West Bengal

Birbhum

CC/52/2019

Sanjoy Pal - Complainant(s)

Versus

LIC, Branch Manager, LICI, Suri Branch - Opp.Party(s)

30 Apr 2024

ORDER

Shri Sudip Majumder- President-in-Charge.

            The complainant/petitioner files this case U/S 12 of Consumer Protection Act, 1986. The fact of the case in brief is that one Sri Sanjoy Pal, by profession- Assistant Teacher, permanent resident of Suri Rabindrapally, P.O. and P.S.- Suri, District-Birbhum who purchased LIC’s Jeavan Arogy (Table 903) policy for himself, his wife and his son. Policy No. 469968339, date of commencement of policy which was 15/05/2012 and by this way the complainant/insured became a consumer/customer under the OP No.1/LICI and yearly premium was Rs. 5603.

            Initial Daily Benefit Rs. 1,000/- for each policy holder, date of cover expiry under Basic plan 15/05/2049.

            It is the further case of the complainant that after insuring, the insured was met with an accident on 10/08/2018 and went to treat himself at Mission Hospital, Durgapur and he was also admitted on 12/08/2018 and operated proximal tibia facture on 14/08/2018 and released the complainant/insured from the said hospital on 17/08/2018. And for that treatment the complainant also incurred a cost of Rs. 1,48,169/- (One lack forty eight thousand one hundred sixty nine only).

            It is the next case of the complainant that after treatment the complainant/insured returned to his house and thereafter the complainant/insured lodged his legitimate claim amounting to Rs. 1,08,806/- (One lack eight thousand eight hundred six only) before the insurance company along with all relevant papers in original.

 

(Page 1 of 4)

 

           

It is the specific version of the complainant that the OP/Insurance Company finally paid Rs. 19,600/- instead of Rs. 1,08,806/-to the complainant and repudiated the claim (partly) of the complainant/insured.

            Hence, after finding no other alternative the complainant is compelled to file this complaint before this Forum/Commission for proper relief and prays for:

1. An order/direction to this OP to pay the claim amount i.e. Rs. 89206/- to this petitioner along with interest.
2. An order/direction to this OP to pay Rs. 30000/- as compensation to this petitioner.
3. An order/direction to this OP to pay Rs. 20000/- as cost for harassment and mental agony to this petitioner.
4. An order/direction to this OP to pay Rs. 10000/- as litigation cost.
5. Any other relief/reliefs as the petitioner are entitled too.

The OP No. 1/LICI, Suri Branch has contested the case by filing written version denying all material allegation of the complainant and stated that there was no deficiency in service on the part of the OP No. 1/LICI and the case is not maintainable, either in law or in fact.

OP No. 1/LICI stated in Para 5 of their written version as “….the complainant Mr. Sanjoy Pal did not opt for accident benefit rider and term assurance rider as reveals from his proposal forms (last column of question No. 1) which are also event from the front page of the original policy bond. Accordingly OP LIC of India not charged any extra premium for Accident Benefit rider & Term Rider. The said policy was purchased by the complainant for certain percentage of major surgical benefit Sum Assured stated in item No. 1. (xxix) under conditions and privilege of the policy.”

OP No. 1/LICI further stated in Para 13 of their written version as “ ….LIC Jeevan Arogya (Table-903) is a FIXED BEBEFIT Health Insurance Policy and it is not a Mediclaim Policy at all. Claim amount for Jeevan Arogya Policy is determined on the basis of benefits stated in the conditions and privileges of the policy which is fixed at the time of inception of the policy. Hence no question arises to reimburse gross hospital treatment expenses.”

Ultimately the OP No. 1/LICI prayed for dismissal of the case.

            Both the parties submitted written notes on argument (W/N/A). Some documents have also been filed by the complainant’s side and compared with original documents. Thereafter, Ld. Advocates for the OP No. 1/LICI also submitted some documents with Firisti.

            Heard Ld. Advocates for both sides.

            Considered.

            Perused all the documents.

(Page 2 of 4)

 

Points for determination/Issues

1.  Whether the complainant is a consumer as per definition of the term ‘Consumer’ of the C.P Act. ?
2. Whether this Commission has jurisdiction to try this case?
3. Whether there is any deficiency in service on the part of the Ops?
4. Whether the complainant is entitled to get any other relief or reliefs as prayed for?

Decision with reasons

Point No. 1:

            In this case, the complainant purchased LIC’s Jeavan Arogya (Table - 903) from the                   OP No. 1/LICI being Policy No. 469968339 on payment of proper fees of this policy. Thus the complainant is a consumer under the OP/LICI and the OP No. 1/LICI is the service provider. Hence, the complainant is a consumer as per Sec. 2(1)d(ii) of the Consumer Protection Act, 1986.

Point No. 2:

            Pecuniary jurisdiction of this Forum/Commission as per Sec. 11(1) of the Consumer Protection Act, 1986 i.e. Rs. 20,00,000/-. OP No. 1/LICI, Suri Branch situated in Birbhum District i.e. within the territorial jurisdiction of this Forum/Commission as per Sec. 11(2) of the Consumer Protection Act, 1986. So, this Forum/Commission has territorial and pecuniary jurisdiction.

In this case, the cause of action arose from 20/03/2019 and the case has been filed on 30/05/2019 and as such it can be said that the complainant has been filed in this case within the statutory period of the C.P. Act, 1986 and, as such, the instant complaint is not barred by limitation U/S 24A of the C.P. Act, 1986.

Point No. 3:

It appears from the documentary evidence as available in the case record that after the accident, the complainant was admitted on 12/08/2018 in Mission Hospital, Durgapur for operation of proximal tibia fracture in his left leg. He was discharged on 17/08/2018 and his legitimate claim was of Rs. 1,08,806/-. Out of this claim the OP No. 1 paid only Rs. 19,600/- to the complainant through Bank and the remaining amount of claim was repudiated by the OP No. 1/LICI.

Our observation:

The complainant purchased LIC’s Jeavan Arogya Policy (Table -903). From the copy of the Policy Bond we came into know that the date of commencement of the said policy was 15/05/2012. The complainant paid Rs. 5603/- as yearly premium for 3 persons. Out of which he paid only Rs. 2990.27/- as yearly premium for himself. The complainant did not opt for accident benefit rider and term assurance rider. Accordingly, the OP No. 1/LICI not charged any extra premium for accident benefit and terms assurance. Thus, the complainant paid a nominal or a minimum premium for the policy in question.

(Page 3 of 4)

 

Moreover, the LIC’s Jeavan Arogya Policy (Table -903) is not a Mediclaim Policy. So, the complainant is not entitled to get the entire claim of his treatment. In case of Mediclaim Policy there exists a sum assured amount and insured entitle to get claim as per the sum assured of his policy. From the policy bond we came into know that Initial Daily Benefit for each insured was Rs. 1000/- only. So, this is a Fixed Benefit Health Insurance Policy not a Mediclaim Policy at all. Claim amount for the LIC’s Jeavan Arogya Policy is determined on the basis of benefits stated in the conditions and privilege of the policy which was fixed at the time of inception of the policy. The general rule is that the lower the premium, the lower the claim.

The consumer brought the policy anyway knowing or without knowing the policy conditions. In this case, the consumer cannot get the full medical expenses as in a Mediclaim policy. There is also no evidence as to what the agent/OP No. 2 explained to the complainant at the time of purchasing the policy.

Hence, there is no deficiency in service on the part of the OP members.

Point No. 4:

            From the above discussion it is proved that there is no deficiency in service on the part of the OP members. So, the complainant is not entitled to get the claim as prayed in the instant case.

            In that analogy, we are sorry not to accede to the prayer made by the complainant in this case. So, the case fails.

Hence, it is,

            O R D E R E D,

                                        that the instant C.F. Case No. 52/2019 be and the same is dismissed on contest but without any cost.

The instant case is thus disposed of.

Let a copy of this order be given/handed over to the parties to this case free of cost.