PBEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM.
Dated this the 27th day of October 2011
Filed on : 08/09/2010
Present :
Shri. A Rajesh, President.
Shri. Paul Gomez, Member. Member.
Smt. C.K. Lekhamma, Member
C.C. No.479/2010
Between
M.T. Varghese, : Complainant
Mundothil house, (By Adv. Tom Joseph,
Pazhoor East P.O., Court road, Muvattupuzha)
Piravom.
And
The Manager, : Opposite party
Life Insurance Corporation (By Adv. P.D. Joseph, ‘Perayil’
of India, Muvattupuzha Branch, S. Janatha road,Palarivattom,
Muvattupuzha. Kochi-682 025)
O R D E R
C.K. Lekhamma, Member.
The case of the complainant is as follows:
The complainant had taken a Jeevan Anand policy (with profits) (with Accident beefit) on 25-03-2006 by remitting Rs. 26,068/- towards premium and also opted critical illness and premium benefit rider by remitting additional premium of Rs. 3,700.12 and Rs. 1,959.21 respectively. The sum assured is Rs. 5 lakhs. The complainant underwent for a major open heart surgery on 05-02-2007 at Medical Trust Hospital, Ernakulam. He spent Rs. 1,83,000/- towards treatment expenses and a claim was lodged before the opposite party for availing critical illness benefit. But no action was taken by the opposite party to settle the claim. Hence a letter was sent to the opposite party on 25-07-2009. The opposite party sent a reply dated 28-07-2009 stating that the policy is in lapsed condition and no provision in the policy to pay hospital expenses. It is also stated that the complainant has not opted for critical illness rider benefit under the policy. Subsequently the complainant contacted the opposite party and produced the document with critical illness and premium waiver benefit rider, the claim has not been settled so far. The act of the opposite party amounts to deficiency of service. The complainant is entitled for the critical illness sum assured Rs. 5,00,000/- along with interest at the rate of12% interest from the date of claim till realization. He is also entitled for the waiver of premium payment from the date of diagnosis of critical illness. Hence this complaint.
2. Version of the opposite party.
The opposite party issued the policy on 25-03-2006 the policy and along with the special document dealing with critical illness rider. The complainant submitted a claim form on 05-03-2007 for critical illness as he had undergone surgery for Acyanotic Congenital heart disease (Arterial Septal defect) at Medical Trust Hospital on 05-02-2007. On receipt of the claim form, the opposite party obtained the form to be completed by the medical attendant/cardiologist Dr. Jose Chacko Periyappuram. From the report, it was observed that the complainant was having hyper tension since one year and was on medication. The ailment/operation for Acyanotic Congenital heart disease (Arterial Septal defect ) is not covered under the critical illness rider. Condition No. 2(b) dealing with disease/ailment for which critical illness rider is applicable incorporated in the policy document do not include Acyanotic Congenital heart disease (Arterial Septal defect). The medical reference has also confirmed in his report that the particular disease is not covered under the policy. Prior to submitting the proposal for insurance, has undergone treatment at JMP Medical Center, Muvattupuzha for ailments like Hyper tension. There has not been any deficiency or defect in service on the part of opposite party and the decision to refuse the critical illness rider is strictly according to the conditions incorporated in the policy.
3. The complainant and the opposite party represented through counsel . Exts. A1 to A4 were marked on the side of the complainant. Opposite party examined as DW1 and Exts. B1 to B5 were marked on the side of the opposite party. Thereafter, we have heard the respective counsel.
4. The points for consideration are as follows:
i. Whether the complainant is entitled to get the sum insured from the opposite party or not?
ii. Compensation and costs if any
5. Points Nos. i&ii. The case of the complainant is that he submitted claim for critical illness benefit before the opposite party but no action was taken by them to settle the claim. And the opposite party informed that the policy is in lapsed condition and no provision in the policy to pay hospital expenses.
6. The opposite party contended that as per the claim they obtained a medical report from a cardiologist, it was observed that the complainant has hypertension since one year and was on medication. The ailment/operation for Acyanotic congenial heart disease is not covered under the critical illness rider.
Ext. A1 is the copy of policy and Ext. A2 is the copy of critical illness and premium Benefits Rider document. These documents go to show that the complainant was opted critical illness and premium benefits rider along with Jeevan Anand policy.. Ext. A3 dated 28-07-2009 is the reply to the complainant’s letter dated 25/07/2009. It goes to show that the same has been issued after the stoppage of payment of premium instalments. The complainant admitted in his complaint that after his surgery on 05/02/2007 he stopped the remittance of subsequent premiums. Therefore in Ext. A3 it is mentioned that the policy is in a lapsed condition. Then the only question to be decided is whether the disease of the complainant comes under the purview of the provisions of the exclusion clause. During cross examination DW1 admitted that the disease of the complainant is not included in clause 2(D) of the exclusions and heart attack is included in Ext. A2 document. He further deposed that their decision for repudiation was based on the opinion of the Medical referee. The said opinion is in the reverse of Ext. B3 letter. He further admitted that such opinion was not supported by reasoning. The other document relied on by the opposite party is Ext. B2 claim form, in which the past history of the complainant’s ailment mentioned by the cardiologist. It is stated that the complainant had hyper tension since one year and was on medication. But the opinion of the doctors in Ext. B2 and B3 are not admissible in evidence since they were not examined to prove those documents. In view of the aforementioned reasons we are of the opinion that the complainant is entitled to get the sum insured of Rs. 5,00,000/- with interest from the opposite party in accordance with the conditions and Restriction in Ext. A2 critical illness and Premium Benefit Rider. But we are not ordering any compensation and costs since we have already ordered sum insured with interest.
In short, we partly allow the complaint and direct the opposite party shall pay Rs. 5,00,000/- being the sum insured to the complainant together with interest @ 12% p.a. from the date of complaint till realization.
The above said order shall be complied with within a period of one month from the date of receipt of a copy of this order.
Pronounced in the open Forum on this the 27th day of October 2011
Sd/-C.K. Lekhamma, Member.
Sd/- A Rajesh, President.
Sd/- Paul Gomez, Member.
Forwarded/By Order,
Senior Superintendent.
Appendix
Complainant’s Exhibits :
Ext.A1 : Copy of schedule
A2 : Copy of schedule
A3 : Copy of letter dt. 28-07-2009
Opposite party’s Exhibits :
. Ext B1 : Copy of schedule
B2 : Copy of claim form
B3 : Copy of letter dt. 01/08/2007
B4 : Copy of certificate of hospital
treatment
B5 : Copy of letter dt. 22-10-2007.
Depositions:
DW1 : V.V. Subramanian
