was regularly remitting the premium amount without default. Meanwhile, the complainant was admitted to PVS Hospital, Ernakulam on 12-04-2014 as she was suffering from terminal ileal ulcers and was discharged on 19-04-2014. She incurred a medical bill of Rs. 36,713/-, which the opposite party was bound to reimburse as per the policy. The medical insurance claim under the head of hospital cash along with the relevant documents were submitted to the 2nd opposite party and the 2nd opposite party had referred it to the 1st opposite party. The opposite parties are not settled the assured amount as per the policy so far. Hence the complainant seeks to pass an order directing the opposite parties to grant the insurance coverage along with compensation and costs.
3. Notices were issued to the opposite parties, who appeared and resisted the claim by filing a version contending inter-alia as follows:
4. Version of the opposite parties
5. The complaint is misconceived and is contrary to the contract entered into between the parties and therefore it deserves to be dismissed. The opposite parties had issued a policy in favour of the complainant on 28-08-2003 after receipt of a premium amount of Rs. 2,842/- with a sum assured amount of Rs. 50,000/- and maturity date was 28-08-2018. As per the policy conditions, under hospital cash benefits , or every period of hospitalization during a policy year, the first 3 days could not be paid for (excluded days under the policy) . In this case also, the first three days of hospitalization were excluded and the complainant was eligible only for claims for 4 days wherein the actual room rent per day of the said hospital was Rs. 1,030/- and 75% of the actual room rent came to be Rs. 772.76. However, the complainant was eligible for room rent for Rs. 200/- only as the daily hospital cash amount shall be Rs. 4/- per one thousand of the sum assured amount of Rs. 50,000/- which was accordingly paid to the complainant. The opposite parties had issued a letter to the complainant on 09-05-2014 in this regard. The hospital cash benefit is paid is only towards the bed charges and not against the illness suffered by her. The complainant has willfully not produced the policy documents before the forum with ulterior motives. The opposite parties have acted in accordance with the terms and conditions of the policy. The expenses incurred towards the treatment of the illness will not be covered under the policy. The complaint is therefore to be dismissed.
7. On the above pleading the following issues were settled for consideration:
i. Whether the complainant has proved that whether there
was any deficiency in service on the part of the opposite
parties?
ii. Reliefs and costs
8. The evidence in this case consists of the documentary evidence Exbts. A1 to A3 on the side of the complainant and the oral evidence of DW1 and Exbts. B1 document on the side of the opposite parties.
9. Issue No. i. Exbt. A1, the Life Insurance Policy issued in the name of Lissy K. Vydian, which originated on 28-08-2003 and is to be terminated on 28-08-2018. Exbt. A2 is the discharge summary issued from PVS memorial Hospital Ernakulam and Exbt. A3 is the bill for Rs. 36,713.53 issued from PVS Memorial hospital which includes room rent at Rs. 7,212.38. The contract of insurance between the parties is binding on both parties and the parties cannot beyond to the terms and conditions of the policy. The complainant did not prove any deficiency of service on the part of the opposite parties. The complainant was unable to prove that the opposite parties had violated any of the terms and conditions of the policy documents. The deficiency in service cannot be alleged without attributing fault, imperfection, short comings or inadequacy in the quality, nature and manner of performance which is required to be performed by a person in pursuance of a contract or otherwise in relation to any service. In the 1st page of Exbt. A1 policy itself, it is seen stated that the hospital cash rider per day was only Rs. 200/- and that amount was already paid by the opposite parties to the complainant, which she had suppressed in the complaint. The complainant was admitted on 12-04-2014 and was discharged on 19-04-2014. Therefore the total days of hospitalization were 7 days. As per the supplementary benefits, clause B of the terms and conditions, shown in page No. 12 of Exbt. A1, for every period of hospitalization during a policy year, the first 3 days would not be paid for. Therefore, the complainant is eligible for hospital-cash benefit for 4 days only. As per clause D in page 12 of Exbt. A1, the reimbursement for each day will be the lower one of (1) 75% of the room rent (2) daily hospital cash benefit. In this case the daily hospital cash benefit is Rs. 200/- only and therefore, the amount reimbursable for 4 days hospitalization, is only Rs. 800/-, since 75% of the room rent claimed is higher than the daily hospital cash benefit. The opposite parties had written a letter dated 09-05-2014 showing these facts.
10. It seems the complainant had misconceived that the disease suffered by her falls under the category of “critical illness benefit”. The critical illness covered under the policy are mentioned in supplementary benefit clause C shown in page No. 9 to 11 of Exbt. A1. The disease “terminal ileal ulcers” does not come under the head of critical illness. Therefore, the complainant has not proved any deficiency in service on the part of the opposite parties. Issue is accordingly found against the complainant.
ii. Issue No. 2. Having found issue No. 1 against the complainant we find that the complaint is liable to be dismissed and is accordingly dismissed.
Pronounced in the open Forum on this the 13th day of January 2016
Sd/-
Cherian K. Kuriakose, President.
Sd/-
Sheen Jose, Member.
Sd/-
Beena Kumari V.K., Member.
Forwarded/By Order,
Senior Superintendent
APPENDIX
Complainants Exhibits
Exbt. A1 : Life Insurance Policy
A2 : True copy of discharge summary
A3 : True copy of discharge bill
Opposite party's Exhibits:
Exbt. B1 : True copy of Life Insurance policy
Depositions:
DW1 : V. Aravind
Copy of order despatched on :
By Post: By hand:
