Dt. of filing- 24/08/2018

Dt. of Judgement- 16/09/2020

Mrs. Sashi Kala Basu, Hon’ble President.

          This complainant is filed  by the complainant namely Shri Uttam Kumar Das under Section 12 of the Consumer Protection Act against the  Opposite Parties ( hereinafter referred to  as OPs ) namely, (1) LIC  of India, Divisional  Office, (2) The  Manager, LIC of India, Divisional Office ,  alleging  deficiency  in service  on their part.

          Case of the  complainant in short is that  he is a LICI, Jeevan Arrogya  Policy Holder under OP No.1 being Policy No. 579521374  in which  the  total instalment  of premium  is Rs. 6289/-. Policy had also  the coverage  of the complainant’s wife  and his son and daughter. On 15.10.2017, daughter of the complainant was admitted in AMRI  Hospital , Mukundapur for  acute  urticaria treatment  and she was discharged from the Hospital on 19.10.2017. Total medical bill of Rs. 51,977.89 paise was incurred. So, complainant sent the required documents to the OP claiming the amount.  OPs have not reimbursed the medical bill. Ultimately complainant who himself is an Advocate by profession, also sent a notice on 11.05.2018 to the OP asking to pay sum of Rs. 51,977.89. But in reply  to the said notice, OP  only agreed  to pay  Rs.4200/- stating that the LICI  Jeevan Arrogya Policy is a Fixed Benefit  Health Insurance Policy  and not a Mediclaim Policy. Complainant  has suffered  mental agony and  harassments and thus the instant complaint is filed by the complainant  praying  for directing the OP to reimburse  medical bill  of Rs. 51,977.89 along with interest, to pay sum of Rs. 2,00,000/- towards the compensation for deficiency in service , Rs. 1,00,000/- for mental agony  and Rs.  15,000/- as litigation cost.

          OP have contested the case by filing written version denying and disputing the allegations made in the complaint. Specific  case of the OP is that  as  per rules  of the policy, any hospitalisation  where no surgery  is required  then the hospital cash benefit  applicable  at that point of time as per rate  opted by the customers/policy holder is paid for the  number of days of hospitalisation  minus  1^st  24 hours. The policy is a fixed Health Insurance Policy and not like Mediclaim Policy  of general insurance. So, as per the rules of the policy, complainant was entitled to an amount of Rs. 4200/- but the same was refused by the complainant. There has not been any deficiency in service on the part of the OP and thus OPs have prayed for dismissal of the complaint.

          Complainant  has   annexed with the  complaint,  letters sent by the complainant  including the notice sent  through his  Ld. Advocate to the OP,  copy of the hospital  treatment  form  submitted before  OP, copy of the renewal premium  receipt  showing  payment  of the premium  and the reply  sent by the OP in response to the  notice  sent by the complainant.

          During the course of the trial, both parties filed their respective affidavit in chief followed by filing of questionnaire and reply thereto. Ultimately, argument has been advanced. Both parties have also filed written notes of argument.

          So, the following points require determination -

1.  Whether there has been any deficiency in service on the part of the OP?
2.  Whether the complainant is entitled to the relief as prayed for ?

Decision with reasons

          Point No. 1 & 2 :

          Both the points  are taken – up together for a comprehensive discussion to avoid repetition.

          Complainant has claimed that he is a policy holder of LIC Jeevan Aroogya Policy being policy no. 579521374 and his wife, son and daughter are also covered under the policy. His daughter was hospitalised  for  5 days  for acute urticaria and  final bill of Rs. 51,977.89 was raised by the hospital. After discharge of his daughter  complainant submitted the relevant medical documents before the OP   to reimburse  the amount but  OP refused  stating that complainant  was entitled to Rs.4200/- only as per the terms and condition  of the policy.

          It may be pertinent to point out at the very outset that complainant is the LIC Jeevan Arogya Policy holder and his wife and children were also covered  under that policy is not disputed. It is also an admitted fact that the daughter of the complainant was admitted  in the AMRI  Hospital, Mukundapur for  acute urticaria treatment and bill of Rs. 51,977.89 was paid by the complainant  towards  the treatment  of his daughter. OP  has not denied that the  relevant medical documents  has been submitted by the complainant before the OP. It is  also not disputed and denied that the complainant has been paying the premium. Only contention raised by the OP is that LICI’s Jeevan Arogya  is different from other mediclaim of different insurance companies. It is a fixed benefit  health insurance policy.

          The concerned policy document highlighting terms  and condition has been  filed by the OP and on perusal of the same, it appears  that  as per the rules/terms of  the policy, policy holder is entitled to the following categories of benefits under the plan :-

1.  Hospital cash benefit.
2.  Major surgical benefit.
3.  Day care procedure benefit.
4. Other surgical benefit.
5. Ambulance benefit.
6. Premium waiver benefit.

In this case, admittedly complainant’s daughter did not undergo any surgery. So as per the policy, complainant is  entitled to daily hospital  case benefit.  It further appears  that for  hospital cash benefit rate of sum  insured  varied from 
Rs.1000/- to Rs.4,000/-. According to OP, complainant opted for Rs. 1000/-. Policy further provides that policy holder is entitled to addition of an amount  equal  to 5% of the initial daily benefit  to the applicable daily benefit the previous policy year. Policy holder is also eligible to addition  of an amount  equal  to’  ‘No claim benefit. However as per the terms of the policy, no benefit  will be payable  for the first  24 hours of hospitalisation. So according to OP complainant  is entitled to  only Rs.4200/-. But on a careful scrutiny  of the terms of the policy, it is apparent  that the terms of the policy  is against the principle of natural justice. It is an  absurd proposition   that the complainant who  is regularly  paying  premium  of Rs. 6289/-, is entitled to  only Rs. 4200/-  towards  medical expenses  even though  he has paid bill of  Rs. 51,977.89. So it can hardly  be disputed that  a term of this nature is wholly one sided, unfair and  unreasonable and thus same is nothing but an unfair  trade practice within the meaning of Section 21  of the Consumer Protection Act.

          In case of Shalabh Nigam –vs. – Orris Infrastructure  Pvt. Ltd. Hon’ble NCDRC while considering the terms of the agreement between the parties relating to compensation held that –

“ No sensible person will volunteer to accept  compensation constituting  about 2-3 % of his investment in case of delay on the part of the  contractor, when  he is  made  to pay 18% compound interest  if there is delay on his part in making payment”.

          Complainant in this  case has specifically  claimed  that he was not told  about the details of hidden  loopholes in the policy which cannot be disbelieved because  no  prudent man would  buy a policy where  premium has to be paid regularly but in return in case of exigency , a meagre amount  is allowed. So there has  been unfair trade practice  on the part of OP and thus   complainant  is  entitled to re-imbursement  of the medical bill  of   Rs.51,977/- but in the given  situation of this  case, we find no justification  to allow compensation.

Hence

                                 Ordered

          CC/523/2018 is allowed on contest. OP is directed  to pay Rs.51,977/- to complainant and further  to pay Rs.10,000/-  as  litigation cost  within  two months from the date of  this order in default entire amount  shall carry interest  @ 8% per annum till realisation.