By. Sri. K. Gheevarghese, President:-
The complaint filed against the opposite parties for the benefit of the Health Insurance Policy.
2. The complaint in brief is as follows:- The complainant joined the LIC's Health Plus Policy on 05.05.2008. The first premium of Rs.20,000/- was remitted at the time of inception of the policy. The terms and conditions of the scheme was that the complainant had to remit Rs.20,000/- for the next two years in total the complainant had to pay a premium for the three years of Rs.20,000/- in each year.
3. The scheme envisages the individual benefit of Rs.2,500/- to the principal insured and Rs.1,500/- to her husband. The major surgical benefit of Rs.5,00,000/- is payable to complainant and Rs.3,00,000/- to her husband. The period of the policy runs from 05.05.2008 to 05.05.2040 for the complainant and for the husband it reaches in its culmination on 05.05.2029. The complainant underwent a surgery in the right hand due to deformity to tunnel cylinder Rs.8,000/- spent for hospital expenses, Rs.3,000/- was the expenses for the medicine and other expenses followed by the surgery. The claim forwarded to the opposite party but it was not processed and no information in that respect was conveyed to the complainant.
4. The policy was subsequently surrendered and the opposite party sent Rs.9,902/- as the surrender value. The request of the complainant for surgical expenses and the subsidiary
treatments not considered and more over the opposite party was not even ready to respond to
the claim of the complainant. There may be an Order directing the opposite parties to pay Rs.11,000/- to the complainant towards treatment and other expenses along with compensation of Rs.5,000/- and cost of Rs.3,000/-.
5. The opposite parties filed version in short it is as follows:- The complainant inception to the policy was on 05.05.2008 and the remittance of the first premium is Rs.20,000/- as admitted. The complainant is the principal insured and the husband Aravindan. K. K is the spouse insured under the scheme.
6. The premium of the first year was remitted and the policy lapsed in the absent of second year premium on 05.05.2009. As per the policy condition after two years from the date of unpaid premium, the policy stands foreclosed and it was on 05.05.2011. A cheque of Rs.9,902/- was sent to the complainant as the surrender value.
7. The principal insured, the complainant underwent surgery for deformity to tunnel cylinder. The policy conditions does not include such type of surgery. As per the policy conditions the insured is to be paid hospitalization expenses of continuous period on completion of 48 hours. In short the first two days from the time of admission for continuous treatment is excluded from the health benefits. The premium if not paid before the expiry of the grace period the policy lapses and if not revived within two years from the date of first unpaid premium. The payment under the scheme is not payable that are not included in the surgical benefit in the annexure and treatment giving hospitals are also specified in the policy conditions.
8. The complainant in this case is not entitled to get Rs.8,000/- for the treatment expenses and Rs.3,000/- for the other expenses incurred for medicines and other treatments. The complainant has not produced all the records necessary for claiming the benefits. The complaint is not maintainable and hence it is to be dismissed with cost.
9. The points in considerations are:-
1. Is there any deficiency in service on the part of the opposite parties?
2. Relief and Cost.
10. Points No.1 and 2 :- The evidence in this case consist of proof affidavit of the 2nd insured, the husband. Ext.A1 to A7 are the documents produced. The Opposite party filed proof affidavit, Ext.B1 is the document marked for the opposite parties. The personal evidence of complainant's husband and opposite party are also considered.
11. The dispute in issue is that the surgery undergone by the principal insured was not considered for the benefit in the health plus plan. The opposite party rejected the claim of the complainant on the ground that the insured had pre-existing deceases. Ext.A4 is the claim rejection letter. Clause H01 elucidates “From the history given by the treating doctor it is known that the patient is having this ailment since seven months. Hence not payable as it is existing before the commencement of the policy”. The surgery that had undergone by the insured was not given benefit of the plan for reason of pre- existing decease. Ext.A6 is the discharge summary produced by the insured. The admission of the patient in hospital was for pain and numbness of both hands. The opposite party produced Ext.B1 which is the heath plus plan. The exclusion clause explains the major surgical benefits which are categorized in the provisions. If the surgery of the insured is due to pre-existing ailment the benefit cannot be claimed under the provisions.
12. The complainant had the surgery of tunnel cylinder. The admission of the patient was for numbness and pain in the hand. The date of admission as per record is 19.12.2008 and discharged on 22.12.2008. The diagnosis of the ailment is Carpal tunnel syndrome. Ext.A4 is the claim received by the opposite parties. The amount of claim as per this document is Rs.2,500/-. The complainant has not produced any documents to substantiate the contention that how much is the amount spent in the hospital for the treatment expenses. Whereas according to the complainant he already spent Rs.8,000/- as hospital expenses and Rs.3,000/- towards the medicine and other expenses. But the claim of the complainant before the opposite party was for Rs.2,500/- as per Ext.A4. The policy conditions clause 2-1 exempt the policy holder the treatment expenses for the first 48 hours.
13. The opposite party is examined as OPW1, from the evidence of this witness and is admitted by the insured that the policy was lapsed after the non payment of the second premium. The claim of the insured was within the relevant period. The insurer had not received any written statement regarding pre-existing deceases from the doctor who treated. It is also admitted by the opposite party that no documents is produced by the opposite party that the insured had the ailment which was pre-existing. The surgery done to the insured is only a minor and that does not come in the category of major surgery that are exempted . No expert opinion reasoning the rejection of claim brought out in this case. The complainant has not produced any medical bills to make estimation of the expenditure made by the insured for the remaining dates after the 48 hours. Any how the claim of the complainant was only for Rs.2,500/- from the face of the records.
In the result the complaint is partly allowed. The opposite party is directed to pay the insured Rs.2,500/- (Rupees Two Thousand and Five Hundred Only) towards the claim amount along with cost of Rs.500/- (Rupees Five Hundred Only). This is to be complied by the opposite party within one month from the date of receipt of this Order.
Pronounced in Open Forum on this the day of 30th March 2012.
Date of Filing:24.08.2011.
