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KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSION
Mr. Justice Sri. S.S. Satheesachandran President and Sri. V.V. Jose Member
HEALTH INSURANCE LIC OF INDIA - Appellant
Versus
S. BIJU BHAVAN - Respondent
First Appeal No. 391 of 2014 in Case No. CC/232 of 2011
Decided on : 07-08-2017
Sri. G.S. Kalkura, Advocate, for the Appellant; Sri. K.N. Justin and B. Ajith, Advocates, for the Respondents
The judgment established the importance of strict adherence to the policy's renewal conditions, waiting period, and eligibility requirements for claim settlement under the health insurance policy.
Headnote:
Health Insurance Policy - Medical Expenditure Claims - LIC Health Plus Plan - 90 days waiting period for revival of policy - Accidental bodily injury requirement - Ananthapuri Hospital treatment claim disallowed - Upasana Hospital treatment claim allowed
Fact of the Case:
The complainant's wife was hospitalized twice, and the insurance claims for medical expenses were denied by the appellants based on policy renewal and waiting period conditions. The District Forum upheld the claims, awarding compensation and costs to the complainant.
Finding of the Court:
The court found that the claim for medical expenses incurred at Ananthapuri Hospital during the waiting period was not allowable, but the claim for expenses incurred at Upasana Hospital after the waiting period was valid. The compensation and costs awarded by the District Forum were affirmed.
Issues: The key issues involved the interpretation of the health insurance policy's renewal conditions, waiting period, and the requirement for accidental bodily injury for claim eligibility.
Ratio Decidendi: The court held that the medical expenses claim within the waiting period was not allowable as it did not arise from accidental bodily injury, as required by the policy. However, the claim for expenses incurred after the waiting period was upheld as it met the policy requirements.
Final Decision: The court set aside the claim for treatment expenses at Ananthapuri Hospital but upheld the claim for expenses at Upasana Hospital, along with compensation and costs awarded by the District Forum.
ORDER
S.S. Satheesachandran, President. - Appellants are the 2nd and 3rd opposite parties in CC.232/11 of the Consumer Disputes Redressal Forum, Kollam. Aggrieved by the order of the District Forum directing the appellants and first respondent to pay sums of Rs. 38,107/- and Rs. 42,807/- with 9% interest from the date of complaint till realization, compensation of Rs. 10,000/- and costs of Rs. 2500/- the appellants have preferred this appeal.
2. First respondent/complainant had taken a health policy from the first appellant, paying premium of Rs. 12,000/- policy which provided medical insurance coverage for himself, his wife and two children. Medical coverage for his wife was up to Rs. 2,00,000/- and for the two children up to Rs. 1,00,000/- each. His wife who suffered from brain stroke was treated as an inpatient from 15.2.2010 to 24.12.2010 at Ananthapuri Hospital, Thiruvananthapuram, and an amount of Rs. 38,207/- was incurred for her treatment. She again suffered the same ailment and was admitted and treated at Upasana Hospital, Kollam from 14.6.2011, for which medical expenditure of Rs. 42,817/- was incurred. Claims made for payment of the medical expenditure incurred were turned down by the respondents and, thereupon he filed the complaint for the expenditure incurred for treatment of his wife with compensation of Rs. 50,000/-.
3. The appellants alone filed version and they contended that the instalment for renewal of the policy was not paid in time but only later during the waiting period. Such renewal was subject to riders that no claim other than claims arising from accident during the waiting period is allowed. Treatment of the wife of the applicant at the first instance at Ananthapuri Hospital was within the waiting period provided for renewal and the claim thereof was not allowable under the policy. So far as the claim for the 2nd stage of treatment at Upasana Hospital, Kollam, the respondents contended that hospitalization of complainant's wife was only for evaluation and she was administered only for oral medication. Her admission to that hospital was not justified and as such claim made under the policy was not allowable, according to the appellants.
4. On the materials placed by both sides which consisted by the oral evidence of complainant as PW 1 and Exts. P 1 to P 3 on his side and that of DW 1 and Exts. D 1 to D 4 for the appellants, and appreciating the issues involved, the Forum repelling the contentions of the opposite parties passed the impugned order directing all three of them to pay the complainant sums of Rs. 38,107/- and Rs. 42,817/- with interest at 9% per annum and compensation of Rs. 10,000/- and a costs of Rs. 2500/-.
5. We heard the counsel on both sides and perused the records of the case.
6. The point for determination is whether the order passed by the Forum granting reliefs as afore mentioned to the complainant suffers from any infirmity warranting interference.
7. Concededly, complainant has taken a policy under LIC Health Plus Plan paying a premium of Rs. 12,000/-, from the LIC of India, on 28.8.2009 which provided medical insurance coverage for him, his wife and two children. As per the terms and conditions of the policy yearly instalments have to be paid for renewal of the policy till the expiry date fixed in 2037. Complainant defaulted to pay the instalment in time. Policy conditions provided for renewal within the grace period of one month or within the further period fixed, styled as waiting period, subject to the riders applicable thereto. Complainant renewed the policy paying the instalment premium after the expiry of the grace period but within the waiting period provided.
8. Learned counsel for the appellants pointing out that the policy taken by the complainant was issued under the LIC's Health Plus Plan invited our attention to the booklet containing the conditions applicable to such policy. The above policy was a term policy stipulating payment of instalment every year and it w
