Orissa

Sambalpur

CC/39/2018

Umesh Kumar agrawal - Complainant(s)

Versus

1-LIC Of India , Divisional Manager - Opp.Party(s)

Sri. S.K.Mahapatra, B.K. Mahapatra & M. Mahapatra

30 Jan 2023

ORDER

PRESIDENT, DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SAMBALPUR

Consumer Complaint Case No.- 39/2018

Present-Dr. Ramakanta Satapathy, President,

  Sri. Sadananda Tripathy, Member

Umesh Kumar Agrawal,

S/O-Late Debendra Lal Agrawal,

R/O-Dalaipara, Sambalpur Town, Ps-Town,

PO/Dist-Sambalpur, Odisha.                                 ...………..Complainant

                                                Versus

1. Life Insurance Corporation of India,

Sambalpur through its Divisional Manager, Division Office,

Po/Dist-Sambalpur.

2. Branch Manager, LIC of India,

Branch Office No.1, Jeevan Prakash, Sambalpur-768004.

3. Manager(HI) LIC of India,

Divisional Office, Sambalpur.                              ………...Opp.Parties

Counsels:-

1. For the Complainant         :-       Sri. S.K.Mahapatra, Advocate & Associates
2. For the O.Ps                        :-       Sri. A.K.Das, Advocate

Date of Filing:03.07.2018,Date of Hearing :XXXXXDate of Judgement : 30.01.2023

Presented by Dr. Ramakanta Satapathy, President

1. The case of the Complainant is that Policy No. 594629225, Jeevan Arogya Policy was obtained from O.Ps after payment of premium of Rs. 16,639/- covering himself, wife Anita and minor son Anmol. In January 2017 Anita got pain on her right leg, which was swollen, treated by Dr. N.Agrawalla, Sambalpur and it was reported that for better she should be shifted to higher Medical treatment Hospital. The Complainant went to Appollo Speciality Hospital, Chennai, Consulted Dr. Shankar Srinivasan, Oncologist and as per his advise on 11.02.2017 X-ray, E.C.G. etc. done and on 12.02.2017 ECG of abdomen was done along with other test. Anita was admitted as an indoor patient from 15.12.2017 to 27.02.2017 and discharged with an advice to take medicine and to check CBS on 02.03.2017 and to appear before him on 16.03.2017 with blood report for further treatment.

The Complainant’s wife took chemotherapy on 06.04.2017, 27.04.2017, 18.05.2017 and 08.06.2017. The Complainant paid Rs. 2,46,240/- to Appollo Hospital bill for the period 15.02.2017 to 27.02.2017.

Again Anita Admitted in hospital from 15.03.2017 to 17.03.2017, given chemotherapy and Rs. 84,387/- was spent.

In the third cycle of chemotherapy from 06.04.2017 to 07.04.2017 spent Rs. 84,877/- to-wards bill of the hospital.

In the 4^th cycle from 27.04.2017 to 28.04.2017 Rs. 84,892/- was spent.

The Complainant up to 28.04.2017 submitted bills of Rs. 5,23,096/- 0before the O.P. no.3 but repudiated the claim on 05.07.2017 and 14.07.2017.

The O.P. No,1 has transferred Rs. 30,000/- on 30.12.2017, Rs. 2500/- on 23.01.2018 through NEFT in S.B.A/C No. 20632484891 Allahabad Bank of the Complainant without intimation in place of Rs. 4,38,204/-. The Policy was started on 28.03.2012 and continued. The O.P. No.2 also has not supplied the policy kit. Repudiation of the claim amounts to deficiency in service.

Being Agrieved the complaint was filed.

2. The O.Ps appeared through Sri. A.K.Das, Advocate but not filed any version within the statutory period nor participated in the hearing of the case.
3. Perused the documents filed by the Complainant. Policy No. 594629225 started from 28.03.2012 and mode of premium payment was yearly basis. The Complainant paid Rs. 16,639/- premium for self, wife Anita and son Anmol. (Table 903) The repudiation letter dated 05.07.2017 discloses that the cause f repudiation is “Pre-existing illness irrespective of prior medical treatment of advice.” Repudiation letter dated 14.07.2017 discloses that “Total hospitalisation period is 28 hours or less that 28 hours.” Both the repudiation code assigned “H-01” and “L-18”. The Complainant submitted Hospital Treatment form from 15.02.2017 to 27.02.2017, discharge summary, bills for Rs. 2,46,239.58P. history of clinical examination, advice on discharge, chemotherapy schedule, bill dated 17.03.2017, Rs. 84,387, hospital treatment form 06.04.2017 to 07.04.2017 and bill of Rs. 84,877/- Bill for 27.04.2017 to 28.04.2017 for Rs. 84,892/-. Account statement in S.B. A/C No. 20632484891 and bill of Rs. 27,700/- dated 25.04.2017.
4. The Complainant has come to this commission alleging deficiency in service of the O.Ps. Jeevan Arogya policy No. 594629225 was issued by the O.Ps in favour of the complainant and in the name of family members. During the period of treatment 11.02.2017 till 14.07.2017 in a phased manner treatment of Anita has been made before Appollo Hospital, Chennai. The O.Ps on the ground of Pre-existing illness and total hospitalisation period is 28 hours or less than 28 years, repudiated the claim simply. At the time of hearing also not participated nor filed any version, which shows the whimsical attitude of the O.Ps.

Perused the clinical examination report issued by Appollo Hospital, Chennai, history of hypertension, historoctomy etc. Anita has undergone three times LSCS in 1992, 1996 and 2004. This might have the cause of repudiation of the claim. The O.Ps have not submitted the medical examination report of Complainant, Anita and Anmol issued at the time of policy proposal received and insurance medical officer. Non-submission of the report is also amounts to deficiency in service of the O.Ps.

The medical treatment undergone by Anita is in a phased manner but continued and cannot be termed as less than 28 years or 28 hours. The repudiation letter of the O.Ps dated 05.07.2017 and 14.07.2017 are not acceptable accordingly set-aside.

Here a question arise at the time of policy proposal the Complainant has not disclosed the pre-existing disease. It was the duty of O.Ps medical officer to check-up thoroughly and report. For better medical treatment the Complainant has taken the policy for his family members, paid premium O.Ps are liable to pay the expenditure borne by the Complainant.

Mere sending Rs. 30,000/- and Rs. 2500/- through NEFT cannot exempt the O.Ps from liability. Accordingly, it is ordered:

 

6698606.  

The complaint is allowed against the O.Ps. The O.Ps are liable to pay the agreed amount as per policy bond to the Complainant for medical treatment of his wife Anita Agrawal i.e. Rs. 4,38,204/- along with interest @ 7% P.A. from 05.07.2017 within one month of this order, failing which the amount will carry 12% interest P.A. till realisation. The O.Ps are to pay Rs. 10,000/- compensation and litigation cost of Rs. 5000/- to the Complainant.

Order pronounced in open Court on this 30^th Jan 2023.

Supply free copies to the parties.