PRESIDENT DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SAMBALPUR

            CONSUMER COMPLAINT NO.93/2022

Present-Dr. Ramakanta Satapathy, President,

  Sri. Sadananda Tripathy, Member,

1. Sasmita Sahoo,

         W/O-Pramod Kumar Sahoo,

        At-Ajodhya Vihar, Near St. John School,

        PO-Dhankauda, Dist-Sambalpur-768006.

2. Apurba Priyadarsini Sahoo

At-Ajodhya Vihar, Near St. John School,

PO-Dhankauda, Dist-Sambalpur-768006.                    .……….......Complainants.

Vrs.

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1. Divisional Manager L.I.C. of India, “JEEVAN PRAKASH”
2.  
2. Zonal Manager, L.I.C. of India, East Central Zone.

         Jeevan Deep, 6^th Floor Exhibition Road,

        Patna, Bihar-800001.

3. T.P.A. Heritage Pvt.Ltd.

          Kolkata, NICCO House, 5^th Floor,

        Hare Strret, Kolkata-700001, India.                                  ..........................Opp. Parties

Counsels:-

1. For the Complainants                  :-Self
2. For the O.P. No.1 & 2                  :-Sri. D.Thakur & Associates
3. For the O.P. No.3                                    :-Sri. M.K. Mallick, Representative (Ex-Parte).

Date of Filing:06.12.2022,Date of Hearing :23.05.2023, Date of Judgement : 10.07.2023

  Presented by Dr. Ramakanta Satapathy, PRESIDENT

1. The Complainant availed ‘Jeevan Arogya’ health insurance Policy No. 594924276 dated 28.03.2014 from L.I.C. of India. The policy covers Complainant Sasmita Sahoo and her two children namely Apurba Priyadarshini Sahoo and Mr. Om Prasad Sahoo. As per term and conditions of the policy the L.I.C will pay Rs. 1000/- from the date of admission in case of non I.C.U. and in case of I.C.U. it is double. Half yearly premium of Rs. 1851/- was paid from 28.03.2014 to 28.09.2019. The Complainant No.2 suffered from problem in her Spinal cord and undergone treatment in AIIMS, Bhubaneswar from 20.05.2018 to 24.06.2018. Due to infection in internal operation she was again admitted from 10.07.2018 to 19.09.2018 and spent Rs. 3.00lakhs. The Complainants submitted vouchers with O.P. No.1 amounting to Rs, 3,02,251/- but vide letter dated 22.01.2020 the claim was rejected.

Due to Covid-19 epidemic Complainants could not agitate the matter before higher authority of LIC but on 17.02.2020 submitted grievance before O.P.No.2 but no any result found.

Being aggrieved this Complaint was filed.

2. The O.P. No.1 & 2 in their version submitted that policy No. 594924276 was issued on 28.03.2014 in favour of Complainants. Half yearly premium for the policy has been paid from 28.03.2014 to 28.09.2018 and for which policy remained valid till 28.03.2019. The O.Ps verified the claim and treatment record of Complainant No.2 and found that she had been suffering from ‘Scoliosis of the Spine’ since last 8 years, which was gradually progressive. The Complainants knowingly suppressed the facts at the time of procuring the policy i.e. on 28.03.2014. Further the case is neglected early on set Scoliosis which is evident from discharge summary dated 19.09.2018 of the AIIMS, Bhubaneswar.

The claim was rejected vide letter No. SD/HI/TPA dated 22.01.2020 under code L-99 i.e. any other rejection not covered in the list supplied. The Complainants have violated the contract of insurance, “Uberima Fide”

Sri. Pramod Kumar Sahu, is a CM’ club member agent who is the husband of Complainant No.1 and father of Complainant No.2. The policy is completed under his agency code. The father being the agent was privy to the personal information of health and habits of the insured child and suppressed material facts. The contract is null and void.

There is no deficiency on the part of the O.Ps and the Complainants are not entitled for any claim.

3. The O.P. No.3 Third party Agent Heritage Pvt. Ltd., Kolkata appeared through representative Sri. Mukesh Kumar Mallick, Senior Mediclaim Executive but not filed any version.
4. Perused the documents filed by the Complainant. The O.Ps have only filed the filled up proposal form wherein nominee Pramod Kumar Sahoo, LIC Agent. The O.Ps submitted the medical consultation papers dated 09.05.2018 of AIIMs, Bhubaneswar, Hospital treatment form and discharge summary dated 24.06.2018 and 19.09.2018.
5. It is the admitted case of both the parties that ‘Jeevan Arogya’ Policy No. 594924276 under plan-904 commenced from 28.03.2014 and was in force till 28.03.2019. It is also admitted by both the parties that Complainant NO.2 has undergone treatment in AIIMs, Bhubaneswar from 20.05.2018 to 24.06.2018 and due to infection from 10.07.2018 to 19.09.2018. At the time of undergoing surgery the policy was in force.
6. The O.P. No.1 & 2 submitted that due to suppression of pre-existing disease of Complainant No.2 “Scoliosis of Spine” the claim was rejected vide letter No. SD/H1/TPA dated 22.01.2020 with following observation:

“We have sent the claim papers to TPA Heritage Pvt., Kolkata. On Scruting of the claim papers, it is found that patient was suffering from Scoliosis since last 8 years and which was gradually progressive. This fact has been noted in the hospital documents submitted by you. So when the policy was completed on 28.03.2014 patient was already suffered by the disease Scoliosis of Spine as per Hospital documents submitted.

Again this was rejected under code-199 [Any other rejection not covered in the list supplied]”

The policy proposal was given on 31.03.2014 and health details and medical information has been given by the Complainant. Covering point No. 3, 6 and 7(x)

The answers of the Complainants are quoted below:

                   Details                                                                                              Other insured

3. During the past 5 years has the life to be insured ever

Suffered from any illness, disorder, disability or

Injury which has required any form of medical or                                                NO

Specialised examination (including X-ray, blood tests,

E.C.G., U.S.G, CT/MRI, gynaecological investigations,

Consultation, hospitalisation or surgery?

6. Has the life to be insured planned for a surgery or is currently

Aware of any medical condition that might require medical                                  NO

Advice/surgery in near future?

       7(x) Musculoskeletal diseases disc, back or neck complaint, any

    physical disability or other disorder of the bones, joints,                    NO

    arthritis, gout etc.

          The allegation of the O.Ps is that Supression of Pre-existing disease “Scoliosis” is suppressed by the Complainants and Pramoda Kumar Sahoo, Agent(husband and father of Complainants No.1 & 2 respectively) Medical report reflects:

“C/O Deformity on Back……………….8 years

Back Pain

The Clinical Summary says:

“Neglected early on set Scoliosis,” C/o- Deformity in the back for last 8 years which is gradually progressive”.

Basing on the above statement the O.Ps repudiated the claim. The O.Ps failed to appreciate the words “Neglected early on set Scoiliosis”. The O.Ps have not submitted any documents prior to 2014 to prove that the Complainant was having “Scoliosis”. Basing on a mere statement without documentary evidence of pre-existing disease rejection of claim is not proper and proper application of mind. The T.P.A. (O.P. No.3) not submitted his report basing on which claim was rejected. It amounts to deficiency in service.

Since 2014 to 2018 the Complainant paid the premium and the O.Ps continuously taken the same not rejected the policy. Further the O.Ps have examined the insured in 2014 to 2018 but not submitted the medical report of penal doctor, it amounts to deficiency in service.

In the present case the decision of hon’ble Supreme Court of India, Civil Appeal No. 8386/2015, Manmohan Nanda Vs United India Assurance Co. Ltd & another can be referred. The object of the insurance policy was to “ Cater to medical expenses incurred by the assured.” The proposal form supplied by the O.Ps does not have any specific question to seek information and obtain clarity as to the undelying risks in the policy which is greater than the normal risks. Accordingly, the Contra proferentem” can be interpreted in a way that would be favourable to the assured.

After issuing a policy the burden of proving that the insured had made false representation and suppressed material facts is on the insurer. The O.Ps failed to establish the pre-existing disease. The O.Ps are not right in repudiating the policy in question.

Accordingly it is ordered:

ORDER

The complaint is allowed on contest against the O.Ps. The O.P. No.1 & 2 are directed to settle the claim of medical expenses of the Complainants within one month of this order. For deficiency in service and harassment the O.P. No.3 is to pay compensation of Rs. 1.00lakh and litigation expenses of Rs. 20,000/-. In case of non payment within one month the O.P. No.1 & 2 shall bear 12% interest P.A. w.e.f. date of claim till realisation and in the case of O.P. No.3 the amount will carry 12% interest P.A. w.e.f. date of order till realisation.

              Order pronounced in the open court on 10^th day of July 2023.

              Supply free copies to the parties.