Haryana

StateCommission

A/1067/2015

LIFE INSURANCE CORP.OF INDIA - Complainant(s)

Versus

BHOM SINGH - Opp.Party(s)

SATYAWAN AHLAWAT

27 Jul 2016

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                 

First Appeals No: 1067/2015 & 163/2016

Date of Institution: 14.12.2015 & 23.02.2016

Date of Decision: 27.07.2016

 

Appeal No.1067 of 2015

 

Life Insurance  Corporation of India, SCO No.3,4 and 5, Sector-1, HUDA Rohtak, District Rohtak, through its Manager (L&H), Division Office, Chandigarh.

                                      Appellant/Opposite Party

Versus

 

Bhom Singh s/o Sh. Mange Ram, Resident of House No.299/16, near Hercules Gym, Model Town, Jhajjar, Tehsil and District Jhajjar.

                                      Respondent/Complainant

 

Appeal No.163 of 2016

 

Bhom Singh s/o Sh. Mange Ram, Resident of House No.299/16, near Hercules Gym, Model Town, Jhajjar, Tehsil and District Jhajjar.

 

                                      Appellant/Complainant

Versus

 

Life Insurance  Corporation of India, SCO No.3,4 and 5, Sector-1, HUDA Rohtak, District Rohtak, through its Manager (L&H), Division Office, Chandigarh.

                                      Respondent/Opposite Party

 

 

CORAM:             Hon’ble Mr. Justice Nawab Singh, President.

                             Shri B.M. Bedi, Judicial Member.

                             Shri Diwan Singh Chauhan, Member   

 

Present:              Shri Satyawan Ahlawat, Advocate for Life Insurance Corporation of India.

Shri Ravi Kumar, Advocate proxy for Shri Chanderhas Yadav, counsel for Bhom Singh-Complainant.

 

                                                   O R D E R

 

B.M. BEDI, JUDICIAL MEMBER

 

This order shall dispose of afore-mentioned two appeals bearing No.1067 of 2015 and 163 of 2016 having arisen out of common order dated October 14^th, 2015, passed by District Consumer Disputes Redressal Forum, Jhajjar (for short ‘the District Forum’), in complaint No.67 of 2014 filed by Bhom Singh.

2.      Bhom Singh-Complainant (respondent herein) and his wife Bala Devi, obtained LIC’s Health Plus Plan, insurance policy (Exhibit P-5) from Life Insurance Corporation of India (LIC)-Opposite Party for the period March 31^st, 2009 to March 31^st, 2023. During the subsistence of the policy, the complainant suffered neck pain and backache. He was admitted in Medanta The Medicity Hospital, Gurgaon (for short ‘Medanta Hospital’) on November 7^th, 2012. He was diagnosed a patient of ‘Degenerative Cervical stenosis C5-6 and was operated upon November 8^th, 2012. He was discharged from the hospital on November 11^th, 2012. He paid Rs.2,30,206.03 in the above said hospital vide bill Exhibit P-4. Claim being filed, the LIC repudiated vide letter dated February 4^th, 2013 (Exhibit P-1). For ready reference, the operative part of the repudiation letter is reproduced as under:-

“From the answers given in the proposal form submitted and the declaration given in the proposal by you for effecting the Health Insurance cover under the policy, we observe that you/insured member have suppressed the details pertaining to the pre existing diseases which has relation to the nature of the claim made.

We have reviewed the details given in the Claim forms and also various other reports given by you/collected by the TPA/us in the course of verification/investigation.

We observe that your claim can not be considered for admission and payment as per the terms & conditions specified in the policy, for the following reasons:

Sr.No.	Repudiation Code	Cause of Repudiation
1.	H01	Pre-existing illness irrespective of prior medical treatment or advice
2.	M01	Surgery not listed in the allowed surgeries as per policy conditions.
3.	M02	Pre-existing illness irrespective of prior medical treatment or advise.

 

Hence we regret to inform you that your claim is repudiated and nothing is payable under the policy for the above referred hospitalization.”

3.      Aggrieved thereof, the complainant filed complaint under Section 12 of the Consumer Protection Act, 1986 before the District Forum.

4.      The LIC-Opposite Party contested complaint by filing reply raising plea that the policy taken by the complainant was not a scheme meant for reimbursement of hospitalization expenses and the policy taken by him was of Health Plus, that is, Plan No.901. So, as per terms and conditions of the Insurance Policy, the complainant’s claim was not covered under the policy. It was prayed that the complaint be dismissed.

5.      After evaluating the pleadings and evidence of the parties, the District Forum vide impugned order allowed the complaint directing the LIC as under:-

“…….it is directed that the respondent shall make the payment of a sum of Rs.25,000/- as sum insured under policy in question towards hospital cash benefits alongwith an interest @ 9% p.a. from the date of admission i.e. 7.11.2012 till realization of final payment to the complainant. The complainant is also entitled for a sum of Rs.10,000/- from the respondent as compensation on account of mental agony, harassment etc and a sum of Rs.5500/- on account of litigation expenses for the present unwanted and unwarranted litigation only due to the deficiency in service on the part of the respondent.”

6.      Aggrieved by the order of the District Forum, the LIC has filed appeal No.1067 of 2015 for setting aside the impugned order and the complainant has filed appeal No.163 of 2016 praying for enhancement of the compensation.

7.      Learned counsel for the LIC has argued that the surgery for which the insured/complainant was treated, was not covered under the policy.

8.      The Terms and Conditions (Exhibit R-9) of the policy have been perused. Under the heading of ‘Major Surgical Benefit’, the policy covers hospitalization. Clause 6 (a) deals with Hospital Cash Benefit and Clause 6(b) deals with ‘Major Surgical Benefit’. Under Clause 6(a), the insured is entitled to the ‘Applicable Daily Benefit’ for 24 hours or part thereof provided any part stay exceeds a continuous period of 4 hours and the hospitalization is more than 48 hours.  For ready reference, the relevant portions of Clause 6(a) and 6(b) are reproduced as under:-

“6. OTHER TERMS AND CONDITIONS:

a)      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 the Cover Period and causing an Insured’s Hospitalization to exceed a continuous period of 48 hours within the Policy Period, then, subject to exclusions mentioned in para 7a. and the terms and conditions of the Policy, the following is payable by the Corporation:

xxxx

b)      Major Surgical Benefit:

In the event of an Insured under this Policy undergoing any Surgery (listed in Annexure II hereto) in a Hospital due to Accidental Bodily Injury or Sickness first occurring or manifesting itself after the Date of Cover Commencement and during the Cover Period, then, the respective benefit percentage of the Major Surgical benefit Sum Assured, as specified against each of the eligible surgeries mentioned in Annexure II, shall be payable subject to exclusions mentioned in Para 7.b and the following terms and conditions: 

-In the event of a claim becoming eligible for payment under this benefit, and regardless of the actual costs incurred, the Corporation will pay the chosen Major Surgical Benefit Amount, calculated as a percentage of Sum Assured as specified against each of the eligible surgeries in Annexure II.

- The Major Surgical Benefit shall be paid as a lump sum and is subject to providing proof of surgery to the satisfaction of the Corporation. 

-The maximum Benefit Amount payable in any Policy year for an insured person during the Cover Period shall not exceed 100% of the Sum Assured in respect of each member.

-If more than one Surgery is performed on the Insured, through the same incision or by making different incisions, during the same surgical session, the Corporation shall only pay for that Surgery performed in respect of which the largest Benefit Amount shall become payable. 

-The Major Surgical Benefit for any Surgery cannot be claimed and shall not be payable more than once for the same Surgery during the term of the Policy. 

-The total Benefit Amount payable in respect of each Insured during the Cover Period shall not exceed a lifetime maximum limit of three (03) times the Sum Assured mentioned in the Policy Schedule. Once the total Benefit amount paid in respect of an Insured equals this lifetime maximum limit, the Major Surgical Benefit under this Policy in respect of that Insured will cease.

- No payment shall be made under this benefit for the operations performed, which are not listed in the Annexure. All surgical procedures claimed should be confirmed as essential and required, by a qualified Physician or Surgeon, to the satisfaction of the Corporation. 

-A child included in the policy will be automatically covered for Major Surgical Benefit from policy anniversary on which the age last birthday is 18 years. There will be no option for the PI to exclude the cover. Till that period such child is not covered for this benefit. 

-The Major Surgical Benefit shall be payable only if the Surgery has been performed within India. 

-The benefit will be payable only after the Corporation is satisfied on the basis of medical evidence that the specified surgery covered under the policy has been performed. 

-The Applicable Benefit Limits in respect of an Insured under this Policy, shall solely and exclusively apply to that Insured. Any unclaimed Major Surgical Benefit on any one Insured is not transferable to any other Insured. 

-If a person is covered under various policies of the Corporation under this plan, then the maximum benefit on such Insured life under all policies put together shall not exceed the cap on benefits under this plan.

xxxxxx”

 

9.      Adverting to the admission and discharge of Medanta Hospital Exhibit P-3, the complainant was admitted on November 7^th, 2012; surgery was performed on November 8^th, 2012 and he was discharged from the hospital on November 11^th, 2012 at 08:00 A.M. Thus, the hospitalization period would work out to five days. The rate of hospitalization benefit is Rs.500/- per day. Thus, the hospitalization cash benefit to which the complainant is entitled to, works out to Rs.2500/-.

10.    Under the heading of Major Surgical Benefit, Clause 6(b), Schedule-II covers the nature of surgeries which are covered for Major Surgical Benefits. Under the heading of ‘Nervous System, the surgery covers ‘repair of Cerebral or Spinal Arterio Venous Malformations and Cerebral Aneurysms’. The percentage of sum assured is 100%. The operative part of (Annexure-II) Terms and Conditions (Exhibit R-9) of the policy is reproduced as under:-

                   “Nervous System:

List of Surgical Procedures	Percent of the Sum Assured
xxx	xxx
Repair of Cerebral or, Spinal Arterio Venous Malformations and Cerebral Aneurysms	100%

 

11.    Again adverting to the treatment record of Medanta Hospital (Exhibit P-3), the complainant was subjected to surgery of spinal cord. Course in Hospital (Exhibit R-8) is as under:-

                   “Course in Hospital-

Patient was admitted with above mentioned complaints & relevantly investigated. MRI Cervical Spine with screening of remaining spine was done findings are suggestive of cervical spondylosis with prominent posterior marginal osteophyte with broad based posterocentral and right paracentral disc protrusion at C5-C6 level causing compression of the ventral cervical cord surface and ligamentum flavum thickening causing focal secondary spinal canal stenosis with intramedullary T2-hyperintensity at this level representing focal myelomalacic cord changes….”

12.    The complainant having undergone spinal surgery, was covered under the heading Major Surgical Benefit, which is permissible as per Clause 6(b) and Annexure-II of the terms and conditions of the policy.  The sum assured for Major Surgical Benefit is up to Rs.1.00 lac.

13.    The complainant has placed on the file bill of the Medanta Hospital (Exhibit P-4) for Rs.2,30,206/-. However, since the sum assured is restricted to Rs.1.00 lacs, therefore, the complainant is only entitled to Rs.1.00 lac under the heading of ‘Major Surgical Benefit’.

14.    In view of the above, it is established that the benefit to which the complainant is entitled to under the heading of hospital ‘Cash Benefit’ and major surgical benefit comes to Rs.1,02,500/-. The District Forum fell in error in awarding Rs.25,000/- to the complainant for Hospital Cash Benefit. So, the LIC is directed to pay Rs.1,02,500/- to the complainant instead of Rs.1,25,000/-. Rest of the order is maintained.

15.    The impugned order is modified in the manner indicated above and both the appeals stand disposed of.

16.    The statutory amount of Rs.25,000/- deposited at the time of filing the appeal No.1067 of 2015, be refunded to the complainant against proper receipt and identification in accordance with rules, after the expiry of period of appeal/revision, if any.

 

Announced 27.07.2016

(Diwan Singh Chauhan) Member

(B.M. Bedi) Judicial Member

(Nawab Singh) President

CL