Ld. Advocate(s)
For Complainant: Safikul Alam
For OP/OPs :Rajkumar Mandal
Date of filing of the case :11.09.2018
Date of Disposal of the case :19.03.2024
Final Order / Judgment dtd.19.03.2024
Failure to get the medical benefit claim from the opposite parties LICI led this complainant to file the present case. The concise fact of the case of the present case in a nutshell is that the complainant Prabir Kumar Roy purchased LICI Policy Jeevan Arogya Policy No.136965559 from the OP No.1 LICI, Krishnagr Branch. So, the complainant is a consumer under the OP. The said policy started from 11.02.2017 and during the continuance of the said policy the
(2)
CC/147/2018
complainant along with his family went to visit Chennai on 26.03.2017. Date of cover expiry was 11.02.2047 and date of cover option on 11.02.2026, assured sum of Rs.2,00,000/-. The complainant paid each premium to OP. On 28.03.2017 while the complainant had been travelling with his family members in Chennai suddenly, he felt illness accidentally with pain in his chest and was admitted to Chennai Apollo Hospital and undergone heart operation to save his life. For the said operation the complainant incurred Rs.2,79,305.68 only. On 04.08.2017 the complainant was under cover of Jeevan Arogya Policy. Accordingly, he applied to OP No.1 LICI, Krishnagar Branch for all cost of his treatment for bypass surgery. Some delay caused as he returned back to home after completion of treatment. On 15.09.2017 the said claim was rejected by the OP showing improper ground. The complainant, therefore, sent a legal notice through his Advocate Mr. Swapan Kumar Mondal on 14.03.2018 to which the OP replied by rejecting the claim. The said rejection amounts to unfair trade practice and deficiency in service. At the time of purchasing the policy the complainant was physically good but on 28.03.2017, he accidentally fell ill. The said policy bond was not handed over to the complainant on the date of commencement of the policy but the agent informed that the complainant will get the privilege from the date of commencement of the policy. The complainant filed documents to prove the case. The said rejection of claim is arbitrary and not according to law . Cause of action for the present case arose on and from 15.09.2017 and continued till the filing of the case. The complainant , therefore, prayed for an award for Rs.2,79,305.68 against the OP towards medical expenses, Rs.20,000/- for mental pain and agony and cost of the case.
The OP contested the case by filing W/V wherein they denied each and every allegation. The OP No.1&2 challenged the case on the ground that the present complaint is barred by special law of limitation. The positive defence case of the OPs in brief is that the complainant purchased a policy being Jeevan Arogya Policy plan no.904 from the LICI, Krishnagar Branch with date of commencement from 11.02.2017. The said plan was a Health Insurance Policy with initial daily benefit for hospitalisation of Rs.2,000/- and the sum assured was 100 times of initial daily benefit that is Rs.2,00,000/-. The complainant submitted the claim form with supporting bill for Rs.2,68,306/- continue on 04.08.2017 to the OP for hospitalisation and treatment cost for the period 28.03.2017 to 06.04.2017. As per the above policy terms and conditions the claimant is required to submit the claim within one month from the date of discharge as per item no. 19 of the policy. In the instant case
(3)
CC/147/2018
the complainant was discharged on 06.04.2017 but submitted his claim on 04.08.2017 that is after about 4 months. As per terms and conditions of the policy under item no.6 of the policy bond waiting period shall be no waiting general period for hospitalisation or surgery and there shall be general waiting period during which not benefit shall be payable in the event of hospitalisation or surgery if the said hospitalisation or surgery occurred due to sickness . The general waiting period shall be 90 days from the date of commencement in respect of each insured. In the present case the date of commencement of the policy was 11.02.2017 and date of admission in hospital is 28.03.2017 which is not beyond the said 90 days from the date of commencement of the policy. In coronary uteri bypass surgery general waiting period is 90 days . The claim was lodged on 15.09.2017 which is after the statutory period of policy condition. The OP replied to the legal notice of the complainant wherein it was clearly stated that Jeevan Arogya Policy is not a medical policy for reimbursement of the expenses due to hospitalisation. The rejection of the claim was as per privileges and condition of the policy. The treatment and surgery done were not due to any accident but it was due to sickness of the complainant which is against the conditions of the policy. The OP claimed that the case is liable to be dismissed with cost.
The reciprocal case of the parties led this Commission to ascertain the following points for consideration.
Points for Determination
Point No.1.
Whether the case is barred by limitation.
Point No.2.
Whether the complainant is entitled to get the relief as prayed for.
Point No.3.
To what other relief if any the complainant is entitled to get.
Decision with Reasons
Point No.1,2 &3.
In view of the peculiar facts of the case and the specific
(4)
CC/147/2018
defence taken by the OPs all the points are taken up together for brevity and convenience of discussion.
The opposite parties challenged the case as not maintainable on the ground that it is barred by special law of limitation. In fact, there is no special law of limitation. The law of limitation relates to time limit for filing any case in the instant case is filed within the limitation period but Ld. Defence Counsel challenged the case on the ground that it is barred by special law of limitation because the claim was raised before the expiry of 90 days which is the statutory period under the relevant policy in dispute.
In order to ascertain the said question of law the Commission considers it relevant to go into the merit of the case.
The complainant in order to substantiate the case proved the following documents in evidence:-
Annexure-1(1) is the LIC Policy no. 136965559 date of commencement 11.02.2017.
Annexure-2(1) is the Postal Receipt .
Annexure-2(2) is the legal notice issued by Swapan Kumar Mondal Advocate to the Chief Manager LICI, Krishnagar dated 07.03.2018.
Annexure-3 is the letter dated 04.08.2017 issued by the complainant to the OP.
Annexure-3(1) is the Hospital treatment form consisting of 21 pages.
Annexure-4(1) is the claim rejection letter to the complainant by the OP dated 15.09.2017.
Annexure-4(2) is the claim rejection letter dated 08.09.2017 by the Scheme Manager TPA to the LICI.
Annexure-5(1) is the claim rejection letter dated 14.03.2018 by the OP to the complainant consisting of 3 pages.
It is the admitted fact that the said policy was commenced on and from 11.02.2017. The complainant claimed to have been fell ill and medically treated at Apollo Chennai hospital where he incurred medical expenses for Rs.2,79,305.68 due to heart operation.
(5)
CC/147/2018
The OP contended that the claim is not admissible since the claim is outside the purview of the statutory waiting period. Ld. Senior Defence Counsel for the OP drew attention of this Commission that as per clause 6 of the said policy the complainant had to wait for a period of 90 days for availing the said medical benefit.
The original insurance policy is filed in the instant case wherefrom, it is revealed that as per clause 6 there shall be no general waiting period in case of hospitalisation or surgery due to Accidental Bodily Injury. There shall be general waiting period during which no benefit shall be payable in the event of hospitalisation or surgery, if the said hospitalisation or surgery occurred due to sickness . (i) The general waiting period shall be 90 days from the date of cover commencement in respect of each insured.
In the instant case the date of commencement of the policy is 11.02.2017 and the date of medical operation is 26.03.2017. So, it is within the statutory waiting period. The OP claimed that the complainant is not entitled to get the medi-claim in the instant case .
Ld. Advocate for the complainant argued that the present policy of the complainant is also covered under the benefit scheme. It is not a medical policy. The complainant suffered heart disease which is accidental.
Ld. Defence Counsel disputed the said claim on the ground that it is not an Accidental Bodily Injury. The policy was health policy. The complainant has to follow the terms and conditions of the policy. If the complainant actually fell ill within the statutory period that is after 90 days then only he is entitled to raise the claim. If the complainant had met with any accident and thereby he had incurred any medical expenses then only he could have raised the claim.
The argument has reasonable force in as much as, as per clause 6 of the said policy the general waiting period shall be 90 days from the date of commencement in respect of each insured.
In the instant case the complainant could not establish that the said operation was undergone due to Accidental Bodily Injury. The opposite parties filed some documents. As per annexure-5(1) of the complaint, being a letter issued by the OP to the complainant dated 14.03.2018, it is categorically stated about the ground for rejection on the ground that the benefits under the policy is not
(6)
CC/147/2018
directly related to the actual expenses incurred by the complainant. The claim was rejected under the code W02-not accidental claim and hospitalisation within 90 days from the date of commencement of the policy. The policy commenced on 11.02.2017 and date of admission is 28.03.2017 that is within 90 days . So, the claim is rejected.
The complainant could not establish sufficient ground that it is a case of Accidental Bodily Injury. So, the defence taken by the opposite parties are reasonable and lawful.
Ld. Senior Advocate for the complainant referred to certain case law. As per decision reported in volume I (2019) CPJ 220 Delhi it was held that critical illness:- Claim repudiated-2. It amounts to deficiency in service, since surgery was done on advise of cardiologist.
The said case law does not apply in as much as there is nothing in the said case law that there was any waiting period.
Another case law referred by the Ld. Advocate for the complainant is that in volume II (2018) CPJ 374 (NC) it was decided that if insurance company correlate the each and every decease with pre-existing condition, consumer will never succeed. Policy was renewed continuously-revision petition not justified.
The said case law does not apply because the facts of the reported case and the case in hand are completely different. In the instant case clause 6 of the insurance policy debarred the complainant from raising the claim.
Ld. Senior Advocate for the complainant referred to another decision reported in volume II (2012) CPJ 119 (NC) wherein it was held that claim repudiated due to pre-existing disease. Impugned order set aside.
The said case law does not match here because under the reported case the policy was subject to renewal in every year and continued. But in the said case there was no waiting period. Moreover, it was rejected due to pre-existing disease but in the instant case the claim of the complainant is barred due to waiting for a specific period of 90 days.
In a decision reported in volume III (2012) CPJ 44 (NC) referred to by Ld. Advocate for the complainant, it was held that respondent underwent CABG Surgery after taking insurance policy. The claim was rejected since there was pre-existing disease.
(7)
CC/147/2018
But in the reported case there was nothing about statutory waiting period unlike the instant case. So, the said case law does not apply here.
Ld. Senior Advocate for the complainant further referred to a decision reported in volume II (2009) CPJ 265 wherein it was held that risk must be held to have commenced on the date of commencement of policy.
In the reported case the date of commencement has been given emphasise it means the statutory date of commencement and statutory date of waiting period should be taken into consideration. So, the said case law does not help the complainant .
After perusing the evidence in the case record it transpires that the complainant admitted about the date of commencement of the policy and the date of undergoing operation. As per question no.9 the complainant was admitted to Apollo Hospital within 90 days from the date of commencement of the insurance policy. So, the statutory period of 90 days has not been covered.
Regard being also had to the argument of the Ld. Defence Counsel that the said terms and conditions of the OP company was duly approved by the IRDA which has not been challenged by any authority and the Commission should consider it as legal and valid.
The argument is reasonable and acceptable.
Thus having assessed the entire pleadings of the evidence in the case record vis-a-vis the observation made in the foregoing paragraph the Commission is of the view that the present claim of the complainant is barred under the statutory provisions of the policy as enumerated in clause 6 of the said policy. So, the Commission has no alternative but to accept the defence plea for rejection of the said claim.
Accordingly, point no.1,2&3 are answered in negative and decided against the complainant.
In the result the complaint case fails.
Hence,
It is
(8)
CC/147/2018
Ordered
that the complaint case no.CC/147/2018 be and the same is dismissed on contest without cost.
All Interim Applications (I.A) stand disposed of accordingly.
D.A to note in the trial register.
The case is accordingly disposed of.
Let a copy of this final order be supplied to both the parties at free of costs.
Dictated & corrected by me
............................................
PRESIDENT
(Shri HARADHAN MUKHOPADHYAY,) ................ ..........................................
PRESIDENT
(Shri HARADHAN MUKHOPADHYAY,)
I concur,
........................................
MEMBER
(NIROD BARAN ROY CHOWDHURY)
