DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

WEST TRIPURA :  AGARTALA

 

CASE   NO:   CC- 03 of  2017

 

Sri Kinkar Chowdhury,

S/O- Lt. Bhupesh Ch. Chowdhury,

East Shibnagar, P.O. Agartala College,

Agartala, West Tripura. ….....…...Complainant.

 

 

              VERSUS

 

1. Life Insurance Corporation of India,

2nd Floor, Jeevan Bima Marg, Mumbai- 400 021,

India, Represented by the Chairman.

 

2. The Branch Manager,

Life insurance Corporation of India,

Agartala Branch No.1, 

Paradise Chowmuhani,

Hospital Road Extension,

Agartala, West Tripura. .......... Opposite parties.

 

 

                      __________PRESENT__________

 

 SRI A. PAL,

PRESIDENT,

  DISTRICT CONSUMER  

DISPUTES REDRESSAL FORUM,

      WEST TRIPURA, AGARTALA. 

 

SMT. Dr. G. DEBNATH

MEMBER,

  DISTRICT CONSUMER 

DISPUTES REDRESSAL FORUM, 

  WEST TRIPURA,  AGARTALA.

 

SRI U. DAS

MEMBER,

  DISTRICT CONSUMER 

DISPUTES REDRESSAL FORUM, 

  WEST TRIPURA,  AGARTALA.

 

 

C O U N S E L

 

For the Complainant : Sri Amritlal Saha,

  Smt. Sumi Datta,

  Sri Kajal Nandi,

  Advocates.     

  

For the Opposite Party : Smt. Pushpita Chakraborty,

    Advocate.

 

 

JUDGMENT  DELIVERED  ON:   04.05.2017

 

J U D G M E N T

    This case arises on the petition filed by one Kinkar Choudhury U/S 12 of the Consumer Protection Act. Petitioner's case in short is that he purchased one Health Policy, LICI Health Plus Plan on 19.01.2009. Annual premium was Rs.10,500/-. Accordingly petitioner was paid the premium since 2009 to 2016. During the continuation of the policy he was hospitalized in Apollo Hospital on 25.05.15 due to Coronary Artery Disease and was discharged on 30.05.15 after operation. Complainant prayed for paying Rs.2,56,000/- as cost of treatment. He also spent Rs.70,000/- in additional for airfare and other expenses. After discharge from the hospital he submitted the claim on 16.06.15 in prescribed format for an amount of Rs.1,80,000/-. Complainant received communication from LIC Silchar on 07.07.15. He was asked to submit hospital treatment form, prescriptions, letter of condonation of delay. Again he received communication on 24.08.15 asking him to submit investigation report. On 19.11.15 it was informed that major surgical benefit was not available for him. Rs.3510/- was offered as Hospital cash benefit by LIC. Thus the valid claim of the petitioner was rejected by the O.P. O.P. practiced unfair trade practice and therefore petitioner claimed Rs.1,80,000/- as per terms of the policy and also Rs.5 lacs as compensation. 

 

2. O.P. LICI appeared, filed W.S. denying the claim. It is stated that the petitioner was fully satisfied with the terms and conditions of the policy and extent of coverage. The policy holder was informed about the list of allowed surgery through booklet of 'The condition & Privileges'. The surgery underwent by the complainant do not cover in the list of allowed surgery.  So, his claim was rightly denied. And there was no deficiency of service. 

 

3. On the basis of contention raised by both the parties following points cropped up for determination;

(i) Whether the surgery underwent by the petitioner was covered by the policy or not?

(ii) Whether there was deficiency of service by the O.P. and petitioner is entitled to get compensation?

 

4. Petitioner produced LIC Health Plus Plan, Annual installments premium,  discharge summary, money receipt, claim petition, communications, hospital treatment from, exhibited and marked Exhibit-1 Series. Petitioner also produced the statement on affidavit of Kinkar Choudhury, complainant of the case. 

 

5. O.P. on the other hand produced incomplete form, hospital treatment form, petitioner's letter, letter under reference. O.P. also produced the statement on affidavit of M.A. Choudhury.

 

Findings:

6. We have gone through the Health Plus Plan Certificate. Surgical benefit limits as per clause 3 of the Major Surgical benefits  shall be payable only if the surgery has been performed within India subject to provide proof of surgery to the satisfaction of the corporation. For Cardio Vascular system- major surgery of Arota, open chest surgery for repair of any Heart valves, initial implantation of pacemaker in the heart,  coronary Angiopasty with stent implantation is covered. It was informed by the Manager, LICI by letter dated 07.12.15 that the particular surgery is not listed in the allowed surgeries, the condition and privilege referred in the policy documents of the booklet. It is admitted position that in case of major surgery policy is covered for getting Rs.1,80,000/- as principal insured  was Rs.900/-. O.P. did not dispute over it.    

 

7. We have gone through the discharge summary. It is found that coronary Angiogram was done and thereafter angioplast done for stent implantation. Petitioner was 44 years old. He was hospitalized in the Apollo Hospital, Chennai and underwent operation for coronary artery disease. This is also not denied by the O.P. and there is sufficient papers to support it. 

 

8. From the documents submitted by the O.P. it is found that claim application was received on 06.07.15 but it was not sent to TPA because of shortfall and O.P. made correspondence with the complainant for giving some documents. Again correspondence made on 24.08.15 for giving some documents, filled up the form completely. The same was complied. Investigation report along with the claim form was sent. MSB limit was Rs.1,80,000/- and it was received on 30.10.15. But the policy was admitted for hospitalization claim for Rs.3510/- as per TPA letter dt. 05.10.15. 

 

9. Kinkar Choudhury, P.W. 1 in his deposition stated that he underwent operation and stent was implanted on 27.05.15. He was discharged on 30.05.15 and he spent Rs.2,56,000/- in the Apollo Hospital. He submitted the claim form along with treatment details papers and letter of condonation. 

 

10. We have gone through the letter and policy certificate, discharge summary and found that claim was taken up by the LIC but finally the claim was rejected on the recommendation of TPA. 

 

11. O.P.W.1, M.A Choudhury stated that Major Surgical benefit is calculated 200 times HCB. So, admittedly HCB was 900 and coverage was for Rs.1,80,000/-. The contention of O.P. as found in their written argument is that the condition and privileges not covered by the policy is to be followed. Petitioner was aware about it. Claim was forwarded on 16.09.15 to process and doing the needful. TPA received this on 01.10.15 and settled the claim within 5 days. But why TPA considered this angioplasty operation not major surgery not explained at all. 

 

12. In the booklet the surgical procedure is described in Page- 25. There Coronary Angiopasty with stent implantation is mentioned. The percentage of sum assured is written 40%. In the policy documents major surgical benefits sum assured is written Rs.1,80,000/- for the petitioner. But the O.P. assessed the treatment cost only Rs.3,510/- instead of Rs.1,80,000/-. Reasons not given at all properly. Only it is stated that policy terms and condition did not cover the same.

 

13. We have gone through the treatment papers and found that huge amount was spent. Rs.2,56,000/- spent for the treatment and in addition to it petitioner had to spent huge amount for fooding, lodging and airfare. He was paying the premium from 2009 @ Rs.10,500/- per year. Treatment was covered. But O.P. Insurance company failed to provide proper service when the claim was placed. Even 40% of the major surgical operation was not given to him and also not assessed. This is unfair trade practice and deficiency of service by the O.P. Petitioner is entitled to get compensation for this. Petitioner is also entitled to get 200% of the  900  i.e., Rs1,80,000/-. Both the points are decided accordingly.

 

14. We therefore direct the O.P. to pay the petitioner the sum assured Rs.1,80,000/- and also pay Rs.15,000/- to the petitioner for his harassment as compensation. Rs.5,000/- for litigation cost. Total Rs.2 lacs. We direct the O.P. to pay the amount within 2 months. If not paid it will carry interest @9% P.A.

 

Announced.

 

 

SRI A. PAL

PRESIDENT,

DISTRICT CONSUMER  DISPUTES 

REDRESSAL FORUM,

WEST TRIPURA,  AGARTALA.

 

 

 

SMT. DR. G. DEBNATH,

MEMBER,

 DISTRICT CONSUMER DISPUTES 

REDRESSAL FORUM, 

WEST TRIPURA, AGARTALA SRI U. DAS

MEMBER,

  DISTRICT CONSUMER 

DISPUTES REDRESSAL FORUM, 

  WEST TRIPURA,  AGARTALA.