Punjab

Sangrur

CC/460/2014

Sarabjit Singh - Complainant(s)

Versus

LIC of India - Opp.Party(s)

Shri A.S. Dullet

10 Apr 2015

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

 

                                                               

                                                Complaint No.    460

                                                Instituted on:      08.08.2014

                                                Decided on:       10.04.2015

 

Sarabjit Singh son of Mohan Sing R/o Village Lasoi, Majra Patti, Tehsil Malerkotla, Distt. Sangrur.

                                                        …Complainant

                                Versus

1.     Life Insurance Company Ltd. Satta Bazar Chowk, Malerkotla, Distt. Sangrur through its Branch Manager.

2.     Life Insurance Company Ltd. of India, Divisional Office, Sector 17-B, Chandigarh through its Manager.

3.     E-Meditek Services Ltd. (TPA) Plot No.577, Udyog Vihar, Phase-V, Gurgaon, Haryana through its General Manager.

                                                        …Opposite parties

For the complainant    :               Shri A.S.Dullat, Adv.

For OPs.                   :               Shri Amit Bedi, Adv.

 

Quorum:    Sukhpal Singh Gill, President

                K.C.Sharma, Member

                Sarita Garg, Member

 

 

Order by : Sukhpal Singh Gill, President.

 

1.             Shri Sarabjit Singh, 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 purchased a health protection plus policy bearing number 164954729 dated 2.3.2011 after paying the requisite amount of premium and the complainant has been paying the instalments of premium regularly since then.  The case of the complainant is that he fell ill and was got admitted in Khosla Hospital, Model Town, Ludhiana and remained there for the period from 15.10.2013 to 17.10.2013 and further took treatment for two months and spent the amount on his treatment from his own pocket.  It is further averred that after completion of the treatment the complainant submitted his claim with the Ops and submitted all the relevant documents/bills for Rs.35,000/- approximately, but the Ops did not settle the claim rather repudiated the claim vide letter dated 5.2.2014, which is said to be wrong and illegal. 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 an amount of Rs.35,000/- along with interest @ 18% per annum and further claimed compensation and litigation expenses.

 

2.             In reply, preliminary objections are taken up on the grounds that the complaint is bad for misjoinder of the parties, that the Ops have been unnecessarily dragged into litigation as such complaint is said to be dismissed with special costs.  On merits, it is admitted that the complainant had purchased the policy in question and paid regular premium for the same. It is also admitted that the complainant submitted his claim documents to the OPs. it is further averred that the claim of the complainant was forwarded to the TPA i.e. OP number 3 for processing of the claim, but the claim was repudiated by the TPA  as total hospitalisation period was less than 52 hours. It is stated that as per medical record received from Khosla Hospital on 30.1.2014, the complainant was admitted in the hospital on 15.10.2013 at 10 AM and discharged on 17.10.2013 at 10.30 AM. It is further stated that the said form has been duly signed and stamped by Dr. Rajesh Khosla of Khosla Hospital.   It is further stated that the claim of the complainant was rightly repudiated.  However, any deficiency in service on the part of the OPs has been denied.

 

3.             The learned counsel for the complainant has produced Ex.C-1 affidavit of the complainant, Ex.C-2 copy of policy, Ex.C-3 copy of policy detail, Ex.C-4 prescription slip, Ex.C-5 copy of certificate of Khosla Hospital and closed evidence. On the other hand, the learned counsel for the Ops has produced Ex.OP-1 affidavit along with annexure (R-1 to R-6) and Ex.OP-2 copy of insurance plan and closed evidence.

 

4.             We have carefully perused the complaint, version of the opposite parties and heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits acceptance, for these reasons.

 

5.             It is not in dispute that the complainant took a LIC’s Health Protection Plus Plan policy bearing number 164954729 on 2.3.2011 by paying the requisite premium of Rs.6000/- on yearly basis under which he was insured for Rs.1,00,000/-.  It is also not in dispute that the complainant fell ill and remained admitted in Khosla Hospital, Ludhiana and thereafter lodged the claim with the OPs.  The OPs thereafter forwarded the claim along with the documents to the TPA, OP number 3.  It is also not in dispute that the TPA repudiated the claim of the complainant on the ground that the total hospitalisation period of the complainant was less than 52 hours. 

 

6.             The learned counsel for the complainant has contended vehemently that the OPs have wrongly and illegally repudiated the rightful claim of the complainant to the tune of Rs.35,000/- which he spent in the Khosla Hospital for the period from 15.10.2013 to 17.10.2013.  The learned counsel for the complainant has further contended that the complainant was never apprised that no claim will be payable if the hospitalisation is less than 52 hours, nor, any such terms and conditions were ever provided to the complainant, which the Ops have now produced on record as Ex.OP-2.  On the other hand, the learned counsel for the OPs has contended vehemently that the complainant was supplied the terms and conditions alongwith the policy in question.  As such, the repudiation of the claim is said to be quite justified.

 

7.             We have very carefully gone through the LIC’Health Protection Plus Plan issued in the name of the complainant, which is on record as Ex.C-2, but we failed to find any such condition in Ex.C-2 that the claim shall only be admissible if the hospitalisation is more than 52 hours.   We further perused Ex.C-2 and found nothing mentioned therein that any such terms and conditions were enclosed therewith as produced by the Ops on record as Ex.OP-2 i.e. LIC’s Health Protection Plus Conditions and Privileges, meaning thereby the OPs kept the terms and conditions in their own pocket without supplying the same to the complainant along with the policy.  As such, we are unable to accept such a contention of the learned counsel for the Ops that such terms and conditions can be made applicable to the complainant in the present case, more so when the same were never supplied to the complainant.  Since the complainant was never made known by the OPs about the conditions and privileges of the policy, we feel that the same cannot be made applicable to the complainant.   Further the Ops have not produced any documentary evidence on record to show that any such conditions and privileges were ever provided to the complainant. As such, we are of the considered opinion that the conditions and privileges were never provided to the complainant.

 

8.             The learned counsel for the complainant has cited Life Insurance Corporation of India and others versus Ashok Manocha 2007(1) CPC 71 (Punjab State Commission),  wherein it has been held that the insurer is duty bound to explain the terms and conditions of the policy to the insured.  In the present case, the Ops have produced nothing on record to show that such terms and conditions were ever explained to the insured.  Further we have perused Oriental Insurance Co. Ltd. versus Brahmdeo Panjiyara 2012(30 CLT 682 (NC), wherein the insurance company repudiated the claim only on the basis of exception clause.  Since the insurance company did not make available to the complainant the special exceptions which were in the specimen copy of the insurance policy nor the same were appraised about, as such findings of the State Commission were upheld that the claim cannot be repudiated by the insurance company by citing the Special Exceptions conditions of the insurance policy.    As such, the insurance company was directed to pay the claim to the complainant.  In the present case also, the OPs have not produced any cogent, reliable and trustworthy evidence on record to show that the LIC’s Health Protection Plus Conditions and Privileges (Ex.OP-2) were ever provided or explained to the complainant.  Accordingly, we find that it is not open for the OPs to repudiate such a rightful claim of the complainant. As such, we are of the considered opinion that the Ops are deficient in repudiating the claim of the complainant.

 

9.             Now, coming to the quantum of compensation payable to the complainant. In the present case, the complainant has claimed the claim amount of Rs.35,000/- as mentioned in the complaint as well as mentioned in the repudiation letter Annexure R-2 that the amount of claim is Rs.35,000/-. The Ops have produced nothing on record that the amount was less than Rs.35,000/-, as such, we accept the claim of the complainant accordingly.

 

10.            In the light of above discussion and in view of the legal position explained above, we allow the complaint and direct the Ops to pay to the complainant an amount of Rs.35,000/- along with interest @ 9% per annum from the date of filing of the present complaint i.e. 08.08.2014 till its realisation in full.  Ops are further directed to pay to the complainant an amount of Rs.5000/-  on account of compensation for mental tension and litigation expenses.

 

11.            This order of ours be complied with within a period of thirty days of its communication. A copy of this order be issued to the parties free of cost. File be consigned to records.

                Pronounced.

                April 10, 2015.

                                                (Sukhpal Singh Gill)

                                                     President

                               

 

                                                   (K.C.Sharma)

                                                        Member

 

 

                                                    (Sarita Garg)

                                                       Member