DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

                                                Complaint No.  105

                                                Instituted on:    01.03.2018

                                                Decided on:       27.05.2019

Rajdeen Khan S/o Rohi Khan, resident of Village Khadial, Tehsil 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 Sandip Goyal, Adv.

For Opp.Parties.       :       Shri Amit Goyal, Adv.

Quorum:   Vinod Kumar Gulati, Presiding Member

                Mrs.Manisha, Member

Order by : Vinod Kumar Gulati, Presiding Member.

1.             Shri Rajdeen Khan, complainant (referred to as complainant in short) has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the complainant is the consumer of the OPs by obtaining one Medi claim insurance policy, namely, Jeevan Arogya bearing number 165641402 for Rs.1,00,000/- on 16.11.2013 of which he has been paying the premium of Rs.1076/- on half yearly basis.  The policy in question is a fixed medical benefit policy with initial daily benefit limit of Rs.1000/- along with major surgical benefits and other surgical benefits.  Further case of the complainant is that he suffered urinary obstruction/problem and was admitted in Baba Barsiana Sahib Charitable Hospital, Dirba, where surgical procedure i.e. PCNL and right Nephrotomy was done and stone was removed. The complainant was admitted on 11.9.2016 and was discharged on 16.9.2016 and again he was got admitted on 22.9.2016 with the problem of obstruction in right ureter and underwent reconstruction operation and was discharged on 28.9.2016 and the complainant lodged the claim with the Ops and submitted all the documents.  It is stated further that the complainant remained admitted for a period of 13 days and is entitled for HCB to the tune of Rs.13000/- and surgeries undergone by the complainant falls under 40% and 20% category of the sum assured under major surgical head and on this account he is entitled for a sum of Rs.73,000/- , but the Ops made the payment of Rs.41,800/- and withheld the amount of Rs.31,200/- without assigning any reasons. No such amount was paid despite his best efforts. 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 remaining claim amount of Rs.31,200/- along with interest @ 18% per annum and further claimed compensation and litigation expenses.

2.             In reply filed by the Ops, preliminary objections are taken up on the grounds that the complaint is not maintainable, that the complainant has not come to the Forum with clean hands and that intricate questions of law and facts are involved in the present case, which require extensive evidence and same cannot be decided in summary proceedings before this Forum.  On merits, the issuance of the policy in question to the complainant has been admitted. It is further stated that the complainant remained admitted for 13 days and claim was lodged by him with the OPs. It is denied that the surgeries undergone by him falls under 40% and 20% category of MSB (I.e. Major Surgical Benefit) and the complainant is not entitled to the amount of Rs.60,000/-. It is stated further that the amount of Rs.41,800/- has rightly been paid as per the rules and as per the calculation made in the written reply.   Lastly, the OPs have prayed for dismissal of the complaint with special costs.

3.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-31 copies of documents and affidavit and closed evidence. On the other hand, the learned counsel for the OPs has produced Ex.OPs/1 to Ex.OPs/16 copies of documents and affidavits and closed evidence.

4.             We have carefully perused the complaint, version of the opposite parties and evidence produced on the file and also heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits dismissal, for these reasons.

5.             It is an admitted fact between the parties that the complainant obtained one Medi claim policy, namely, Jeevan Arogya bearing number 165641402 from OP number 1 for Rs.1,00,000/- for the period from 16.11.2013 under which the complainant was paying the premium of Rs.1076/- on half yearly basis. It is further not in dispute that the complainant suffered urinary obstruction/problem and was admitted in Baba Barsiana Sahib Charitable Hospital, Dirba, where surgical procedure i.e. P.C.N.L. and right Nephrotomy was done and stone was removed and the complainant remained admitted in the hospital from 11.9.2016 to 16.9.2016.  The complainant again remained admitted for the period from 22.9.2016 to 28.9.2016 and underwent reconstruction operation.  The grievance of the complainant is that he was paid only an amount of Rs.41,800/- against the due amount of Rs.73,000/- as he remained admitted for 13 days and is entitled for HCB to the tune of Rs.13,000/- and surgeries underwent by the complainant falls under 40% and 20% category o the sum assured under Major Surgical Head and on this account, he is entitled for the amount of Rs.60,000/- i.e. total Rs.73,000/-.   On the other hand, the learned counsel for the Ops has contended that the due amount of the claim i.e. Rs.41,800/- has already been paid to the complainant as per the terms and conditions of the policy.  Further from the perusal of the documents, it has been observed that the policy is not a mediclaim policy, but it is a fixed medical benefit policy.  Also we have gone through the list of the major surgeries submitted by the complainant, Ex.C-30 and have found that the surgeries undergone by the complainant does not fall under the list of major surgeries nor the complainant has produced any document showing that the surgeries suffered by the complainant are covered under the Major Surgical Benefits under the policy.   As such, we find that the Ops have already paid the full claim amount as per the terms and conditions of the policy and no more amount is payable.

6.             Accordingly, in view of our above discussion, we find no merit in the complaint and as such, the same is dismissed. However, the parties are left to bear their own costs. A copy of this order be issued to the parties free of cost. File be consigned to records.

                        Pronounced.

                        May 27, 2019.

                                                        (Vinod Kumar Gulati)

                                                          Presiding Member

                                                               (Manisha)

                                                                 Member