West Bengal

Birbhum

CC/112/2015

Md Rafiuddin, S/O Lt Hasmot Mondal - Complainant(s)

Versus

Branch Manager, LICI,Sainthoa branch - Opp.Party(s)

Sanjit Kr Acharya

26 Mar 2019

ORDER

The case of the Complainant Md. Rafiuddin in brief is that he took a L.I.C.’s Health plus Policy under Plan No. 901, bearing Policy No. 468334211 for a term of 26 years having Annual Premium of Rs. 5000/- with Major Surgical Benefits sum assured Rs. 50,000/- under date of commencement 19/06/2009 from his O.P. No. 1 LICI Sainthia Branch for availing medical benefits as per terms and conditions under the said LIC’s Health Plus Policy.

            The OP No. 2 Md Sasujjaha is Agent of OP No. 1 and OP No. 3 Medicare TPA services is the third party Administrator.

            It is the further case of the Complainant that on 13/08/2012 while he was returning with stone loaded vehicle driver of the same applied brake and they were entangled with live electric line of 11000 volts and the complainant sustained major injuries due to shock and became senseless. He was brought to Bellon Nursing Home and Diagnostic centre Pvt. Ltd. Kolkata.

            It is the further case of the Complainant that he incurred expenses of Rs. 2,06,270/- and submitted claim before OP No. 1. But OP No. 3 by sending a letter repudiated his claim contending interalia claim does not fall under preview of the policy condition. On 26/09/2013 the District officer of the OP No. 1 also sent a letter of repudiation, which is completely illegal and arbitrary.

            It is the further case of the Complainant that he purchased the policy from the OP No. 1 through their agent OP No. 2. That prior to sell of the aforesaid policy the Agent/OP No. 2 of OP No. 1 induced the complainant explaining advantages/privileges of policy and the bright side of the same that he at the time assured to the complainant that all types of diseases, surgery will be covered under the policy and being convinced he agreed to purchase the policy.

            It is the further case of the complainant that no terms and condition in respect of the policy was supplied to the complainant even he was not informed about the terms and condition of the policy and as such he was unaware about the terms and condition of the policy. The complainant is not educated and none from the OP No. 1 explained any such terms and condition and if he was informed pros and cons he could have accept cooling off provision to cancel the policy for dissatisfaction with the agreement, but he did not get any opportunity to do the same rather he was informed that major surgical benefit (MSB) Hospital cash benefit (HCB) are covered under the policy. That the complainant has been given hospital cash benefit to Rs. 9,792/- but no surgical benefit was given illegally they did not settle the surgical benefit towards the complainant only to deprive him from his legitimate claim, although the complainant is entitled to get entire expenses incurred by him for his treatment.

            Hench this case for directing the OP No. 1/Ins. Co. to pay Rs. 2,06,270/- as claim amount with 18% interest PA since 13/08/2012 till realization with compensation of Rs. 1,00,000/-.

            The OP No. 1/Ins. Co. has contested the case by filing W/V denying all material allegation of the complaint

 

contending inter alia that the case is not maintainable and the complainant has no cause of action to bring this case.

            It is the specific case of the OP No.1 that the Complainant Md. Rafiuddin took a L.I.C.’s Health Plus Policy under Plan No. 901, bearing Policy No. 468334211 for a term of 26 years having Annual Premium of Rs. 5000/- with date of commencement 19/06/2009 from the OP No. 1, LIC of India, Sainthia Branch for availing Medical benefits, as per Terms and Conditions of LIC’s Health Plus Policy. The Complaint Md. Rafiuddin purchased the said Health Plus Policy from this OP LIC of India for availing Hospital Cash Benefit & certain percentage of Major Surgical Benefit against 49 Surgical Cases stated in the Conditions and Privileges referred to in the policy documents. The OP LIC of India accepted the proposal and communicated the acceptance by issuing the relevant Policy Bond bearing No. 468334211. As per certificate issued by Nursing Home Authority on 15/05/2014, it is observed that the Complainant availed medical treatment for Electric Contact Burns on face from the Nursing Home which is not at all included in the list of allowed Surgeries No. 1-49 mentioned in the Terms and Condition of the Policy for reimbursement of Major Surgical benefit Limits.

            It is the further case of the OP No. 1 that as per the certificate issued by Hospital the complainant stayed in the hospital for 36 days and TPA was correctly settled the hospital cash benefit by paying a sum of Rs. 9792/- for 34 days stay (excluding 48 hours as per terms and Condition of policy).

            It is the further case of the OP No. 1 that Insurance Policy is a contract between the two parties and in terms & conditions once accepted are binding both the parties. The terms of the policy have to be construed as it is and we cannot add or subs tract something. So the Insured Md. Rafiuddin cannot claim anything more than what is covered by the insurance policy.

            Ultimately the OP No. 1 prayed for dismissed of the case with costs alleging that there was no deficiency in their part.

            Inspite of due service of none OP No. 2 Md. Sasujjaha OP No. 3 Medicare TPA service (I) Pvt. Ltd. have not contested the case and the case was heard exparte of against them.

            Considering the complaint and other materials on record with think following points are to be decided in this case.

1. Whether the complainant is a consumer under Sec. 2(1)(d)(ii) of the C.P. Act.?
2. Whether this Forum has jurisdiction to try this case?
3. Whether there is any deficiency in service or unfair trade practice on the part of the O.P.?
4. Whether the complainant is entitled to get any other relief or reliefs as prayed for?

DECISION WITH REASONS

During the trial the complainant Md. Rfiuddin has filed examination in chief. He has been cross

examined by contesting O.P No. 1. He has also field some documents. 

O.P No. 1 has not filed any oral evidence but submitted some documents.

Heard argument of both sides.

Point No.1:: Complainant Md. Rafiuddin in brief is that he took a L.I.C.’s Health plus Policy under Plan No. 901, bearing Policy No. 468334211 for a term of 26 years having Annual Premium of Rs. 5000/- with Major Surgical Benefits sum assured Rs. 50,000/-.

So, the complainant is a consumer u/s 2(1)(d)(ii) of the C.P. Act.

Point No.2:: Total valuation of the case is Rs. 3,26,270/- with interest which is far less than maximum limit of the pecuniary jurisdiction of the Forum i.e. Rs. 20,00,000/-.

            The O.P No.1 has office and OP No. 2 has residence within jurisdiction of the Forum.

So, this Forum has pecuniary and territorial jurisdiction to try this case.

Point No. 3 and 4:: Both points are taken up together for convenience of discussion as they are related to each

 

other.

            Admittedly the Complainant Md. Rafiuddin took a L.I.C.’s Health plus Policy under Plan No. 901, bearing Policy No. 468334211 for a term of 26 years having Annual Premium of Rs. 5000/- with Major Surgical Benefits sum assured Rs. 50,000/- under date of commencement 19/06/2009 from his O.P. No. 1 LICI Sainthia Branch for availing medical benefits as per terms and conditions under the said LIC’s Health Plus Policy.

            It is also admitted fact that on 13/08/2012 while the Complainant was returning with stone loaded vehicle driver of the same applied brake and they were entangled with live electric line of 11000 volts and the complainant sustained major injuries due to shock and became senseless. He was brought to Bellona Nursing Home and Diagnostic centre Pvt. Ltd. Kolkata.

            Copy of police Report dated 14/18/2012 sent by Bellona Nursing Home and Diagnostic Center, Kolkata to police shows that Md. Rafiuddin sustained Electro Moist Bunn (app 40%) due to overhead electric connection with dumper when the was ridden.

            It is the specific case of the OP No. 1 that The Complaint Md. Rafiuddin purchased the said Health Plus Policy from this OP LIC of India for availing Hospital Cash Benefit & certain percentage of Major Surgical Benefit against 49 Surgical Cases stated in the Conditions and Privileges referred to in the policy documents. The OP LIC of India accepted the proposal and communicated the acceptance by issuing the relevant Policy Bond bearing No. 468334211. As per certificate issued by Nursing Home Authority on 15/05/2014, it is observed that the Complainant availed medical treatment for Electric Contact Burns on face from the Nursing Home which is not at all included in the list of allowed Surgeries No. 1-49 mentioned in the Terms and Condition of the Policy for reimbursement of Major Surgical benefit Limits.

            On carful security of the policy condition we find that surgery regarding Electric moist bunn has not been included in the list of major surgical benefit.

            We further find from the copy of the letter dated 30/07/2013 sent by OP No. 3 to the Complainant that the claim of the complainant was repudiated on the ground that the complainant was not eligible for claim as it does not fall under preview of the policy condition.

            We further find that admittedly the OP No. 1 has paid Rs. 9,972/- as hospital cash benefit.

It is the case of the complainant that he purchased the policy from the OP No. 1 through their agent OP No. 2. That prior to sell of the aforesaid policy the Agent/OP No. 2 of OP No. 1 induced the complainant explaining advantages/privileges of policy and the bright side of the same that he at the time assured to the complainant that all types of diseases, surgery will be covered under the policy and being convinced he agreed to purchase the policy.

            It is the further case of the complainant that no terms and condition in respect of the policy was supplied to the complainant even he was not informed about the terms and condition of the policy and as such he was unaware about the terms and condition of the policy. The complainant is not educated and none from the OP No. 1 explained any such terms and condition and if he was informed pros and cons he could have accept cooling off provision to cancel the policy for dissatisfaction with the agreement, but he did not get any opportunity to do the same rather he was informed that major surgical benefit (MSB) Hospital cash benefit (HCB) are covered under the policy.

            But there is nothing to show that practically there was existence of any Agent like OP No. 2 Md. Sasujjah in between the complainant and OP No. 1 Ins. Co. at the time of obtaining policy by the complainant.

            We further find that beside uncorroborated testimony of PW1/Complainant Md. Rafiuddin no such evidence is forthcoming before the forum that alleged Agent falsely induced the complainant to obtain policy assuring that all type of disease, surgery are covered with the said policy.

            At the time of hearing of argument Ld. Advocate/Agent of the complainant submitted a ruling reported in 2011(2) CPR 173 (Nc), where in a case of insurance Hon’ble National Commission has been pleased to hold that the

 

parties to the contract of insurance are bound by terms and conditions of the policy.

            He cited copy of another judgement passed by Hon’ble National Commission in Revision Petition No. 429/2017, where petitioner had insured himself and his family under Medical Insurance. His new born son was included in policy on 20/02/2014. Petitioner’s son was treated for ‘Heart Ventricular Septal Defect’s and reimbursement claimed. Claim repudiated on the ground of pre-existing disease & exclusion clause in policy. DCF allowed complaint of deficiency in service. State Commission upheld the appeal’.

            The Hon’ble National Commission has been pleased to dismiss the Revision Petition observing that the claim repudiation correct since conditions of the policy come into picture in either scenario. It is incumbent upon the consumer to be an informed and responsible consumer in order to be able to avail of relief under the Consumer Protection Act, 1986. Ignorance of terms and conditions of the policy is not excuse and provides no shelter to the petitioner complainant.

            Considering overall matter into consideration and materials on record and relying upon the ruling cited above we are constrained to hold that the OP No. 1/Ins. Company duly repudiated the insurance claim of the Complainant and the case is liable to be dismissed.

            Both the points are decided against the Complainant.

            The case fails.

            Proper fees have been paid.

Hence,

O R D E R E D

that C.F case No. 112/2015 be and the same is dismissed on contest against the O.P No. 1 and exparte of against the OP No. 2 and 3 without any costs.

            Copy of this order be supplied to the parties each free of cost.