Delhi

East Delhi

CC/46/2014

MANGE RAM - Complainant(s)

Versus

LIC OF INDIA - Opp.Party(s)

24 Jan 2018

ORDER

          DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, EAST, Govt of NCT of Delhi

              CONVENIENT SHOPPING CENTRE, 1^st FLOOR, SAINI ENCLAVE, DELHI 110092  

 

                                                                                                   Consumer complaint no.         46/2014

                                                                                                   Date of Institution              13/01/2014

                                                                                                   Order reserved on               24/01/2018        

                                                                                                   Date of Order                       29/01/2018                                                                                     

 

In matter of

Mr Mange Ram, adult   

s/o- Sh Ved Prakash

R/o- HN A-510, New Ashok Nagar, Delhi 110096…...…………….Complainant

                             

                                      Vs

The Manager/ Director

Life Insurance Corporation of India,   

District Branch Office,

Laxmi Nagar District Centre, Delhi1100902 …………….…………..Respondent

 

Complainant  Advocate…………………..Mr Puneet Tandon   

Opponent Advocate………………………..Md. Mansi Bajaj   

 

Quorum   Sh Sukhdev  Singh       President

                  Dr P N Tiwari                Member

                  Mrs Harpreet Kaur      Member                                                                                              

 

Order by Dr P N Tiwari  Member  

Brief

This complainant has been filed u/s 12 of C P Act, 1986 against OP for alleged deficiency in their services for refusing death claim against the policy.

Facts of the case                                                                                                

Complainant  purchased LIC Jeevan Arogya policy from OP/LIC vide policy no. 256782263 and 256782261 on 12/08/2014 after filling policy proposal form (Ex CW1/1) and receipt of payment (Ex CW1/1A)  with policy schedule.

Complainant was paying annual premium of Rs 6854/-up to Aug. 2013. On 18/01/2013, complainant felt sever pain and congestion so was admitted at Metro Hospital, Noida and was discharged on 21/01/2013. It was stated that the said hospital was on the panel of OP still denied cashless facility to the complainant, hospital bill of 2,28,438/-was paid by the complainant. Complainant approached OP on 18/01/2013 (para 19 of complaint) for paying amount Rs 2 lacs as he was sum insured for 2 lacs.  It had been stated that despite of repeated visit to OP office, no relief was provided by OP. Seeing Because of as unfair and illegal of OP, complainant filed this complaint claiming refund of premium amount Rs 2 lacs with 18% and compensation Rs 2 Lacs for harassment and litigation cost Rs 55000/-.

After receiving notice, OP submitted written statement denying all the facts and allegations of deficiency in services and justified their repudiation of death claim. It was admitted that complainant had purchased LIC’s Jeevan Arogya Non linked Health Insurance Plan policy vide UIN 512N266V01 (table 903) and after reading all terms and conditions had put his signature under ‘Declaration’ on dated 28/02/2013 from Noida (Ex OPW2).

Complainant had submitted his Claim Discharge Form under ‘Full and Final Settlement’ of hospital bills and had given his bank details also. It was also submitted that as per discharge summary details (Anne. 4), complainant was suffering from SVD (single vessel diseases) and was treated for the same ailment, but not covered under the list of major surgeries. Only under sub clause 12, it was payable to 40% of HCB and NOT to SA as presumed by the complainant.

It was submitted that after scrutinizing the discharge summary of treating hospital dated 21/01/2013 (Ex. OP Anne-4), complainant was diagnosed as a case of “CAD Coronary Artery Disease” where CAG was done followed by PTCA/STENT to proximal RCA in case of LVEF 60% and TPA paid claim amount as per the policy terms and conditions to sum Rs 11560/- as HCB for time spent in ICU Rs 3150/- and OSB (PTCA to RCA in SVD) to Rs 8400/-on 05/04/2014.

OP submitted that their all annexures 01 to 10 were on record. As the said policies were in the second year, so had 5% bonus plus hospital cash benefit (Ex OPW1/1). Due to increase of 5% in HCB and Hospital cash benefit Rs 1050/-were calculated and was informed to the complainant and cheque of a sum of 11550/-was prepared, but complainant did not collect so it was paid through online in the account of complainant on 18/11/2013 though there many mistake in dated and OP had omitted number of mistakes in writing the complaint.

It was also submitted that TPA had informed complainant about the amount cleared for reimbursement under the policy terms and same was intimated to the divisional office at Meerut vide dated 27/04/2013.

Complainant filed his rejoinder and denied all the replies submitted by OP and stated that contents of his complaints were correct and true. He submitted his own affidavit and reaffirmed that all evidences were true and submitted on record.

OP also submitted their evidence on affidavit through Mr D K Joshi, Manager Legal with OP and reaffirmed on oath that all their evidences were on record and amount paid to the complainant through online were as per the terms and conditions of the policy and there was no deficiency on their services. It was also submitted that complainant had thoroughly and fully had read the contents of the policy terms and conditions and had put his signature on it. He had also received amount on full and final settlement basis. Hence there was no deficiency and this complaint be dismissed.  

 

Arguments were heard from both the party counsels and order was reserved.

Appreciating arguments of complainant’s counsel who stressed on reimbursement of hospital bill more than 2 lacs as sum insured presuming to be a ‘mediclaim policy’, OP was totally  deficient in their services for not passing the genuine claim, so we scrutinizing all the facts and evidences on record and specifically the terms and conditions applicable to this policy under Ex OPW1/1 under the heads -‘Major surgeries having sub head as Cardio vascular System s.n. 12 which reads as–“Coronary Angioplasty with STENT implantation (two or more than two coronary arteries must be stented)-  would get  40% of Sum Insured policy  value and would come under category 3, in this case, one stent was implanted in LVEF 60% as good ejection volume ratio and BP 120/30 mmHg, so it was not a critical case as per the terms and conditions. The complainant was a non smoker and non diabetic and was diagnosed as case of Ac IWMI in discharge summary.

OP had rightly calculated HCB and bonus in second year policy 5% in HCB, so hospital cash benefit Rs 1050/-and Rs 8400/-as ICU stay was calculated and was duly informed to the complainant about cheque amount Rs 11550/-was paid through online in the account of complainant on 18/11/2013.

OP had issued policy after complainant had filled the policy proposal form and had put his signatures of Declaration form and receiving premium amount.

The said policy was renewed also, but after scrutinizing the first policy receipt with terms and conditions, it was seen said LIC policy commenced from 12/08/2011 and with yearly premium of Rs 6854/-, the tenure of the policy was up to 12/08/2048; meaning thereby said policy tenure is up to 12/08/2048.

There was a provision to give additional benefit in case complainant gets ill and remains admitted in the hospital, then under the ‘Benefit’ clause(a) would get Rs 1000/- in non ICU for “Bodily Injury, sickness” where more than 4 hours or 24 hours stay was required. Under “ICU conditions, HCB would be double ie Rs 2000/-. In case, if hospital stays increases more than seven days, than no HCB would be applicable.

Thus, we come to the conclusion that complainant could not understand the additional benefits provided by OP in this policy. After receiving applicable benefits, filed this complaint with lots of typographical mistakes. We do not find any deficiency in the services of OP by any evidences in complaint. As additional benefits were already received in case of continuous of tenure of policy up to 2048, so there are no merits in this complaint and deserves dismissal with cost, but in the interest of justice, cost on complainant is waived off and complaint is dismissed without any order to cost.  

The copy of the order be sent to the parties under the Regulation 18 of the Consumer Protection Regulation 2005 (in short the CPR) and the file be consigned to Record Room under regulation20(1) of the CPR.

 

(Dr) P N Tiwari  Member                                                                       Mrs  Harpreet Kaur  Member                                                    

                                      

                                                    Sukhdev Singh  President