| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BATHINDA C.C. No. 270 of 24-07-2015 Decided on : 21-02-2017 Raj Kumar S/o Sh. Charan Dass, R/o H. No. 19251, Street No. 6, Guru Teg Bahadur Nagar, Bibiwala Road, Bathinda. …...Complainant Versus Life Insurance Corporation of India, Jeevan Parkash, Urban Estate, Phase-I, Ludhiana, through its Senior Divisional Manager Life Insurance Corporation of India, Jeevan Jyoti Building, Bibiwala Road, Bathinda, through its Senior Manager
.......Opposite parties Complaint under Section 12 of the Consumer Protection Act, 1986. Quorum : Sh. M.P.Singh. Pahwa, President Sh. Jarnail Singh, Member Present : For the complainant : Sh. Ramji Dass, Advocate. For the opposite parties : Sh. Sanjay Goyal, Advocate. O R D E R M. P. Singh Pahwa, President Raj Kumar, complainant (here-in-after referred to as 'complainant') has filed this complaint under Section 12 of the Consumer Protection Act, 1986 (here-in-after referred to as 'Act') against LIC of India, Ludhiana and another (here-in-after referred to as 'opposite parties'). Briefly stated the case of the complainant is that LIC agent Sh. Raghubir Singh, agency code No. 3847-174 approached him and allured about the benefits of Health Plus LIC by mis-representation of facts. He insisted the complainant to purchase policy of the same. The complainant having been induced by tall claims made by the insurance agent/advisor of the opposite parties, purchased a LIC policy (Health Plus) for himself and his wife having Plan No. 901-20 for total sum of Rs. 3,00,000/-. He paid yearly premium of Rs. 19,500/-. The proposal form was filled by Raghbir Singh LIC agent. All the details regarding health and medical information was also incorporated in the proposal form before/in the presence of Dr. R K Madan, MBBS, MD, Madan Nursing Home, Bathinda, authorized medical examiner of LIC of India under his seal and signatures on the proposal form. The signatures of the complainant were obtained on various blank printed forms without explaining contents of the same to the complainant. Subsequently policy certificate/Cover No. 301871075 dated 31-12-2009 was sent to the complainant. It is pleaded that on 20-7-2014, the complainant suddenly slipped down from the stairs in his house and suffered from acute alignment tear. He was immediately taken to Dr. Wadi's Multi-Speciality Hospital where he was provided first-aid. He was subjected to various tests. Since the condition of the complainant was critical, he was referred to some higher medical institution/hospital for further consultation and treatment. As advised by Dr. Wadi, he was taken to Fortis Hospital, Noida for medical advice and treatment. The complainant was got admitted there. The tests required were under taken but keeping in view the expensive treatment at Fortis Hospital and being unable to afford the said expenses, the complainant came back and got himself admitted in Cheema Medical Complex/Hospital. He underwent major operation for left secondary arthritis left subtaiar joint/C/ODM on 28-8-2014. Then again on 24-11-2014 and 25-11-2014 for Ex-fix stabilization with ring fixator removal. The complainant spent a total sum of Rs. 1,32,999/- for his operation and treatment including medicines besides other misc. expenses of travelling, attendants and special diet etc., It is further pleaded that complainant submitted his medical claim bill for a sum of Rs. 1,32,999/- with the opposite party No. 2 at Bathinda and requested the opposite parties to honour his lawful claim at the earliest. The opposite party No. 2 sent case file of complainant to Senior Manager, LIC, Ludhiana but instead of honouring the claim, he received document i.e. deficiency letter No. LIC/MAIPL/Claim No. 11401 dated 12-01-2015 from M/s. Medi Assist India TPA Pvt. Ltd.. with the following objections :- (a) Past History (duration) of Hypertension and diabetes (since how many years the patient is suffering from this ailment) from the Hospital. (b) First consolidated reports from the hospital when diagnosed with HTN and diabetes. (c) Self declaration from the insured narrating the complete details of injury (where, why, when, how time place and time) (d) Confirmation from the treating doctor whether the patient was under the influence of alcohol at the time of accident. On the very next date, another notice dated 13-1-2015 (claim rejection letter ) from M/s. Medi Claim was received rejecting the claim of Rs. 20,000/- with the objection that total hospitalization period is 52 hours or less and surgeries not listed in the allowed surgeries, but this was without giving any opportunity of hearing to the complainant. Vide letter/reminder No. LIC/MAIPL/Claim No. 11401 dated 5-2-2015, complainant was asked to supply certain documents/information whereas no such reference was received from the office of LIC. In response to this letter, the complainant submitted the requisite information in the office of opposite party No. 2 on 16-2-2015 but MA India Pvt. Ltd., rejected the whole claim of Rs. 1,32,000/- vide its letter dated 20-02-2015 with the remarks that the policy holder is not supplying/providing required details even after repeated reminders, hence the claim is rejected instead of keeping it open indefinitely. All the requisite information had already been furnished/submitted by the complainant to opposite party No. 2 at Bathinda. Even otherwise non supplying of any document as required by the opposite parties, as alleged in the letter, claim of the complainant at the most could have been kept pending and could not have been rejected/repudiated. The complainant again visited the office of LIC, Bathinda and submitted required information but with an ulterior motive to grab his rightful medical claim, vide letter dated 4-5-2015 Medi Assist India Pvt. Ltd., has rejected his medical claim with the objection that injuries self inflicted condition (attempted suicide) under the use of drug or misuse of drug or alcohol without going through the information/record. It is alleged that the opposite parties have concocted a false story only in order to avoid their liability to honour his lawful claim and to wriggle out of their liability. The complainant had sustained injuries accidentally due to fall in the stairs. No adverse remarks were given by the attending doctor who provided treatment to the complainant. On this backdrop of facts, the complainant has alleged deficiency in service on the part of the opposite parties. He has prayed for directions to the opposite parties to reimburse his medical insurance claim of Rs. 1,32,999/-. The complainant has also claimed Rs. 50,000/- as compensation on account of mental tension, agony, botheration and harassment in addition to Rs. 5500/- as litigation expenses. Hence, this complaint. Upon notice, the opposite parties appeared through counsel and contested the complaint by filing their joint written reply. In written reply, the opposite parties raised legal objections regarding locus standi, cause of action, concealment of material facts. It is further pleaded that complaint is frivolous and without any merit. Allegations of deficiency are false and baseless. That the complaint is bad for non-joinder of necessary parties. The third party administrator M/s. Medi Assist India TPA Private Limited has not been impleaded as party which was necessary party. On merits, it is denied that complainant was allured for the purchase of insurance policy or his signatures were obtained on blank papers. All other averments are also denied. It is denied that complainant submitted all the documents as desired by the opposite parties. As per opposite parties, the true facts are that two different claims were lodged by the complainant i.e. one claim No. 11401 which was for Rs. 1,32,999/- and second claim No. 11402 for Rs. 20,000/-. As per IRDA rules, the opposite parties have appointed M/s. Medi Assist India TPA Pvt. Limited as Third Party Administrator which is mandatory for Insurance Companies. Since TPA has been introduced by IRDA for the benefit of both the insurer and insured, it is mandatory to settle the claim as per TPA recommendations viz a viz policy conditions. The Third Party Administrator is an independent body. After receipt of information from complainant, the opposite parties referred the matter to TPA and they are bound to the recommendation of TPA. Whatever documents were sent by complainant to LIC of India were referred to TPA. The claim No. 11402 for Rs. 20,000/- was rejected by TPA as after scrutinization of claim papers with regard to the eligibility of terms of policy terms and conditions and after investigating into the details of hospitalization, nature of ailment etc., As regards another claim No. 11401 of Rs. 1,32,999/-, the TPA demanded certain documents from complainant time and again. Various reminders dated 12-1-2015, 23-1-2015 and 5-2-2015 were issued to complainant but he failed to comply with the same. Ultimately on 20-2-2015, TPA after scrutinization of claim papers with regard to eligibility in terms of policy terms and conditions and after investigating into the details of hospitalization, nature of ailment etc., came to conclusion that complainant is not eligible for the claim as it does not fall under the purview of policy conditions. The policy holder not complying with the required details even after repeated reminders. Hence, claim is rejected instead of keeping it open indefinitely and further the surgery was not listed in the allowed surgeries. It is asserted that rejection of claim by TPA is legal and valid in all respect and is binding upon the opposite parties as well as upon the complainant. It is further mentioned that complainant was admitted to Cheema Medical Complex with history of twisting injury one month age. From the history given by the treating doctor it is known that the patient is a chronic alcoholic (abuse 250 ml/day). The injury under the influence of alcohol cannot be ruled out. As such, claim was repudiated. All other averments of the complainant have been denied. In the end, the opposite parties prayed for dismissal of complaint. Parties were afforded opportunity to produce evidence. In support of his claim, complainant has tendered into evidence photocopy of legal notice (Ex. C-1), postal receipts (Ex. C-2 to Ex. C-6), photocopy of letters (Ex. C-7 to Ex. C-10), photocopy of policy (Ex. C-11 & Ex. C-12), photocopy of letter (Ex. C-13), affidavit dated 19-10-2015 of complainant (Ex. C-14), photocopy of outpatient receipt (Ex. C-15 to Ex. C-19), photocopy of retail invoice (Ex. C-20 & Ex. C-21), photocopy of receipts (Ex. C-22 to Ex. C-29), photocopy of retail invoice (Ex. C-30 to Ex. C-37) and photocopy of receipt (Ex. C-38). In order to rebut this evidence, opposite parties have tendered into evidence affidavit dated 15-9-2015 (Ex. OP-1/1), photocopy of insurance policy (Ex. OP-1/2), photocopy of terms and conditions (Ex. OP-1/3), photocopy of letters (Ex. OP-1/4 and Ex. OP-1/4) and closed the evidence. We have heard learned counsel for the parties and gone through the record. Learned counsel for complainant has submitted that complainant has raised matter only for the claim regarding treatment dated 26-8-2014 to 30-8-2014 availed from Cheema Medical Complex/Hospital. The total bill submitted was for Rs. 1,32,999/- only . All the relevant documents were supplied to the opposite parties. The opposite parties have referred to another claim registered vide No. 11402 but the complainant has not raised any concern with that matter. The controversy is only regarding bill amounting to Rs. 1,32,999/-. The opposite parties have rejected the claim vide letter dated 20-2-2015 and then on 04-05-2015 (Ex. C-9 & Ex. C-10). The claim was rejected by observing that the injury self afflicted or conditions (attempted suicide) and or the use or misuse of any drugs or alcohol. The second ground to justify the rejection is that Surgeries not listed in the allowed Surgeries. The complainant was not made aware about any exclusion. Therefore, these conditions cannot be applied against the complainant. There is nothing on record to prove that injuries are self afflicted or result of use or misuse of any drugs or alcohol. Therefore, the order of rejection of claim is not justified and is liable to be set aside. The opposite parties have repudiated the claim without any justification. It amounts to deficiency in service. The complainant is entitled to reimbursement of amount as well as compensation amounting to Rs. 50,000/- for mental harassment etc., It is further submitted by learned counsel for the complainant that opposite parties have produced on record copy of policy document (Ex. OP-1/3). This document contains terms and conditions and as per this document also benefit under the policy is admissible even for hospitalization in general or special ward. Therefore, the rejection of claim on the ground that surgery is not covered under the policy is also illegal. On the other hand, learned counsel for opposite parties has submitted that complainant has not revealed true facts before this Forum. It is a Health Plus policy. It is only meant for additional benefit regarding health. The benefit is restricted subject to terms and conditions incorporated in the policy document. The major surgical benefits are covered under the policy and surgical benefits are also explained in the Annexure which is part of the policy. These surgeries are restricted to amputation of arm or hand or foot or leg due to trauma or accident. The treatment availed by the complainant is detailed in bill issued by Cheema Medical Complex/Hospital and brought on record as Ex. C-28. It proves that it is not a case of indoor treatment or major surgeries. In the complaint, the complainant has also revealed that he undergone operation for left secondary arthritis left subtaiar joint/C/ODM for Ex-fix stabilization with ring fixator removal. Therefore, the treatment obtained by complainant does not fall under the major surgeries as explained in the policy and Annexure. The opposite parties were justified in repudiating the claim. We have carefully gone through the record and have considered the rival contentions. The admitted facts are that the complainant obtained policy of opposite parties which is known as LIC Health Plus. The opposite parties have also placed on record policy document. The complainant submitted claim of Rs. 1,32,999/-. Although the opposite parties have also revealed regarding another claim registered vide claim No. 11402 but the controversy is regarding claim of Rs. 1,32,999/-. This claim has been repudiated by the opposite parties vide letter dated 20-2-2015 (Ex. C-9) and then letter dated 4-5-2015 (Ex. C-10). The ground for rejection of claim are revealed as under :- The ground for rejection vide letter dated 20-2-2015 : - The policy holder not complying with the required details even after repeated reminders. Hence, the claim is to be rejected instead of keeping it open indefinitely. - Surgeries not listed in the allowed surgeries (1 – 49). The ground for rejection vide letter dated 4-5-2015 : - Self afflicted surgeries or conditions (attempted suicide) and/or the use or misuse of any drugs or alocohol. - Surgeries not listed in the allowed surgeries (1 - 49) Therefore, it is clear that the opposite parties have repudiated the claim on two grounds. Firstly self afflicted injuries or conditions (attempted suicide) and/or the use or misuse of any drugs or alcohol. The second ground that the surgery was not listed in the allowed surgeries. There is no evidence placed on record to prove that injuries were self afflicted or on account of use or misuse of any drugs or alcohol. Therefore, this ground to justify the rejection is not sustainable. The other ground is that surgery is not listed in the allowed surgeries. In order to solve this controversy, the terms and conditions incorporated in the policy will be helpful. Of course as per Annexure which is treated as part of the policy, rates/percentage of sum assured are provided and the injuries/Musculoskeletal system are also detailed which included total replacement of Hip or knee joint following accident and amputation or arm or hand or foot or leg due to trauma or accident. Admittedly the surgery got performed upon the complainant does not fall in this category of surgeries but a perusal of entire policy document will prove that insured is entitled to the benefit of the policy incase of hospitalization in general or special ward. Clause 2 of terms and conditions include 'Health related benefits payable subject to policy being inforce'. These benefits does not restrict to only major surgeries but are available in case of hospitalization also. Therefore, in case the complainant was not eligible under 'Surgical Clause' he was certainly entitled to benefit under 'Hospital Cash Benefit' Clause. The opposite parties have repudiated the claim of the complainant without taking into consideration this clause. Therefore, it amounts to deficiency in service on the part of the opposite parties. Resultantly, this complaint is partly accepted with Rs. 5,000/- as cost and compensation. The opposite parties are directed to re-examine the claim of the complainant and settle the same as per Clause '2' of the policy in question. The claim be settled and amount, if any, found payable to the complainant, be paid. The compliance of this order be made within three months from the date of receipt of copy this order failing which the payable amount will carry interest @ 12% per annum thereafter. The complaint could not be decided within the statutory period due to heavy pendency of cases. Copy of order be sent to the parties concerned free of cost and file be consigned to the record. Announced : 21-02-2017 (M.P.Singh Pahwa ) President (Jarnail Singh ) Member
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