IN THE CONSUMER DISPUTES REDRESSAL FORUM, ALAPPUZHA
Tuesday the 30th day of June, 2015
Filed on 29.4.2013
Present
1.Smt. Elizabeth George (President)
2.Sri. Antony Xavier (Member)
3.Smt.Jasmine.D. (Member)
in
C.C.No.136/2013
between
Complainant:- Opposite Parties:-
Sri. O. Shanavas 1. Life Insurance Corporation of India
Pulimoottil House P & G S Unit Jeevan Jyothi
Peringala P.O., Mukkavala Second Floor Star Junction
Railway Station Road M.C. Road, Kottayam – 686 001
Kayamkulam Represented by its Manager
(By Adv. Omar Salim)
2. Health Insurance Division LIC of
India, Nagambadam, Kottayam
Pin – 686 001, Represented by
its Manager
3. Medi Assist TPA Ltd. Team LIC
# 49, First Main Road Sarakki Indi
Layout, Third Stage, J.P. Nagar
Bangalore – 560 078
Represented by its Manger
4. Life Insurance Corporation of India
Kayamkulam Branch
Represented by its Manager
(By Adv. S. Devalal – for opposite
Parties 1 to 4)
5. Sri. K. Tangal Kunju (LIC agent)
Ozhuku Neettil, Near MSM College
Kayamkulam
O R D E R
SMT. ELIZABETH GEORGE (PRESIDENT)
The case of the complainant is as follows:-
The complainant had availed a LIC Health Plus Insurance Policy. From 16.7.2008 onwards the complainant and his wife and his two children are insured under the LIC Health Insurance Policy named as Health Plus Insurance Policy by remitting an amount of Rs. 30,000/- on 24.7.2008 and extend the policy period by remitting Rs.30,000/- in respective years and altogether remitted an amount of Rs.1,50,000/-. Later, the son of the complainant that is none other than the 4th insurer Faizin Navas had met with a road accident and he was admitted to V.S.M. Hospital, Thattarambalam P.O., Mavelikara with contaminated lacerated wound at Knee, Chin and multiple abrasions over (Rt) forearms and both palms and he was admitted to the hospital on 11.6.2012 and discharged on 19.6.2012. On 24.7.2012 the complainant had filed policy claim for Rs. 62,644/- through the hospital, but to the surprise of the complainant, third opposite party repudiated the claim stating that the surgery undergone by the 4th insured is not listed in the allotted surgeries and by allowing the room charges, spent in on ICU for 3 days. Complainant had issued a registered letter to the second opposite party to prove the entire amount and second opposite party had given a reply stating that the complainant’s claim is repudiated and nothing is payable for the hospitalization. Hence the complaint is filed.
2. The version of the opposite parties 1 to 4 is as follows:-
The LIC received the claim form on 24.7.2012 and the same was sent to the third opposite party the administrator for processing the claim. Authorized doctors of Medi Assist India have scrutinized the claim papers with regard to the eligibility in terms of policy, terms and conditions based on the documents by the policy holder and have come to the conclusion that claimant is eligible for the Hospital Cash Benefit Claim alone and not eligible for Major Surgical Benefit Claim as the surgery underwent is not listed in the list of allowed surgeries as per policy conditions and said fact was informed to the policy holder vide letter dated 27.10.2012. The surgical benefit was rejected for the reason that surgeries undergone by the insured is not listed in the allowed surgeries. At the time of accepting the proposal for the Health Protection Plus Plan, the terms and conditions of the proposed plan have been explained to the complainant by the Agent of the Corporation and this complainant has signed the proposal after fully understanding the terms and conditions of the plan he proposes to take. The complainant is under misconception about the terms and conditions of the policy, hence the complaint may be dismissed.
3. The complainant was examined as PW1. The documents produced were marked as Exts.A1 to A9. One witness was examined as PW2. From the side of the opposite parties 1 document was produced marked as Ext.B1.
4. The points that arose for consideration are as follows:-
1) Whether there is any deficiency in service on the side of the opposite parties?
2) If so the reliefs and costs?
5. It is an admitted fact that the complainant had availed a LIC Health Plus insurance policy and from 24.7.2008 onwards the complainant, his wife and two children were insured under the said scheme. According to the complainant, his son the 4th insured had met with an road accident and he was admitted to VSM Hospital, Thattarambalam, Mavelikara with contaminated lacerated wound at knee, chin and multiple abrasions over (Rt) forearm and both palms and he was admitted in the hospital on 11.6.2012 and discharged on 19.6.2012. On 24.7.2012 the complainant had filed a policy claim of Rs.62,644/-. The claim was repudiated by the opposite parties. According to the opposite parties the claimant is eligible for the hospital cash benefit claim and not eligible for major surgical benefit claim, as the surgery underwent is not listed in the list of allowed surgeries as per policy conditions. According to the complainant as per the regulations of IRDA the proposal form shall specify the terms and conditions of the policy, the opposite parties intentionally suppressed the terms and conditions of the policy and hence the complainant has no knowledge whether the surgery is included in the list. The opposite parties raised the contention that nowhere in the regulation, it is stated that conditions of policy shall be served along with the proposal form. The complainant has signed the proposal after fully understanding the terms and conditions of the plan he proposes to take. It is pertinent to note that in the complaint and the proof affidavit, the complainant admitted that after going through the advertisement and policy terms he had taken the LIC Health Plus insurance policy from the opposite parties. More over in Ext.B1 proposal form it is admitted by the complainant that the terms and conditions of the proposed plan have been explained to the complainant by the agent. Hence there was no reason or evidence to conclude that the complainant was not aware of the terms and conditions of the policy, because he had filled in the proposal form in which it was clearly mentioned that he had read and accepted the terms and conditions in the policy. In addition to that as per clause 6 (2) of the IRDA regulations 2002 “if the policy holder is not satisfied with the terms and conditions of the policy he may return the policy to the Corporation within 15 days from the date of receipt of policy.” In the instant case if the complainant is not satisfied with the terms and conditions he had the option to return the policy to the Corporation. But he has not availed that condition. Hence the allegation of the complainant that the opposite parties have a duty to disclose all material facts within their knowledge to the complainant and they failed to do so is not sustainable.
6. The next question to be decided is whether the surgery underwent by the 4th insured listed in the surgical benefit annexure. As per the Ext.A7 certificate issued from the VSM hospital, Mr.Faizin Navas was admitted in the hospital on 11.6.2012 for the injury sustained like,
- Contaminated lacerated wound (Rt) Knee + Chin
- Multiple abrasions over (Rt) forearm and both palms
While cross examining the PW2 the doctor stated that, he has done surgery to the injured. But to the question put by the learned counsel of the opposite party, “
So from the forgoing discussions, we came to the conclusion that the surgery undergone by the complainant is not listed in the list of surgical benefit annexure. The Hon’ble Apex Court in Hurchand Rai Chandan Lal’s, case IV (2004) CPJ 15 (SC) held that, “the terms of the policy have to be construed as it is and we cannot add or subtract something. However, liberally we may construe the policy, but we cannot take liberation to the extent of substituting the words which are not intended.” In Suraj Mal Ram Naiwas Oil Mills Pvt. Ltd. Vs. United India Insurance Company Ltd. and another, IV 2010 CPJ 38 Hon’ble Apex Court held that, “Thus it needs little emphasis that in construing the terms of contract of insurance the word used there in must be given paramount importance and it is not open for the Court add delete or substitute any words. It is also well settled since upon an issuance of insurance policy the insurer undertaken to indemnify the loss suffered by the insurer on account of risks covered by the policy, its terms have to be strictly construe to determine the extent of liability of the insurer. Therefore the endeavour of the Court should always be to interpret the words in which the contract is expressed by the parties.” In view of the above, we do not find any deficiency in service on the part of the opposite parties in repudiating the insurance claim of the complainant.
In the result, complaint dismissed.
Dictated to the Confidential Assistant transcribed by her corrected by me and pronounced in open Forum on this the day 30th of June, 2015.
Sd/- Smt.Elizabeth George (President) :
Sd/- Sri. Antony Xavier (Member) :
Sd/- Smt.Jasmine.D. (Member) :
Appendix:-
Evidence of the complainant:-
PW1 - O. Shanavas (Witness)
PW2 - Dr. Santhosh Kumar (Witness)
Ext.A1 - Copy of the policy
Ext.A2 - Copy of the conditions and privileges referred to in the policy document
Ext.A3 - Copy of claim settlement letter dated 27.10.2012
Ext.A4 - Copy of the information reminder 2 dated 9.10.2012
Ext.A5 - Copy of the information reminder 1 dated 28.9.2012
Ext.A6 - Copy of the document deficiency letter dated 13.9.2012
Ext.A7 - Copy of the Certificate dated 9.10.2012
Ext.A8 - Copy of the legal notice dated 28.1.2013
Ext.A9 - Postal Receipts
Evidence of the opposite parties:-
Ext.B1 - Copy of the proposal form
.// True Copy //
By Order
Senior Superintendent
To
Complainant/Opposite parties/S.F.
Typed by:- pr/-
Compared by:-pg/-
