Punjab

Sangrur

CC/326/2021

Anita Garg - Complainant(s)

Versus

LIC of India - Opp.Party(s)

Sh. Yashwinder Singh

03 Jun 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SANGRUR .

                                                                        Complaint No. 326

 Instituted on:   01.03.2021

                                                                         Decided on:     03.06.2024

 

Anita Garg aged 60 years w/o Sh. Parmod Kumar C/o Toran Model High School, Ward No.4, Hanzara Marg, Sunam, District Sangrur.

                                                         …. Complainant.     

                                                 Versus

1. LIC of India, Branch Railway Road, Sangrur through its Branch Manager.

2. LIC of India, Divisional Office, Jeevan Prakash Building, Sector-17-B, Chandigarh through Sr. Divisional Manager.

                                                        ..Opposite parties

 

For the complainant  :       Shri Yashwinder Singh, Adv.

For Opp.parties         :       Shri Amit Goyal, Adv.

 

Quorum                                          

Jot Naranjan Singh Gill, President

Sarita Garg, Member

                        Kanwaljeet Singh, Member

ORDER

SARITA GARG, MEMBER

1.             Complainant has preferred the present complaint against the opposite parties  on the ground that she is the consumer of the OPs on the ground that she had obtained one Mediclaim policy namely Jeevan Arogya bearing number 165917089 from OP number 1 by paying the requisite premium of Rs.12582/- on 14.5.2016. It is further averred that the policy in question is a fixed medical benefit policy with initial daily benefit limit of Rs.4000/- alongwith Major surgical benefits and other surgical benefits. It is further averred that during the subsistence of the insurance policy in question, complainant suffered chest pain/pain in rib cage area and consulted doctor at Baba Barsiana Sahib Charitable Hospital Dirba, Tehsil Sunam who advised to take medicine for five days, but the complainant did not got any relief, as such the doctor advised her to get CT scan beside other laboratory tests, which was got done. After inspection of the CT scan report, complainant was advised to take consultation from Cancer Hospital Sangrur as a cyst was found around the rib cage area of complainant. As such, the complainant visited Tata Memorial Cancer Hospital, Sangrur on 9.1.2019, but no malignancy was found.  Further case of complainant is that thereafter she visited DMCH Ludhiana on 17.01.2019, where some tests were conducted and the complainant was admitted on 21.01.2019 and was discharged on 22.1.2019, where she incurred an expenditure of Rs.33,746/- on her treatment. The complainant lodged the claim on 20.4.2019 with the OPs and submitted all the bills and treatment record in respect of above mentioned surgical procedure/treatment. As such, it is stated that the complainant remained admitted for a period of one day and is entitled for HCB to the tune of Rs.4000/- and Major Surgical Benefit i.e. MSB to tune of Rs.80,000/- thus, she is entitled for a sum of Rs.84,000/- from the OPs.  The complainant visited the Ops so many times for settlement of the claim, but the claim was not settled rather repudiated the claim vide letter dated 6.8.2019 by OP number 2  on the ground that the patient is a known case of hypertension since 9 years and diabetes mellitus since 3 years, but the same was not disclosed at the time of proposal, whereas complainant was neither suffering from hypertension or diabetes mellitus, nor she was taking any medicine for the same. The complainant though requested the OPs to settle the claim of the complainant, but all in vain. Thus, alleging deficiency in service on the part of the OPs, the complainant has prayed that the OPs be directed to pay to the complainant the claim amount of Rs.84,000/- alongwith interest @ 18% per annum and further claimed compensation and litigation expenses.

2.             In reply filed by OPs, preliminary objections are taken up on the grounds that the complaint is not maintainable, that the complainant has not come to this Commission with clean hands and has suppressed the material facts, that the complainant has dragged the OPs into unwanted litigation. On merits,  it is admitted that the complainant obtained one  fixed medical benefit policy and a fixed amount is payable for hospitalisation under the plan subject to terms and conditions of the policy. It is admitted that the claim was lodged by the complainant, but the OPs repudiated the claim of the complainant on the basis of medical record and evidence. It has been established that complainant had been suffering from Diabetes Mellitus-type 2 for the last 3-4 years and hypertension for the last 8-9 years, but she did not disclose these facts at the time of making the proposal and has obtained the policy in question by playing fraud upon the OPs. It is stated further that claim of the complainant was repudiated and policy was declared void w.e.f. 23.7.2020 vide letter dated 27.7.2020 on the grounds mentioned in the letter dated 6.8.2019. The other allegations levelled in the complaint have been denied in toto. Lastly, OPs have prayed that the complaint be dismissed with special costs.  Any deficiency in service on the part of the OPs has been denied.

3.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-15 copies of documents and affidavit and closed evidence. On the other hand, the learned counsel for OPs has produced Ex.OPs/1 to Ex.OPs/9 copies of documents and affidavit and closed evidence.

4.             We have perused the record and heard the learned counsel for the parties.

5.             The learned counsel for the complainant has argued vehemently that she had obtained one Mediclaim policy namely Jeevan Arogya bearing number 165917089 from OP number 1 by paying the requisite premium of Rs.12,582/- on 14.5.2016. Learned counsel for the complainant has further contended that during the subsistence of the insurance policy in question, complainant suffered chest pain/pain in rib cage area and consulted doctor at Baba Barsiana Sahib Charitable Hospital Dirba, Tehsil Sunam who advised to take medicine for five days, but the complainant did not got any relief, as such the doctor advised her to get CT scan besides other laboratory tests, which were got done. After inspection of the CT scan report, complainant was advised to take consultation from Cancer Hospital Sangrur as a cyst was found around the rib cage area of complainant. As such, the complainant visited Tata Memorial Cancer Hospital, Sangrur on 9.1.2019, but no malignancy was found.  Further learned counsel for the complainant has contended that case of complainant is that thereafter she visited DMCH Ludhiana on 17.01.2019, where some tests were conducted and the complainant was admitted on 21.01.2019 and was discharged on 22.01.2019, where she incurred an expenditure of Rs.33,746/- on her treatment. The complainant lodged the claim on 20.04.2019 with the OPs and submitted all the bills and treatment record in respect of above mentioned surgical procedure/treatment. As such, it is stated that the complainant remained admitted for a period of one day and is entitled for HCB to the tune of Rs.4000/- and Major Surgical Benefit i.e. MSB to tune of Rs.80,000/- thus, she is entitled for a sum of Rs.84,000/- from the OPs.  Further the learned counsel for the complainant has contended that the complainant visited the Ops so many times for settlement of the claim, but the claim was not settled rather repudiated the claim vide letter dated 6.8.2019 by OP number 2  on the ground that the patient is a known case of hypertension since 9 years and diabetes mellitus since 3 years, but the same was not disclosed at the time of proposal, whereas complainant was neither suffering from hypertension or diabetes mellitus nor she was taking any medicine for the same, as such has prayed that the complaint be accepted.

6.             On the other hand, the learned counsel for the OPs has contended vehemently that the complainant obtained one  fixed medical benefit policy and a fixed amount is payable for hospitalisation under the plan subject to terms and conditions of the policy. It is admitted that the claim was lodged by the complainant, but the OPs repudiated the claim of the complainant on the basis of medical record and evidence. It has been further contended that the complainant was suffering from Diabetes Mellitus-type 2 for the last 3-4 years and hypertension for the last 8-9 years, but she did not disclose these facts at the time of making the proposal and has obtained the policy in question by playing fraud upon the OPs. It is stated further that claim of the complainant was repudiated and policy was declared void w.e.f. 23.07.2020 vide letter dated 27.07.2020 on the grounds mentioned in the letter dated 6.8.2019. Lastly OPs have contended that the complaint be dismissed.

7.             To support her case, the complainant has produced Ex.C-2 copy of the insurance policy which is valid for the period from 14.5.2016 to 14.5.2039. Ex.C-3 is the copy of OPD slip dated 2.1.2019 of the Baba Barsiana Sahib Charitable Hospital, Dirba, which shows that the complainant Anita Garg visited there, where doctor advised medicine for five days and this report is accompanied by various documents and reports etc. Ex.C-4 is the copy of final bill dated 22.01.2019 issued by Dayanand Medical College and Hospital, Ludhiana where the complainant remained admitted for one day, where she spent an amount of Rs.33746/-. Ex.C-5 is the copy of claim form submitted to the OPs for payment of the claim. Ex.C-6 to Ex.C-7 are the copies of letters issued to the Ombudsman (Insurance) by the complainant and Ex.C-8 is reply thereto sent by the office of the Insurance Ombudsman on 19.7.2019. Ex.C-9 is the copy of letter issued by the OPs whereby the claim was repudiated on 06.08.2019 on the ground that the patient is a known case of hypertension since 9 years and diabetes mellitus since three years.  On the other hand, the stand of the OPs is that as per Ex.OP-4 discharge summary it is mentioned in the column ‘treatment given’: PT was admitted with various complaints and patient was evaluated with complete history, examination and investigations. Patient was advised surgery and underwent excision biopsy with sternal stable condition.  But record reveals that the OPs have not produced any cogent, reliable and trustworthy evidence on record to show that the complainant ever suppressed any material information regarding any pre-existing disease suffered by the complainant. It is worth mentioning here that the complainant took the policy in the year 2016 but suffered problem in the year 2019 after a period of about three years. As such, it cannot be said that the complainant is not entitled for any claim or was suffering any pre existing disease. The complainant has claimed an amount of Rs.80,000/- being major surgical benefit, but we are unable to accept such a contention of the learned counsel for the complainant and found that the complainant is not entitled for the claim to such an extent. However, the complainant has produced Ex.C-4 copy of final bill issued by Dayanand Medical College and Hospital Managing Society for Rs.33746/-. As such, we feel that ends of justice would be met if the OPs are directed to pay to the complainant an amount of Rs.33746/-. The complainant is also entitled for an amount of Rs.4000/- being initial daily benefit as the complainant remained admitted for one day. Accordingly, we find it to be a case of deficiency in service on the part of the OPs.  

8.             In view of our above discussion, we allow the complaint and direct OPs to pay to the complainant a total amount of Rs.37,746/- (Rs.33746/- + Rs.4000/- being initial daily benefit) alongwith interest @ 7% per annum from the date of filing of the present complaint i.e. 01.03.2021 till realisation. Further OPs are directed to pay to the complainant an amount of Rs.3000/- as compensation for mental tension, agony and harassment and further an amount of Rs.3000/- on account of litigation expenses. This order be complied with within a period of sixty days of receipt of copy of this order.

9.             The complaint could not be decided within the statutory time period due to heavy pendency of cases.

10.           Copy of this order be supplied to the parties free of cost. File be consigned to the records after its due compliance.  

                        Pronounced.

                        June 3, 2024.