DISTRICT CONSUMER DISPUTES REDRESSAL FORUM  PALAKKAD

Dated this the  14^th day of November 2017

Present   : Smt.Shiny.P.R. President

               : Smt.Suma.K.P.  Member                                 Date of filing:  20/10/2016

               : Sri.V.P.Anantha Narayanan, Member                                      

   (C.C.No.204/2016)

Rajina.K.R,                                                                             - Complainant

W/o K.Sivadas,

Puruvayil House,

Ayakkad P.O, Palakkad.

(Adv.T.V.Krishnadas)                                        Vs

1.  LIC of India Delhi CAB, 1021, 18/60                 

    Geetha Colony, Delhi

    Pin 110031

    (Rep.by Authorised Signatory)

2.   LIC of  India,

     Maharshi Dadhichi Marg,

     Azad Maidan, Fort, Mumbai,

     Maharashtra-400001.

    (Rep by its Manager/ Managing Director or

     Authorised signatory)

3.  LIC of India,

     Branch Office, P.O.25,

     Near Bus stand, Alathur post,

    Palakkad.

    (Rep by its Branch Manager)

    (Adv.T.P.George for opposite parties 1 to 3)                                

4.  Lakeshore Hospital and

    Research Centre Ltd,

    Nettoor post, Cochi 682040,

5.  Lakeshore Hospital and

    Research Centre Ltd,

    Nettoor post, Cochi 682040,                                              -  Opposite parties                  

    (Rep by its manager/managing director or

     Authorized signatory)

(Adv. A.K.Sundareswan for opposite parties 4 and 5)

O R D E R

By Smt.Shiny.P.R, President ,

Brief facts of the complaint

            Complainant has taken LIC’s Health Plus Policy  No. 776585320 from  opposite parties 1 to 3.  The complainant has paid Rs.6,000/- as the yearly premium as stipulated in the policy without any break, laches and omission from 2008 onwards till this time.  Therefore the policy issued for the complainant referred above is still in force.  But unfortunately complainant was affected with kidney and renal related illness and she has to undergo for kidney transplantation and it is carried out in Lakeshore Hospital, Cochin opposite parties 4 & 5.  The complainant was admitted and treated in opposite parties 4 & 5 hospital from 19.01.2013 to 23.02.2013 due to chronic kidney disease for the said renal transplantation.  The complainant has incurred Rs.9,52,000/- for treatment.  Complainant submitted that as on the period of treatment the policy issued by the opposite parties 1 to 3 is existing, they are liable to pay Rs.9,52,000/- to complainant, which is the total amount incurred for the treatment.  Even though the complainant has submitted the entire documents connected with her disease, hospitalization and expenses, they have granted only Rs.2,48,000/-.  The complainant is legally entitled to get Rs.11,52,000/- which includes the incidental expenses incurred to the complainant for the said treatment.  Instead of allowing the claim in toto, the opposite parties 1 to 3 have granted only Rs.2,48,000/- stating that  as per the coverage and conditions of the said policy the complainant is entitled to get only Rs.2,48,000/- on the hands of major surgical benefit and hospital cash benefit (MSB) and (HSB).  Other amounts stated and claimed by the complainant is repudiated without any reasons. The complainant had received the amount of Rs.2,48,000/-  on 15.01.2015.  complainant had sent a lawyer notice demanding the opposite parties 1 to 3 to pay Rs.11,52,000/-.  After receipt of the notice they sent a reply stating that the amount granted and disbursed by them is in accordance with the provisions and conditions stated in the said policy. The non granting of the balance amount amounts to deficiency of service and unfair trade practice. Hence the complaint. Complainant prays for an  order directing opposite parties 1 to 3 to pay Rs.11,52,000/- with interest to the complainant till its full realization and also to pay Rs.25,000/- as the cost of this litigation. 4^th & 5^th opposite parties are the hospital where the complainant had undergone her major surgery for kidney transplantation and at where she had incurred the medical expenses for the said cause of action.  The opposite parties 4 & 5 are arrayed in the party array in the capacity of necessary parties and at where the complainant had undergone her major surgery. 

Complaint was admitted and notices were issued to all the opposite parties. Opposite parties 1 to 3 filed their version jointly. Opposite parties 3 and 4 also filed version. 3^rd opposite party filed IA 32/16 to delete the name of 1^st and 2^nd opposite parties stating that the above policy was issued from the 3^rd opposite party office, 1^st and 2^nd opposite parties are unnecessary parties in the proceedings and 3^rd opposite parties alone is responsible for the ultimate results of this complaint. Hence in the interest of justice IA was allowed.

            3^rd opposite party filed version contending the following:-

This opposite party admitted that the complainant has taken a LIC’s Health Plus Policy No. 776585320 with date of commencement as 06.05.2008 and term 23 years.  As per the policy conditions the policy holder is eligible for three benefits that is Hospital Cash Benefits (HCB) and Major Surgical Benefits (MSB) and Domiciliary Treatment Benefit.  Hospital Cash Benefits depends on the number of days of hospitalization less 48 hours and the daily benefit amount chosen at inspection.  In this case the initial daily Hospital Cash Benefit (HCB) opted by the insured complainant was Rs.1,000/- per day.  This daily benefit amount increases @ 5% in every year.  The Major Surgical Benefit Sum Assured shall be 200 times of the initial daily HCB, which is Rs.2,00,000/- in this case as shown in the policy document.  The Major Surgical Benefit is payable for the surgeries listed out in the policy conditions and privileges referred to in the Policy Document.  It is admitted that the complainant had preferred a claim in connection with a surgery for kidney transplantation.  Immediately on receipt of the claim papers this opposite party forwarded the same to opposite party’s third party Administrator, M/s Medi Assist India Private India Ltd. for processing the claim.  But the supporting papers were found insufficient.  TPA sent a letter to the complainant on 09.04.2013 requesting the complainant to furnish the requirements.  The complainant did not furnish those details.  So TPA expressed their inability to process the claim in the absence of the requirements called for.  Complainant was not willing to co-operate with this opposite party and was repeatedly demanding the settlement of the claim.  Finally officers of the 3^rd opposite party went to Lakeshore Hospital and procured some information related to the claim and this opposite party has taken extra efforts to settle the claim of the complainant.  The health plus policy is not a Medical Reimbursement plan but a Unit Linked Health Insurance Plan which provides for insurance cover of the following defined benefits.  1.  Hospital Cash Benefit (HCB), 2.  Major Surgical Benefit (MSB), 3.  Domiciliary Treatment Benefit.  These are inbuilt fixed benefit and is not related to the actual medical expenses incurred by the insured.  HCB is on per day basis whereas MSB shall be a percentage of sum assured depending on the type of surgical procedure.  For Kidney and Urinary Tract Renal Transplant, the insured is eligible for 100% of the MSB sum assured.  In this case the eligible Major Surgical Benefit (MSB) & Hospital Cash Benefit (HCB) has been settled to the complainant as shown below. 

Major Surgical Benefit :-

200 times of opted initial daily HCB i.e Rs.200x 1,000                                =  Rs.2,00,000/-

Hospital Cash Benefit (HCB) (after 5% increase of HCB is Rs.1,200/-)

ICU – 7 days X 1,200/- x 2                                                                            =  Rs.   16,800/-

NON ICU – 26 days x 1,200/-                                                                       =  Rs.   31,200/-

Total                                                                                                                =  Rs.2,48,000/-

No HCB would be paid for the first 48 hours (2 days), Rs.2,48,000/- was paid and received by the complainant on 15.01.2015.  Annexure page 14-16 of the privileges and conditions it is specified that for Renal Transplant 100% of the sum assured is eligible.  So the Major Surgical Benefit sum assured of Rs.2,00,000/- with eligible daily hospital cash benefit as calculated above is paid to the complainant.  The amount of Rs.2,48,000/- is what the complainant is eligible for under the policy and she is not eligible for any further amount in this claim.  As per policy for Major Surgical Benefits the sum assured was only Rs.2,00,000/- and that was paid.  Only for the said sum assured premium was collected by this opposite party.  The opposite party’s liability is only to the extent of the Major Surgical Benefit sum assured in the policy.  The opposite party is not liable to compensate the entire treatment expenses as claimed in the complaint.  The complaint is not entitled for any remedy sought in the complaint against the opposite party.  Hence complaint is to be dismissed with compensatory cost.

Opposite parties 4 and 5 filed version contending that they are unnecessary parties and no relief was sought against them. Hence the complaint against these opposite parties is to be dismissed

The following issues arise for consideration.

1. Whether there is any deficiency of service from the part of opposite parties ?
2. If so what are the relief and cost?

Issues 1 & 2

Opposite parties 1 to 3 admitted the policy. Ext A1 and B2 show that the Major Surgical Benefit Sum Assured is Rs.2,00,000/-. Perusal of sub clause II (i) of clause 3 benefit limits of conditions and privileges in Ext.A1 reveals that in the event of a claim becoming eligible for payment under this benefit, and regardless of the actual costs incurred, the corporation will pay the chosen Major Surgical Benefit Amount, calculated as a percentage of Sum assured as specified against each of the eligible surgeries in Surgical Benefit Annexure. Annexure of Ext. A1 shows that 100 per cent of the sum assured is given for renal transplant. In the present case the sum assured is Rs. 2,00,000/-. Hence the complainant is entitled to get Rs.2,00,000/- for Major Surgical Benefit.

In this case complainant further submitted that she was admitted and treated in opposite parties 4 & 5 hospital from 19.01.2013 to 23.02.2013 i,e 35 days admitted and treated as in patient. Perusal of clause 2 (a) and (b) of conditions and privileges referred to in Ext. A1 it is revealed that no hospital cash benefit would be paid for the first 48 hours (2 days). Opposite parties 1 to 3 calculated Hospital Cash Benefit for 33 days. Total amount calculated for 33 days is Rs 48,000/-. Therefore the complainant is entitled to get a total claim of Rs. 2,48,000/- from the opposite parties 1 to 3. The opposite parties paid the said amount to the complainant on 15.01.2015. Under the above circumstances we are of the view that opposite parties 1 to 3 rightly settled the claim as per the terms and conditions of the policy and there is no deficiency in service on the part of opposite parties 1 to 3.  Hence the complaint is dismissed.

Pronounced in the open court on this the 14^th  day of November 2017.

                                                                                                                               Sd/-

                           Shiny.P.R.

                           President 

                                 Sd/-        

                           Suma.K.P.

                            Member

          Sd/-

    V.P.Anantha Narayanan

                           Member

Appendix

Exhibits marked on the side of complainant

Ext.A1  -  Original Policy (LIC’s Health Plus Plan) bearing No.776585320 issued by

                 3^rd opposite party to the complainant

Ext.A2 series   -  Photo copy of lawyer notice dated.06.03.2015 sent by the complainant to the 3^rd

                           opposite party  With acknowledgement card

Ext.A3  –  Reply notice dated. 14.03.2015sent by the Manager, Divisional Office, Thrissurto the

                 complainant

Exhibits marked on the side of Opposite parties

Ext.B1 -  True copy of Proposal Form for LIC’s Health Plus Policy

Ext.B2 -  True copy of policy copy & conditions and privileges

Ext.B3 -  True copy of requirement letter dated. 09.04.2013, 20.04.2013 & 03.05.2015 issued by

                the complainant to the Manager Life Insurance Corporation of India, Divisional Office,

                Thrissur

Ext.B4 -  True copy of reply notice dated.22.04.2013 by the complainant received by TPA

Ext.B5 -  True copy of e mail dated.23.07.2013 to Laksehore Hospital and reply

Ext.B6 -  Copy of the circular issued by LIC Central Office dated. 04.01.2008 (24 sheets)

Witness examined on the side of complainant

Nil

Witness examined on the side of opposite party

Nil

Cost   

            Nil