J U D G E M E N T

Sri Biswanath De, Ld. President.

The complainant’s case in brief is that the complaint No. 1 purchased one LICI’s Health plus plan policy vide policy no 455211809 on 27.01.09 from the ops and their appointed Agent O.P. No. 4 after enquiry and physical lest. The O.P. No. 5 issued the above policy in favour of both the complaint. The policy expiry date is 27.01.2013 and the policy covered two members i.e. complainant No.1 & complaint No. 2. On 30.05.2011 due to illness the complaint No.2 was admitted in the “Medical North Bengal Clinic”, Pradhan Nagar, Siliguri and was discharge on 07.06.2011 after then she was treated at AIIMS, Delhi. The Medical expense of Rs.2,17,589/- till 15.05.12 was claimed by the complaints to the O.P.s which was covered by the LICI’s Health Plus Plan.  After submission of all relevant bills and documents to the O.P.s, the O.P.s denied to make payment to the complaint. The complaint has sent his objection to the competent authority of the OPs, i.e., Grievance cell redressed, TPA, City Plaza, Sevoke Road, Siliguri-734 001 but the OP No.2, the LICI authority of Jalpaiguri Division already repudiated the claim of the complaint.  In reply to the complaint’s lawyer’s notice on 12.08.13.  Finding no alternative, the complainant filed this case before this Forum for relief.  

OP Nos.1 & 2 appeared and filed written version denying inter-alia all the material allegations as raised by the complainant.  OP Nos.1 & 2 admits that Health Policy as stated by the complainant was issued to them from 27.01.2009.  The benefit under this policy is major surgical benefit both PI and spouse Rs.1,60,000/- each and initial daily cash benefit IDCB @ 800/-.  As per policy condition, TPA will serve for Health Policy as licensed by IRDA, LIC of India.  The role of TPA is to assist LICI in processing Health Insurance Claims in accordance with guideline by IRDA.  The TPA has absolute authority to adjudicate of the admissibility or inadmissibility of the claim.  It is also their case that the special medical test was done only for Sri Pijush Kanti Mitra and after scrutinizing the report by the empanelled doctor, the policy was accepted in favour of PI with beneficiary of his wife Smt. Minu Mitra.  It is also

Contd……P/3

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submitted that complainant lodged hospitalization claim and intimation to the TPA after the lapse of stipulated time as stated in the policy condition and did not submit the claim as per policy condition.  Accordingly, claim was rejected.  It is their also further plea like other cases that TPA reopened the file again and asked the complainant for submitting some documents, but the complainant did not make submission of those documents as required by TPA.  Accordingly, the claim was rejected with remark TPA L09.  It is also stated that later TPA again opened the file after receiving the letter dated 05.012.2012.  After completion of investigation job, the TPA observed that the claims are not tenable and rejected on grounds of as HO1 meant for pre-existing illness irrespective of prior medical treatment and advice.  This decision was communicated to the complainant.  It is also stated that due to suppression of illness of complainant, the claim has been rejected and the complainant Smt. Minu Mitra suffered illness from 11.02.07 to 12.05.2012 as per prescriptions available to them.  The medicines prescribed are strongly related chronic psychiatric disease and OCD.  Accordingly, for suppression of fact the claim was finally rejected.   

OP Nos.3 & 5 appeared and filed written version denying inter-alia all the material allegations as raised by the complainant.  The positive case is that OP Nos.3 & 5 are unnecessary party in the instant case as there was no contract between the complainant and the OP Nos.3 & 5.  These OP Nos.3 & 5 are Third Party Administrator who has been appointment for settlement of claims, raised by Mediclaim policy holder.  The TPA rejected the claim by the Doctors panel and claim adjudication department of the OP Nos.3 & 5 due to LO9, HO1, HO1 and said decision was communicated to the complainant on 20.02.2013 and 04.03.2013.  So, from the written version of OP Nos.3 & 5, rejected the claim as per decision of Doctor’s Panel and the Claim Adjudication Department of OP Nos.3 & 5. 

OP No.4 is Agent of LICI appeared and filed written version denying inter-alia all the material allegations as raised by the complainant.  This agent OP No.4 stated that the complainant contacted this OP for Health Insurance Policy suppressing the health condition of his wife at the time of submission of proposal to the branch office of the LICI

Contd……P/4

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concerned.  Even the wife of the complainant was asked by the OP at the time of proposal about any disease.  But she did not disclose any chronic disease.  This OP has been falsely implicated in this case.  It is also case that this OP No.4 is an Agent of OP No1 and he is acted on behalf of OP No.1 and he is not personally liable. 

Thus from the above statement of OPs, it appears that OP Nos.1 & 3 shift their liability on TPA OP Nos.3 & 5.  OP No.4 shifts his liability on the complainant Pijush Kanti Mitra, that he called the OP No.4, Agent of LICI to make a Health Insurance Policy suppressing the illness of the complainant’s wife.                           

Points for decision

1.       Whether there is deficiency in service on the part of the OPs ?

2.       Whether the complainant is entitled to get the relief as prayed for ?              

Complainant has filed the following documents :

1.       Copy of Policy.

2.       Copy of Dr. Prescriptions.

3.       Copy of Bill. 

4.       Copy of complain/grievance. 

5.       Copy of rejection letter.

6.       Copy of notice (lawyer).

7.       Copy of A/D no.

8.       Copy of Postal Regn. Slip.

9.       Copy of Certificate by TPA. 

OP Nos. 1 & 2 have filed the following document :-

1.       Proposal form LIC’s Health Plus Policy-Plan 90 of Sri Pijush Kanti Mitra.

2.       Medical Examiner’s confidential report of Sri Pijush Kanti Mitra.

3.       Agent’s confidential Report.

4.       LIC’s Health Plus Plan (Policy Deed) along with conditions and privileges.

5.       Letter dated 21.04.2012 issued by OP LICI to TPA.

6.       Letter dated 15.05.2012 issued TPA to the complainant.

7.       Letter dated 17.06.2012 issued TPA to the complainant.

8.       Letter dated 30.08.2012 issued TPA to the complainant.

Contd……P/5

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9.       Letter dated 05.12.2012 issued by Sri Pijush Kanti Mitra to the TPA through LICI           with 3 prescriptions dated 16.08.08, 08.05.10 & 12.05.12. 

10.     Nine Medical prescriptions of treatment in the name of Smt. Minu Mitra. 

11.     Hospital Treatment Form dated 16.09.2011 issued by AIIMA, New Delhi. 

12.     Repudiation letter dated 20.02.2013 issued by the TPA to the complainant. 

13.     Repudiation letter dated 04.03.2013 issued by the TPA to the complainant. 

14.     Letter dated 12.08.2013 issued by the TPA to the complainant.  

Complainant has filed evidence-in-chief with affidavit. 

Complainant has filed written notes of argument. 

OPs have filed evidence-in-chief and written notes of argument.

Decision with reason.

          All the issues are taken up together for the brevity and convenience of discussion.

In this case the policy in question was firstly done by the OP No.4, agent of LICI, as per word of complainant.  The application form has been filled by the OP No.4.  So, OP No.4 had should know the actual condition of the party regarding their financial capacity and regarding their health capacity. 

From Annexure-I filed by the OP Nos.1 & 2 Column 6, 7, 8 & 9 on which OPs relied as pre-existing disease does not show any reflection in the Annexure 9 to 14.  Ld advocate of the OP Nos.1 & 2 strongly argued on the Sl. No.6 of the Policy of Smt. Minu Mitra ( Annexure-1 page 3).  The TPA has expressed their opinion not to allow the claim of the complainant, but TPA does not show reason regarding their opinion and on which they concluded the opinion. 

In the record, some Xerox copies of document are seen A/9, A/10.  Appears to be prescription in the name of Debasish Sanyal did not make

any remark or did not make any diagnosis regarding the reason of treatment as shows in those annexure.  There is no statement of this

Contd……P/6

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doctor in the record to see that alleged allegation for pre-existing illness comes within the purview of Sl. No.6.  So, the TPA raised argument merely for the sake of cavil and to make a case not to allow the claim.  The TPA again and again has taken the case consideration and shows fruitless and careless attempt to deprive the litigant public to pay money as promised in the Health Plus Plan. 

OP No.4 is an Agent OP Nos.1 & 2.  He has filled in the application form and forwarded the same before the LICI Manager.  His answering questionnaire shows that the complainant’s wife was not suffering from disease.  Accordingly, form has been filled in, otherwise he would not take the policy.  Answer with respect to Question No.14 shows that proposal has been accepted by the LICI after being certified medically and OP No.4 stated that he knows that proposal has been accepted by the LICI after medically certified by the competent authority of LICI.  Accordingly, Question No.14 put to OP No.4 and his answer therein and Question No.15 & 16 and answers therein support the complainant’s case that at the time of making policy there was no disease forbidden by the policy.  The Xerox copy of Annexure 9, 10, 11 & 12 do not clarify anything regarding disease.  The doctors whose annexure have been relied upon i.e., Annexure 9, 10, 11, 12 have been relief upon by the TPA is not proved by cogent evidence of doctor.  So, the facts raised by the OP Nos.1 & 2 and reiterated by the OP Nos. 3 & 4 that there was suppressing of fact of disease as per Sl. No.6 of the proposal form is not proved and the decision of TPA regarding rejection is capricious and order of rejection is without showing any reason and evidence.  The TPA has acted only to help the OP Nos.1 & 2 and to deprive the litigant illiterate policy holders. 

In our country where 80% people are unable to read very small letters scribed in English, they are always pursued by the Agent like the OP No.4 to get a policy.  Any way they took the signature of the proposer in the proposal form telling that he would fill up the remaining part of the form and doctor’s team acts nominally and formally.  They are appointed only for increase the business of the product selling of the company.  This case shows the TPA repeatedly acted for harassment of the complainant demanding some papers.  It is pertinent to note that not only in this case, but also many other cases, the TPA conduct in the

Contd……P/7

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same manner recommending rejection of claim of policy holders.  The material on record does not support the opinion of TPA as stated hereinbefore.  From record, it appears that OP Nos.1 & 2 acted in repudiation the claim of the complainant as per unreasoned advice tendered by the TPA and OP Nos.1 & 2 took the policy collected by the Agent, OP No.4, who has been engaged by the OP Nos.1 & 2 to collect money and to exploit the money from the poor and illiterate people of this country, and like that TPA is also an Agent to act on behalf of the OP Nos.1 & 2. 

The act of the TPA itself shows that they acted negligently.  Not applying their mind to the illiterate litigant claimants.  The OP Nos.1 & 2 also discharged their duty leaving the case upon the TPA.  The premium is being taken by the OP Nos.1 & 2, but at the time of dispute, liabilities are given to the TPA and OP Nos.1 & 2 are selling their product through the Agent, like OP No.4.  Thus, on these premises, the evidence in record and documentary evidence conduct of the parties show that the OP Nos.1, 2, 3, 4 & 5 act negligently without due care and attention which ought to have been applied in this case.  There is enough deficiency in service on the part of the OP Nos.1, 2, 3, 4, 5 & 6 who are responsible for depriving the complainant from his entitlement from getting cost of treatment. 

Accordingly, material on record inspires confidence in the mind of this Forum that material on record proved the complainant’s claim of compensation as prayed by the Section 14 of the Consumer Protection Act, 1986.

The case succeeds on contest.     

Therefore, the complainant is entitled to get total cost of treatment and other compensation as per law. 

The complainant is entitled to get Rs.2,17,000/- being the total cost of treatment from the OP Nos. 1, 2 & 3.

The complainant is further entitled to get compensation of Rs.30,000/- for mental agony from the OP Nos.1 to 6.

The complainant is further entitle to get Rs.30,000/-for harassment from the OP Nos.1 to 6.

Contd……P/8

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The complainant is further entitled to get Rs.10,000/- towards litigation cost OP Nos.1 to 6.      

In the result, the case succeeds.

Hence, it is                                  

                  O R D E R E D

that the Consumer Case No.155/S/2013 be, and the same is hereby allowed on contest in part against the OPs with cost.

The complainant is entitled to get Rs.2,17,000/- being the total cost of treatment from the OP Nos.1, 2 & 3.

The complainant is further entitled to get compensation of Rs.30,000/- for mental agony from the OP Nos.1 to 6.

The complainant is further entitle to get Rs.30,000/-for harassment from the OP Nos.1 to 6.

The complainant is further entitled to get Rs.10,000/- for litigation cost from the OP Nos.1 to 6.

The OP Nos.1, 2 & 6, who are jointly and severally liable, are directed to pay Rs.2,17,589/- being the total cost of treatment by issuing an account payee cheque in the name of the complainant within 45 days of this order.

 The OP Nos.1 to 6, who are jointly and severally liable, are further directed to pay Rs.30,000/- by issuing an account payee cheque in the name of the complainant for mental agony within 45 days of this order.

The OP Nos.1 to 6, who are jointly and severally liable, are further directed to pay Rs.30,000/- by issuing an account payee cheque in the name of the complainant for harassment within 45 days of this order.

The OP Nos.1 to 6, who are jointly and severally liable, are further directed to pay Rs.10,000/- by issuing an account payee cheque in the name of the complainant for litigation cost within 45 days of this order.

In case of default of payment, the complainant is further entitled to get interest @ 9% per annum on the awarded sum from the date of filing of this case till full realization. 

In case of default, the complainant is at liberty to execute this order through this Forum as per law. 

Copies of this judgment be supplied to the parties free of cost.

-Member-                                                  -President-