C.F. CASE No. : CC/10/01
COMPLAINANT : Sri Sanjit Kumar Bhattacharyay,
S/O Late Sukumar Bhattacharyay
C/O Late Nirmal Kumar Sanyal,
R.N. Tagore Road (Opposite to the Kotwali P.S.),
Krishnagar, Nadia, W.B.
OPPOSITE PARTIES/OPS : 1) Branch Manager,
Life Insurance Corporation of India
Krishnagar Branch – 2
Padia Building, Krishnagar, Nadia.
2) Sr. Divisional Manager,
Life Insurance Corporation of India
Kolkata Suburban Divisional Office,
Jeevan prabha, 1/DD-S Sector – 1,
Salt Lake City, Kolkata – 700 064
3) Claim Settlement Officer,
Medicare T.P.A. Service Pvt. Ltd.
Flat No. 10, Paul Mansions,
No. 6 Boshap Lefroy Road,
Kolkata - 700020
PRESENT : SHRI KANAILAL CHAKRABORTY PRESIDENT
: SMT SHIBANI BHATTACHARYA MEMBER
: SHRI SHYAMLAL SUKUL MEMBER
DATE OF DELIVERY
OF JUDGMENT : 17th September, 2010
: J U D G M E N T :
In brief, the case of the complainant is that on 29.03.08 he purchased LIC’s Health Plus policy No. 427/033069 with annual premium of Rs. 15,000/- and with a sum assured of Rs. 2,00,000/-. The policy is valid up to 29.03.23 and it covers the complainant himself along with his wife, Saheli Bhattacharya and son, Shouvik Bhattacharya. On 18.09.09 the complainant became ill and he was admitted at Nadia District Hospital at Saktinagar. Thereafter, he was examined by Dr. Aloke Majumder who diagnosed the disease of gall bladder and suggested for its removal. Accordingly, he was admitted at Multi Care Hospital at Kalyani on 04.10.09 where operation was done on 05.10.09 and he was discharged from that Hospital on 08.10.09. Thereafter, he submitted medical bill along with the relevant documents to the OP No. 3. He had made several correspondences to the T.P.A. (OP No. 3), who by a letter dtd. 23.11.09 informed that the total removal of gall bladder was not listed in the allowed surgeries, though it is covered in the policy page No. 27, but the OP rejected his claim. So having no other alternative he has filed this case praying for the reliefs as stated in the petition of complaint.
The OP No. 1, LICI has filed a written version in this case, inter alia, stating that on the basis of the documents filed by the complainant, the OP No. 3 settled the claim of the complainant on 15.10.09 and benefit amount of Rs. 2,100/- was paid on 21.11.09 which he duly received. He has also stated that as the surgery of the gall bladder is not covered in the medical policy, so the claim of the complainant was rightly rejected by the OP No. 3. Again on the basis of the letter of the complainant the TPA informed that the claim was received by him and this surgery was listed at page No. 27 of LIC Health Plus booklet giving conditions and privileges referred to the policy document. The TPA also asked the complainant to file all the relevant documents at which the complainant did not send any reply. Thereafter, on the basis of the documents received by the TPA on 10.04.10 the claim of the complainant was admitted and it was settled for an amount of Rs. 1,20,000/- on 21.05.10. So the complainant has no cause of action to file this case and the same is liable to be dismissed against him.
The OP No. 3, TPA has filed a separate written version in this case, inter alia, stating that the complainant has no cause of action to file this case. It is his submission also that on 15.10.09 the complainant filed two claims before him on the basis of which those were disposed of. It is his submission also that as Laproscopy Cholecystectomy is not covered under the policy of the complainant, so the claim application of the complainant regarding his treatment and operation at Multi Care Hospital was rejected, but Rs. 2100/- was sanctioned for his other treatments. Therefore, this complainant has no cause of action to file this case and the same is liable to be dismissed against him.
POINTS FOR DECISION
Point No.1: Has the complainant any cause of action to file this case?
Point No.2: Is the complainant entitled to get the reliefs as prayed for?
DECISION WITH REASONS
Both the points are taken up together for discussion as they are interrelated and for the sake of convenience.
On a careful examination of the petition of the complaint along with the written versions filed by the OPs and the annexed documents filed by the parties and after hearing the arguments advanced by the ld. lawyers on both sides it is available on record that the complainant purchased one LIC’s Health Plus policy for Rs. 2,00,000/- which is valid up to 29.03.23. It is available on record that the complainant became ill and due to his illness the entire gall bladder was removed after operation. The complainant thereafter, moved before the OPs for payment of medical claim amount of Rs. 2,00,000/-. Initially the OPs did not sanction any amount for gall bladder operation on the ground that it was not included in the Health Plus policy. But from the policy condition it is available that gall bladder along with liver and pancreas are included within the policy which means that insured amount can be sanctioned in case of gall bladder treatment. The original claim application was submitted by the complainant on 15.10.09 before the OP No. 3 and the OP No. 3 initially sanctioned Rs. 2,100/- instead of Rs. 2,00,000/- as claimed by the complainant on the plea that the total removal of gall bladder is not listed in the allowed surgeries (1 to 49). But subsequently, the OP sanctioned Rs. 1,20,000/- to this complainant relying on a letter issued by LIC authority dtd. 04.05.10 to the extent that the surgery of gall bladder is now allowed for all policies issued up to 14.01.10. This policy of the complainant was issued prior to that date. But the fact is that in the original policy condition gall bladder treatment was included which can not be denied by the OPs. OP No. 3 sanctioned Rs. 1,20,000/- on the plea that 60% of the total insured amount can be granted in case of partial resection of liver or pancreatectomy. In the original list nothing is specifically stated regarding partial or full resection of gall bladder. But in the instant case from the medical papers submitted by the complainant we find that his entire gall bladder was removed after operation which is not also denied by the ld. lawyer for the OPs at the time of argument. Now the question is whether the complainant is entitled to get the entire insured amount for the total removal of his gall bladder through operation. From the documents filed by both the parties it is available that in case of surgery of gall bladder no partial or full is mentioned, either partial resection or total removal. Gall bladder is a major organ of the body and removal of gall bladder after operation is a major surgery one. So we hold in case of total removal of the gall bladder the present complainant is entitled to get 100% of the insured amount and not 60% of the insured amount as sanctioned by the OPs. Besides this, the OP should settle the claim of the complainant after submission of his application as the treatment of the gall bladder is included in the list of surgical procedure. But prior to filing of this case OPs did not settle his claim. Undoubtedly it is a great deficiency in service on the part of the OPs in not settling the claim of the complainant in due time.
In view of the above discussions, our considered view is that the complainant is entitled to get the entire insured amount – the amount already paid to him by the OP No. 3 along with compensation and litigation cost. In result the case succeeds.
Hence,
Ordered,
That the case, CC/10/01 be and the same is allowed on contest against the OPs. The complainant is entitled to get Rs. 2,00,000/- – Rs. 1,20,000/- = Rs. 80,000/- + Rs. 5,000/- as compensation along with Rs. 2,000/- as litigation cost, i.e., in total Rs. 87,000/-. The OP No. 1, 2 & 3 are jointly or severally liable to pay the decretal amount to the complainant within a period of one month since this date of passing this judgment, in default, the decretal amount will carry interest @ 10% per annum since this date till the date of realization of the full amount.
Let a copy of this judgment be delivered to the parties free of cost.
