By Sri. MOHANDASAN.K, PRESIDENT
1.The complaint in short is as follows: -
The complainant subscribed the insurance policy of the life insurance corporation of India through the first opposite party and the policy No. is 795840661, which is valid from 2008 to 2019. The complainant subscribed the policy after proper medical examination of doctors attached to the opposite party. The complainant remitted insurance premium without any default. At the time of subscribing the policy he was not suffering from any sort of ailment and he was healthy person. The complainant remitted Rs. 15,000/- as annual premium and also paid an amount of Rs. 35,000/- as Top-up expense. The policy was covered critical illness hospitalisation expenses benefit in addition to life insurance coverage. Hence as part of the policy the Insurance company is bound to pay the entire hospital expenses of the complainant.
2. The complainant submitted that, he had noticed symptoms of diabetics during the year 2011 and for that he had undergone treatment and he was under the total control of the diabetes. In the Year 2013 the complainant undergone Calculus cholecystitis treatment and in the year 2017 he undergone coronary artery disease. During the hospitalisation he spent Rs. 2,14,884/- for the treatment. The opposite party did not issue critical illness hospitalization expenses or other expenses during the validity period of the insurance. The opposite party denied the insurance coverage stating that he had diabetics 20 years prior to the date of inception of policy. The complainant submits that he never had diabetic ailment prior to the subscription of the policy.
3. The complainant had availed more than ten policies of the opposite parties. The complainant had undergone medical check-up also during the subscription time and no diabetic ailment was detected at the time of medical examination done by the doctors of the opposite parties. The complainant denied the allegations of the opposite party that the complainant was having complaint of diabetic prior to subscription of the policy that to 20 years. The complainants submitted all the treatment bills of 2013 and also 2017 before the opposite party. According to the complainant he is entitled to Rs. 3,00,000/- for the treatment expense during the 2013 and Rs. 2,00,000/- for the treatment in the year 2017. The complainant submits that the claim is proportionate to sum assured and he is entitled other benefits also as per the policy. The opposite party collected premium from the complainant even after detection of diabetics for the last 20 years prior to the subscription of insurance policy. The complainant submits, since the opposite party received premium till 2019, they are bound to provide critical illness benefit cover also. The complainant submits that the above-mentioned facts were submitted before the Ombudsman and the Ombudsman was convinced with the submission of the complainant. The Ombudsman was allowed to proceed against the opposite party for availing the benefits as per the insurance policy. It was stated in the order of the Ombudsman that they are not having this Consumer commission.
4. The complainant submit that the opposite party could not produce any documents to establish that the complainant had diabetics more than 20 years and no document has been mentioned from where the third party administer concluded the history of diabetic ailment. The complainant submitted that, he was not had diabetic complaint while he was 39 years and it was noticed diabetic complaint at the age of 57 years only and for that the complainant followed food control and also had medicine for the same. It is also submitted that the present ailment was not the result of the diabetic ailment.
5. Hence, prayer of the complainant is that he is entitled to treatment expenses for the gall bladder done in the year 2013 and which will be around Rs. 3,00,000/- considering 60% as per schedule and also is entitled for Rs.2,00,000/- for the coronary artery disease and also entitled for the maturity amount of Rs. 1,88,126/-. The complainant also claims of Rs. 2,00,000/- as compensation and Rs. 1,00,000/- cost of proceedings also.
6. On admission of the complaint notice was issued to the opposite parties and 1st and 2nd opposite parties entered appearance and filed detailed version. The opposite parties denied the entire averments and allegations in the complaint and contented that the complaint is false, frivolous, vexatious and not sustainable either in law or facts. The opposite parties submitted that the alleged hospital bills of the complainant was already considered and rejected by Third Party Administrator and the complainant was not preferred any appeal before any higher authorities against the claim rejection. But the complainant preferred an appeal before the Hon’ble Insurance Ombudsman against the rejection of maturity benefit and the Ombudsman passed an award and the opposite party complied with the award and paid the amount to the complainant. Hence the opposite party submitted that the rejection order of Third-Party Administrator is final and binding the complainant.
7. The opposite parties admitted that the Life Insurance Corporation of India, Tirur branch office had issued the Unit linked Health Plus Policy bearing No. 7958 40661 dated 31/03/2008 in favour of the complainant on the basis of proposal form filled and signed and submitted by the complainant and the term of policy was 11 years and also submitted that the complainant had two hospital admissions during the year 2013 and thereafter in 2017.
8. The opposite parties specially denied the averment of the complainant that he inflicted with diabetes only subscribing the policy and LIC and third-party administrator not considered those factors. The LIC and TPA duly considered those factors and contentions of the complainant and discarded / rejected the same on merit. The opposite party admitted that the complainant remitted premium of the policy Rs. 15,000/- and invested Rs. 35,000/- as top up in the first year and paid premium till maturity. The opposite parties submitted that they paid back premiums Rs. 90,000/- to the complainant. The opposite party admitted that they denied maturity benefit to the complainant as well as the hospital bills and the complainant had approached Insurance Ombudsman and the Insurance Ombudsman passed an award directing the opposite parties to pay maturity benefit to the complainant.
9. The opposite party submitted that the life insurance is an alienated contract on the principles of at most good faith and performance of contract is as per the conditions and privileges embodied in the policy documents, which is evidence of the contract and binding to the parties. It is submitted that the insurance contract secured by violating the fundamental principle of utmost good faith is void abinitio. The opposite party, Tirur branch office had issued the Unit Linked Health Policy bearing No. 795840661 dated 31/03/2008 in favour of the complainant on the basis of proposal form filled and signed and submitted by the complainant. The insured had also signed a declaration at the foot of the proposal form stating that all the answers given in the proposal form is correct.
10. The opposite parties submitted the health plus policy has given three benefits to the policy holders under the health insurance cover as follows: -
(a) Hospital cash benefits: - This is one of the three benefits available under the health insurance cover. In the event of accidental bodily injury or sickness first occurring or manifesting itself after the date of cover commencement and during the cover period, causing an insurer hospitalisation to exceed a continuous period of 48 hours, then the principal insured will be eligible to get the reimbursement of hospital expenses at the rate which he has chosen at the commencement of policy.
(b) Major surgical benefit (MSB): -This is second benefits available under the health insurance cover. In the event of P1 or any of the insured lives covered under the policy, due to medical necessity, undergoing any of the surgeries listed in the eligible major surgeries, the respective benefits percentage of the MSB sum assured, as specified against each of the eligible surgeries shall be payable subject to terms, conditions and exclusions. Schedule of eligible surgeries procedures and percentage of sum assured allow as MSB each shown in the conditions and privileges of the policy documents.
(c) Domiciliary treatment benefits (DTB): - This is the third benefit available under health cover. Health plus policy provides a unique investment vehicle for long term savings in the form of units. These units can be withdrawn or redeemed subject to certain medical contingencies over and above HCB/MSB payments. These expenses could be for a treatment from a physician or a doctor visiting home or for any prescribed diagnostic investigation. The benefit as specified above shall be paid as lumpsum and will be subject to providing proof of occurrence of hospitalization or surgery as applicable to the conditions laid by the corporation for settling the claim.
11. The opposite parties submitted that when the insured claims any benefits as per the policy the insured should provide all necessary and accurate information to the authorised Third-Party Administrator, who is authorised for claims settlement and follow the process and instructions as stipulated by such third-party administrator. The opposite party submitted that in this complaint, the complainant preferred a claim under the policy on 21/03/2013 for Calcus cholecystitis, hypertension and type 2 diabetes mellitus and dyslipidemia for the treatment at Baby Memorial Hospital, Kozhikode for the period 20/02/2013 to 25/02/2013. On scrutiny of claim papers the third party administrator M/s Medi Assist India TPA private limited required vide their document deficiency letter dated 12/04/2013 and directed the complainant to submit (a). Indoor Case papers (with admission notes /treatment chart, / doctors chart /OT notes) from the hospital, (b). First consultation report from the hospital when diagnosed with diabetes mellitus, HTN, Dyslipidaemia, (c). Past history of diabetes mellitus, HTN, Dyslipidaemia (since how many years the patient is suffering from this ailments) from the hospital, (d). Pre-anaesthetic check up from the hospital and (e). Admission notes from the hospital. Since no reply was submitted by the complainant, then TPA sent reminder on 02/05/2013 asked him to submit the documents within 10 days. The opposite party submitted that the TPA had conducted simultaneously house investigation at Baby Memorial Hospital, Kozhikode on 29/04/2013 and the documents obtained from the hospital revealed that the complainant was under treatment for diabetes mellitus (DM) and a hypertension (HTN) and was consuming insulin and had a history of HTN and dyslipidaemia for 20 years earlier to February 2013. The complainant had not disclosed the above facts at the time of taking with policy. In the proposal form submitted by the complainant for the questions relating to previous treatments was answered as “No’. It is submitted that if the fact was disclosed, the health policy could have been regretted. Hence the submission of the opposite party is that the complainant subscribed the policy by suppressing the material facts, i.e., the knowledge of pre-existing disease, based on this claim was rejected and the same was conveyed to the complainant. So, the submission of the opposite party is that repudiation was done due to the suppression of material facts and on the basis of valid reasons with solid proof.
12. The opposite party contented that any pre-existing conditions are exclusions and no benefits are available there under and no payment will be made by the corporation or any claim that is any medical conditions or any related conditions that have arisen at some part prior to the commencement of the policy, irrespective of whether any treatment or advice was sought. Any such condition or related condition about which the principal insured or insured dependent know, knew or could reasonably have been assumed to have known will be deemed to be pre-existing. Upon receiving rejection letter of the opposite party, the complainant made representation on 03/06/2013 where in complainant admitted in writing that the main reason for the claim rejection was misrepresentation of past history of health of diabetic, hypertension for the 20 years and the omission crept in only due to ignorance of the complainant about the rules and he had not given serious thought to those ailments which are common to the majority people. The opposite party submitted that the letter is clear proof for his knowledge of pre-existing disease. So, suppression of material facts is clear and the rejection of claim was made as per rules and policy condition and the request of the complainant was not considered by opposite party and the same was communicated to the complainant also.
13. The opposite party submitted that the policy holder continued to remit the yearly premium and completed the term of 11 years on 31/03/2019. As per policy condition if any pre-existing disease have diagnosed leading to suppression of material facts, contract ceases and policy holder need not remit further premium. But the opposite party submitted that however the complainant remitted the full premium under the policy. Though the policy was not eligible for maturity benefits the case was considered as a special case and was put up before the claim review committee and the committee decided to refund the premium remitted by the policy holder from 3/2013 to 3/2018 i.e., the premium remitted under the policy after the first claim was rejected on the basis of pre-existing disease. As per the decision of the review committee the opposite parties refunded 6 annuals premium Rs. 90,000/- remitted by the complainant for the period 3/2013 to 3/2018 on 18/06/2019. Later the complainant filed a complaint on 25/11/2019 with Hon’ble Insurance Ombudsman, Kochi against the rejection of maturity benefits under the policy. The Ombudsman after hearing both the parties passed an award on 19/05/2020 directing the opposite parties to pay Rs. 98,127/-, after deducting Rs. 90,000/- already refunded to the complainant on 18/06/2019 towards the maturity amount of Rs. 1,88,127/-. Hence the opposite party submitted that they have paid the entire amount as per the awards of Ombudsman. The opposite party discarded the hospitalisation claim as per policy condition. Hence the submission of the opposite party is that they have acted as per the policy condition and had given human consideration and justice to the complainant. According to the opposite parties there is no question of deficiency of service, cause of action, mental agony, hardship or financial loss to the complainant and so the complaint is liable to be dismissed with cost.
14. Both parties filed affidavit and documents. The documents on the side of complainant marked as Ext. A1 to A10 and documents on the side of opposite parties marked as Ext.B1 to B13. Ext. A1 is letter issued by opposite party to the complainant dated 14/10/2019. Ext. A2 is copy of order along with letter from the office of the insurance Ombudsman dated 19/05/2020 / 30/03/2020. Ext. A3 is copy of request issued by complainant to the Insurance Ombudsman. Ext. A4 is copy of letter issued from office of the Insurance Ombudsman dated 18/09/2020. Ext. A5 is LIC Health plus plan Table 901 conditions and privileges referred to policy documents. Ext.A6 is a letter issued by LIC’s regarding refund of premium dated 18/06/2019. Ext. A7 is letter regarding maturity value of the policy dated 04/09/2019 / 01/04/2019. Ext. A8 is a copy of discharge summary issued from Aster MIMS dated 11/11/2017. Ext. A9 is a discharge summary issued from Baby Memorial Hospital during the year 2013. Ext. A10 is application made to Insurance Ombudsman, Ext. B1 is proposal form for LIC’s Health plus policy plan 901. Ext. B2 is Health Plus Plan (Plan No.901) form to be filled by the Member (beneficiary) in case the member is not a minor. Ext. B3 is copy of LIC’s Health Plus Plan (Table 901). Ext. B4 copy of conditions and privileges referred to in the policy document of Unit Linked Health Insurance Plan (T.No.901). Ext. B5 is a copy of document deficiency letter dated 12/04/2013. Ext.B6 is information reminder dated 02/05/2013. Ext. B7 is a copy of Medi Assist India TPA Private Limited investigation report dated 29/04/2013. Ext. B8 is a claim rejection letter dated 08/05/2013 issued by the LIC. Ext. B9 is a copy of letter of acknowledgement issued by LIC’s to the complainant dated 04/06/2013. Ext.B10 is a copy of claim rejection letter dated 12/02/2018. Ext. B11 is hospital treatment form for Health Insurance policies issued from Baby Memorial Hospital, Calicut. Ext. B12 is a copy of letter of appeal submitted by complainant before the opposite parties dated 03/06/2013. Ext. B13 is treatment details issued from Baby Memorial hospital.
15. The complainant and opposite parties heard, perused affidavits and documents.
The following points arise for consideration: -
1. Whether the complainant was having pre-existing disease while subscribing
the insurance policy?
2. Whether there is deficiency in service from the part of the insurance
company?
3. Reliefs and cost?
16. Point No.1: -
Then opposite party admitted the issuance of insurance policy in favour of the complainant as policy No. 795840661 dated 31/03/2008. The term of the policy was 11 years starting from 31/03/2008 and matured on 31/03/2019. The opposite parties also admitted that the complainant had two hospitals admissions, i.e., one in 2013 and another one in 2017. The opposite parties also admitted that they early premium was Rs. 15,000/- and invested Rs. 35,000/- as top up in the first year and paid premium till maturity without any default. The opposite parties admitted that they denied the maturity benefits as well as the hospital bills and as per the order of Insurance Ombudsman, the opposite party paid maturity benefit to the complainant. Now the issue is with respect to the hospital bills during the valid period of insurance policy. The opposite party submitted that they denied the benefit under the insurance policy due to non-disclosure of pre-existing disease to the complainant ie, diabetes mellitus of having history of 20 years prior to the subscription of insurance policy. According to the opposite parties the insurance is an alienated contract on the principles of at most good faith and performance of the contract is as per the conditions and privileges embodied in the policy document and the violation of the fundamental principle of at most good faith is sufficient reason to hold the insurance contract as void ab-initio. In this complaint the complainant submitted proposal form filled and signed by the complainant and also assured through a declaration at the foot of the proposal form stating that all the answers given in the proposal form as correct.
17. The opposite party contented that as per the conditions and privileges of the policy any pre-existing conditions and exclusions and no benefits are available there under and no payment will be made by the corporation for any claim, that is any medical conditions or any related conditions that have arisen some part prior to the commencement of the policy, irrespective whether any medical treatment or advise was sought. In this complaint, the opposite party submitted that the insurer should have provided all necessary and accurate information to the authorised TPA (Third Party Administrator) along with claim of the insured, who is the authorised for claim settlement and follow the processes and instructions as stipulated by such TPA. The Third Party Administrator required certain further documents from the complainant, but that was not submitted and so TPA conducted house investigation at Baby Memorial Hospital, Kozhikode on 29/04/2013 and based on the hospital documents submitted an investigation report, which revealed that the complainant was under treatment for diabetes mellitus and Hypertension and was consuming insulin and had a history of HTN and dyslipidaemia for 20 years earlier to February 2013. The complainant had not disclosed this fact at the time of taking the policy and the questions related to previous treatment in the proposal form was answered as ‘No’ by the complainant. The contention of the opposite party is that, if the same was disclosed the health policy could have been regretted and so the submission is that the complainant subscribed the health policy suppressing the material facts regarding the pre-existing disease and so the claim was rejected.
18. The opposite party produced Ext.B1to B13 to substantiate the contention of the opposite party. In this complaint the complainant subscribed the policy in the year 2008 and he undergone treatment in the year 2013 and a claim was preferred before the opposite parties. But the opposite parties repudiated the claim stating pre-existing disease while subscribing the policy. But the opposite party continued to receive premium from the complainant thereafter up to 2019 i.e., for 6 years. The opposite party had not explained under what circumstances the opposite party continued to receive the premium from the complainant in case of a void policy according to the contention of the opposite party. It is also pertinent to not that after submission of claim form, the opposite party considered the claim of the complainant by the claim review committee and decided to refund Rs. 90,000/- to the complainant. It is to be noted that the refunded Rs. 90000/- was the amount collected by the Insurance Company after the 2013 claim for medical bill. Aggrieved by the repudiation process of the opposite party the complainant duly approached Insurance Ombudsman and the Ombudsman considered the averments of the opposite parties regarding suppression of pre-existing disease and found that there is no evidence to substantiate the contention of the insurance company regarding pre-existing disease of 20 years. Hence the finding of the Insurance Ombudsman was to pay the entire insurance benefit to the complainant. But the insurance Ombudsman did not consider medical bills and so as directed by the Insurance Ombudsman the complainant approached this Commission for the medical benefits as per the insurance policy during the valid period of the insurance. The opposite party herein also contended that the complainant suppressed pre-existing disease of diabetes mellitus and justified the repudiation of the medical bills. The document produced by opposite parties do not reveal that the complainant had undergone any sort of treatment prior to the hospitalization during 2013. The complainant subscribed the policy during the 2008 and he underwent treatment after 4 years. The opposite parties produce Ext. B13 to show that the complainant was suffering from diabetes mellitus for 20 years and which is issued in the year 2013, at his first hospitalization period. But there is no other treatment record to show that he was undergone treatment of diabetes mellitus prior to the admission in the year 2013 for the laparoscopic Cholecystectomy. The complainant submitted that he had subscribed nearly more than 10 policies of the opposite parties and almost all the occasions there was medical check-up by the opposite party doctors. In this complaint also it can be seen that the proposal form has been counter signed by the medical officer and which is specifically mentioned that the certificate issued since the policy being a medical case and the same also certified that the proposal form are properly recorded. So, it will not be proper to hold that after obtaining certificate from medical officer, who is duly authorised by opposite party for the medical cases that the insured was having pre-existing disease. It is not expected to put a signature by medical officer in a proposal form of health insurance policy without verifying the statement of the insured. The opposite party vehemently tried to evade the liability contenting that the complainant had given a letter to the opposite party stating that the omission crept in the claim form was due to the ignorance of the complainant regarding the rules and also the complainant thought that the ailments of diabetes which are common to the majority of people and so he requested to condone the mistake. The perusal of the document B12 treatment record also shows that it is dated 03/06/2013. The perusal of the same cannot be taken as an admission that the complainant was suffering diabetic for 20 years and was undergoing treatment for the same. The complainant contented throughout in the complaint that he was not undergone treatment for diabetes prior to the inception of policy in the year 2008 and no point of time the diabetes was detected also.
19. The perusal of documents produced by complainant as well the opposite parties do not establish the case of the opposite party that the complainant was having pre-existing disease, 20 years prior to the inception of insurance policy in the year 2008. It is also vital to not that the opposite party without any hesitation collected premium from the complainant after 2013 up to 6 years, that is after revealing pre-existing disease of diabetes mellitus for 20 years as per the contention of the opposite party. The insurance Ombudsman also found that the complainant was not having history of diabetic ailment with history of 20 years prior to inception of policy. It was also found that the policy was valid and not void as contented by opposite party and directed to pay the maturity benefit. The opposite party has not challenged the same but admitted through the payment of maturity benefit. Hence the view of the Commission is that the opposite parties are absolved from contenting that the complainant is not entitled for the benefit as per the policy. The commission finds that there was no pre-existing disease of diabetes mellitus for 20 years prior to the inception of policy in the year 2008 and we answer the first point accordingly.
20. Point No.2: -
The complainant admittedly undergone treatment in the year 2013 and thereafter in the year 2017 and approached the opposite party with treatment records and medical bills. But the opposite party contenting suppression of material facts i.e., pre-existing disease and denied the insurance to the complainant. The complainant made communications with the opposite party stating the real facts that he was not suffering from any sort of ailment prior to the inception of policy as stated in the proposal form. The complainant has got a case that the opposite party had issued nearly ten policies to the complainant and almost in all occasions there was medical certification along with proposal form. The submission of the complainant is that at no point of time prior to the inception of policy in the year 2008 he had undergone treatment as contented by the opposite party. The complainant had submitted all the treatment records which are available to him regarding the treatment actually he had undergone. The Third-Party Administrator directed the complainant to produce certain documents which were originally not in existence and so he could not produce. The opposite party on the basis of a report of so-called investigation of the Third-Party Administration repudiated the insurance claim and the same resulted filing complaints one after another. Since the insurance Ombudsman already hold that there is no document to show pre-existing disease, and so the complainant was declared as entitled the insurance maturity benefit as per the policy. Hence it was proper on the side of insurance company to consider the medical bills as claimed by the complainant. The Ombudsman hold that the complainant is entitled insurance benefit as per the policy means the complainant is entitled for all other benefits also as per the policy. There is no document to show that the insurance Ombudsman considered the medical bills and rejected the same as contented by the opposite party. So, the act of repudiating insurance claim by the opposite party amounts deficiency in service. The complainant is having number of policies with the opposite party and from whom the insurance company received premium amount for the 6 years without any authority and proper justifications. The act of collecting premium towards void insurance is also amounts unfair trade practice and deficiency in service and so we find that in this complaint there is gross deficiency in service on the part of the opposite party, and we find the second point accordingly.
21. Point No.3
The complainant claims Rs.3,00,000/- for the treatment expense during the year 2013 and Rs. 2,00,000/- for the treatment expense in the year 2017. According to the complainant the claim is proportionate to sum assured and he is entitled other benefits also. The complainant submitted that he is entitled for the treatment expenses for the Gall bladder done in the year 2013, which will be around Rs.3,00,000/- considering 60% as per schedule and also entitled for Rs. 2,00,000/- for the coronary artery disease and also an amount of Rs. 1,88,126/- towards the maturity amount. The complainant also claims compensation of Rs. 2,00,000/- and cost of Rs. 1,00,000/-.
22. The opposite parties filed version and affidavit stating that they had issued maturity amount as per the order of Hon’ble Insurance Ombudsman. The complainant submitted that all the treatment records and medical bill were submitted the opposite parties as part of the claim from. The complainant submitted that during his 2013 hospitalisation he spent 2,14,884/- for the treatment . the complainant contented that he is entitled Rs. 3,00,000/- towards the treatment expenses during the 2013 and Rs. 2,00,000/- for the treatment expenses in the year 2017. But the contention of the opposite parties that if the claim had been allow by the opposite parties if there was no pre-existing disease the complainant would have received Rs. 5,400/- as HSB for three days . (Applicable HCB as on the date of surgery is Rs. 1,800/-). It is submitted that the surgery done cholecystectomy is not coming under the list surgeries policy holder is not an eligible for major surgical benefit. The opposite party submitted that, if the claim for the treatment undergone by the complainant for the period from 07/11/2017 to 09/11/2017 for Coronary Artery disease treatment at Aster MIMS Hospital, Kottakkal the complainant would have received major surgical benefits for the surgery Coronary Angioplasty with stent implementation (if two or more arteries stent) and an amount equal to 40% sum assured would have been received. The sum assured as applicable to the complainant was Rs. 3,00,000/- and 40% of the said amount will come up to Rs. 1,20,000/- as MSB. The complainant also had been given Rs. 8,700/- as HCB. The opposite party submitted that the complainant was entitled Rs. 4,350/- as two days ICU expense and another Rs.4,350/- as two days NICU expense at the rate of Rs.2,175/- per day. So it can be seen that for the second treatment underwent by the complainant during 2017 the complainant is entitled a total amount of Rs. 1,28,700/-. It appears there is no reason to disregard the contention of the opposite party. So it can be seen that the complainant is entitled Rs. 5400/- as HSB for his treatment in the year 2013 and he is entitled Rs. 1,28,700/- for the treatment undergone during the year 2017. It can be seen that the complainant approached the opposite party for the treatment benefit at the time of his treatment itself .But the opposite parties denied the claim without satisfactory reason. Hence the complainant is entitled to a reasonable amount as compensation and we consider the same as Rs. 1,00,000/-. We also allow Rs. 10,000/- as cost of the proceedings.
23. It is also to be noted that the complainant made the insurance Ombudsman as third opposite party in this complaint which is an unnecessary party in the proceedings and so the Commission delete the third opposite party from the complaint as party.
24. Hence we allow this complaint as follows: -
- The opposite parties are directed to pay Rs. 1,34,100/-(Rupees One lakh thirty four thousand and one hundred only) to the complainant towards the treatment expenses.
- The opposite parties are directed to pay Rs.1,00,000/- (Rupees One lakh only) as compensation on account of deficiency in service and thereby caused inconvenience and hardship to the complainant.
- The opposite parties are also directed to pay Rs.10,000/- (Rupees Ten thousand only) as cost of the proceedings.
The opposite parties shall comply this order within one month from the date of receipt of copy of this order failing which the opposite parties are liable to pay interest at 9% Per annum for the above said entire amount from the date of filing this complaint till the date of payment.
Dated this 19thday of October , 2022.
MOHANDASAN K., PRESIDENT
PREETHI SIVARAMAN C., MEMBER
MOHAMED ISMAYIL C.V., MEMBER
APPENDIX
Witness examined on the side of the complainant : Nil
Documents marked on the side of the complainant : Ext.A1to A10
Ext. A1 : Letter issued by opposite party to the complainant dated 14/10/2019.
Ext. A2 : Copy of order along with letter from the office of the insurance Ombudsman
dated 19-5-2020 / 30-3-2020.
Ext. A3 : Copy of request issued by complainant to the insurance Ombudsman.
Ext.A4 : Copy of letter issued from office of the Insurance Ombudsman dated
18/09/2020.
Ext.A5 : LIC Health plus plan Table 901 conditions and privileges referred to policy
documents.
Ext.A6 : Letter issued by LIC’s regarding refund of premium dated 18/6/2019.
Ext. A7 : Letter regarding maturity value of the policy dated 4/09/2019 / 1/4/2019. Ext. A8 :Copy of discharge summary issued from Aster MIMS dated 11/11/2017.
Ext. A9 : Discharge summary issued from Baby Memorial Hospital during the year
2013.
Ext. A10 : Application made to Ombudsman.
Witness examined on the side of the opposite party : Nil
Documents marked on the side of the opposite party : Nil
Ext. B1 : Proposal form for LIC’s Health plus policy plan 901.
Ext. B2 : Health plus Plan (Plan 901) form to be filled by the Member (beneficiary) in
case the member is not a minor.
Ext. B3 : Copy of LIC’s Health plus plan (Table 901).
Ext. B4 : Copy of conditions and privileges referred to in the policy document of Unit
Linked Health Insurance Plan (TNo.901).
Ext. B5 : Copy of document deficiency letter dated 12/04/2013.
Ext.B6 : Information reminder dated 02/05/2013.
Ext. B7 : Copy of Medi Assist India TPA Private Limited investigation report dated
29/04/2013.
Ext. B8 : Claim rejection letter dated 08/05/2013 issued by the LIC.
Ext. B9 : Copy of letter of acknowledgement issued by LIC’s to the complainant dated
04/06/2013.
Ext.B10 : Copy of claim rejection letter dated 12/02/2018.
Ext. B11 : Hospital treatment form for Health Insurance policies issued from Baby
Memorial Hospital, Calicut.
Ext. B12 : Copy of letter of appeal submitted by complainant before the opposite
parties dated 03/06/2013.
Ext. B13 : Treatment details issued from Baby Memorial hospital.
MOHANDASAN K., PRESIDENT
PREETHI SIVARAMAN C., MEMBER
MOHAMED ISMAYIL C.V., MEMBER
