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NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION
Mr. V.K. Jain, Presiding Member
LIFE INSURANCE CORPORATION OF INDIA - Appellant
Versus
RAMPHAL - Respondent
Revision Petition No. 1479 of 2016 (Against the Order dated 03/02/2016 in Appeal No. 887 of 2015 of the State Commission Haryana)
Decided on : 04-10-2016
Mr. Vishnu Sharma, Ms. Anupama Sharma and Mr. Subhash Chandra, Advocates, for the Petitioner; Mr. B.S. Sharma, Advocate, for the Respondent
Policyholders are bound by the terms and conditions of the insurance policy, and entitlement to benefits is subject to meeting the specified requirements, as interpreted by the court.
Headnote:
Insurance Policy - Hospital Cash Benefit - The court held that the complainant was not entitled to reimbursement for treatment expenses as he did not meet the requirement of hospitalization for 24 hours or more under the policy.
Fact of the Case:
The complainant sought reimbursement for treatment expenses under an insurance policy after not being hospitalized for 24 hours, but the claim was denied by the petitioner corporation.
Finding of the Court:
The court found that the complainant was not entitled to reimbursement as he did not meet the hospitalization requirement specified in the policy, and dismissed the complaint with no order as to costs.
Issues: The main issue was whether the complainant was entitled to reimbursement for treatment expenses under the insurance policy despite not meeting the hospitalization requirement.
Ratio Decidendi: The court held that the complainant was bound by the terms and conditions of the policy, and since he did not meet the hospitalization requirement, he was not entitled to reimbursement.
Final Decision: The court set aside the impugned orders, dismissed the complaint with no order as to costs, and ordered the complainant to refund the amount received from the petitioner corporation within four weeks.
ORDER
Mr. Justice V.K. Jain, Presiding Member(Oral) - The complainant/respondent purchased an insurance policy called Jeevan Arogya, which was a fixed benefit plan, from the petitioner corporation on 05.07.2012, for a sum assured of Rs. 1,00,000/-. One of the benefits available under the said policy was hospital cash benefit which could be availed in case of hospitalization exceeding a continuous period of 24 hours during the cover period.
2. The complainant/respondent having fallen ill, he took treatment at PGIMS, Rohtak incurring an expenditure of Rs. 70,000/- on the said treatment. However, he was not hospitalized for 24 hours or more in order to take the said treatment. The respondent/complainant then filed a claim with the petitioner corporation, seeking re-imbursement of the aforesaid expenditure. The claim having not been paid, he approached the concerned District Forum by way of a complaint. The complaint was resisted by the petitioner corporation, primarily on the ground that OPD treatment was not covered under the policy taken by the complainant. It was also pointed out in the reply filed by the petitioner corporation that the second premium was not paid in time by the complainant.
3. The District Forum vide its order dated 27.08.2015, allowed the complaint and directed the petitioner corporation to pay a sum of Rs. 70,000/- to the complainant along with compensation quantified at Rs. 2200/-.
4. Being aggrieved from the order passed by the District Forum, the petitioner corporation approached the concerned State Commission by way of an appeal. The said appeal having been dismissed vide impugned order dated 03.02.2016, the petitioner corporation is before this Commission by way of this revision petition.
5. One of the benefits available to the complainant under the policy taken by him was hospital cash benefit and the relevant clause of the policy in this regard reads as under:
Benefits:
(1) Hospital Cash Benefit:
In the event of Accidental Bodily Injury or Sickness first occurring or manifesting itself after the Date of Cover Commencement and during a continuous period of 24 hours within the Cover Period, then, subject to the terms and conditions, waiting period and exclusions of the Policy, the Daily Benefit is payable by the Corporation as follows, regards of the actual costs incurred:
(a) In case of Hospitalization in the General or Special Ward (i.e. a Non-Intensive Care Unit Ward/Room) of a Hospital.
(b) In case of Hospitalization in the Intensive Care Unit of a Hospital.
(c) Combined stay in Non-ICU and ICU Ward/Room.
It would thus be seen that the benefit under the policy taken by the complainant was payable only in case of hospitalization exceeding a continuous period of 24 hours. Admittedly, the complainant was not hospitalized in PGIMS, Rohtak for 24 hours or more. Therefore, the expenditure incurred by him in taking treatment in the aforesaid hospital is not re-imbursable to him, under the policy taken by him.
6. It is contended by the learned counsel for the complainant/respondent that the terms and conditions attached to the insurance policy were not supplied to the complainant and therefore, he cannot be said to be bound by the said terms and conditions. On a perusal of the insurance policy issued to the complainant/respondent, I find that the said policy was subject to the conditions and privileges attached thereto. Therefore, in ordinary course, the terms and conditions forming part of the policy would be attached when the policy is issued to the policy holder. More importantly, there is no allegation in the complaint that the terms and conditions attached to the insurance policy taken by the complainant were not provided to him. There is a specific reference to policy number as well as the date of the policy in para 3 of the complainant, but there is no averment that the terms and conditions attached to the policy were not supplied to the complainant. In case the said terms and conditions were not sup
