Punjab

Ludhiana

CC/15/107

Sunita Tripathi - Complainant(s)

Versus

LIC of India - Opp.Party(s)

L.C.Bector adv.

01 Feb 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

Consumer Complaint No. 107 of 23.02.2015

Date of Decision            :   01.02.2016 

 

Sunita Tripathi wife of Sh.Dhruv Narain Tripathi, resident of House No.142, Basant Nagar, Nr Gaushala Road, Khanna District Ludhiana.

….. Complainant

                                                         Versus

1.Life Insurance Corporation of India, 2^nd Floor, Improvement Trust, Khanna, District Ludhiana.

2.Life Insurance Corporation of India, Divisional Office, Dugri Road, Ludhiana.

 

…Opposite parties

 

             (Complaint U/s 12 of the Consumer Protection Act, 1986)

 

QUORUM:

SH.G.K.DHIR, PRESIDENT

SH.SAT PAUL GARG, MEMBER

MS.BABITA, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant                      :          Sh.L.C.Bector, Advocate.

For OPs                          :          Ms.Anju Khullar, Advocate

 

PER G.K.DHIR, PRESIDENT

 

1.     Complainant, an holder of LIC Health Protection Plus Plan (Table 902) policy claims to have purchased policy No.301801906 with validity from             15.2.2011 to 15.2.2040. At the time of purchase of the policy, the complainant was medically fit and she did not conceal any facts qua her health. At the time of issuing of the said policy, OPs assured the complainant that in case she suffered any health problem, then she will be provided due services. Complainant paid the premium on the said policy. However, complainant fell ill on 4.12.2012, due to which, she had to get herself admitted in Post Graduate Institute of Medical Education and Research at Chandigarh(hereinafter in short referred to as ‘PGI’) with problem of Charcinoid Tumor and surgery was performed on her on 12.12.2012. Complainant was discharged from there on 22.12.2012. Complainant had to pay total bill amount of Rs.80,000/- for such treatment. Thereafter, complainant contacted Ops for requesting them to disburse the above said amount of the bill, but to no effect. Rather, OPs sent letter dated 25.2.2013 for intimating the complainant that her claim has been rejected. That rejection is without application of mind and in violation of the terms and conditions of the policy and that is why complainant seeks recovery of Rs.80,000/- along with compensation for mental pain, agony and harassment of Rs. 1 lac.

2.                In the joint written statement filed by Ops, it is claimed that LIC’s Health Protection Plus Plan (Plan No.902) was introduced on 29.4.2009 for providing insurance cover against hospital cash benefits and major surgical benefits. Welcome Kit containing conditions and privileges under Health Protection Plus Plan was also supplied to the complainant. As per terms and conditions of the said policy, the insurer will not be liable for pre-existing condition because clause 6(1)(i) provides so. From the brief summary of treatment provided by the complainant, it became crystal clear that the complainant was suffering from cough and expectoration for last 6 years and as such, her claim was duly rejected. Complainant acted malafide and she has not approached this Forum with clean hands and as such, in view of that complaint alleged to be filed with ulterior motive and prayer made for its dismissal by claiming that there is no deficiency in service on the part of OPs. Admittedly, OPs received the proposal form of complainant through which information was provided by the complainant. As per clause 6(1)(i) of the policy, the insurer will not be liable,if Principal insured or dependent is suffering from pre-existing condition, but the complainant was suffering from disease as referred above and as such, the complainant has obtained the policy by mis-representation of facts. Report dated 25.2.2013 submitted by TPA clearly indicated that claim has been rejected because of pre-existing illness and same action defended by the OPs through filed written statement. It is claimed that TPA has intentionally not been made as a party.Each and every other averment of the complaint denied.

3.                Complainant to prove his case tendered in evidence her affidavit Ex.CA along with documents Ex. C1 to Ex. C33 and thereafter, her counsel closed the evidence.

4.                On the other hand, counsel for Op tendered in evidence affidavit Ex.RW1/A of Sh.C.L.Lalhal, Manager of OPs along with documents Ex.R1 to Ex.R3 and then closed evidence.

5.                Written arguments have not been submitted by any of the parties, but only oral arguments were addressed and heard. Records gone through carefully.

6.                Undisputedly, the LIC policy in question with validity period from 15.2.2011 to 15.2.2040 was purchased by the complainant from OPs as revealed by insurance cover note Ex.C1. Record produced to show that the complainant remained admitted in PGI, Chandigarh for treatment from 4.12.2012 to 22.12.2012. Documentary evidence Ex.C2 to Ex.C6 in that respect has been produced along with record of expenses on purchase of the medicines because the copies of bills Ex.C7 to Ex.C31 has been produced in this respect on record. Terms and conditions of the insurance policy cover note Ex.C33 has even been produced on record. Admittedly, the complainant lodged the claim for medical reimbursement with OPs, but the same was rejected due to clause 6(1)(i) of Ex.C3 vide rejection letter dated 25.2.2013 Ex.C32(Ex.R3). After rejection of the claim on 25.2.2013, this complaint was filed on 23.2.2015 that is at the fag end of expiry of limitation period of 2 years. Even then the complaint is within limitation being filed within two days prior to the expiry of limitation period contemplated by Section 24-A of Consumer Protection Act, 1986. The effect of late filing of complaint will be that the complainant will be entitled to interest from the date of filing of complaint, if her claim found sustainable.

7.                After going through the brief summary contained in Ex.R2, it is made out that complainant was suffering from cough with expectoration for the last 6 years. In column of diagnosis, it is mentioned as if complainant was having symptom of Carcinoid Tumor involving chest. Further, in the column of brief summary, it is mentioned that complainant was having symptom of “EPBODES of Haemoptysis since 4 months”. In view of this, it is vehemently contended by counsel for OPs that in fact the complainant was suffering from pre-existing condition prior to the obtaining of the policy because she was suffering from Cough   with expectoration for the last 6 years prior to admission in PGI, Chandigarh on 4.12.2012. However, the policy in question was purchased on 15.2.2011 and as such, it is contended that complainant was suffering from cough problem even at the time of obtaining the policy in question. There is nothing on record to suggest that the complainant due to sufferance of cough problem was having any reason to believe that she was suffering from Tumor problem. Pre-existing condition as defined in clause 6(1)(i) of Ex.R1 provides that pre-existing means any medical condition or any related condition (e.g.illnesses, symptoms, treatments, pains) that have arisen at some point prior to the commencement of the coverage, irrespective of whether any medical treatment or advice was sought. Further as per this clause 6(1)(i) of Ex.R1, 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. No record has been produced by Ops to show that diagnose of cough with expectoration problem was earlier got treated by the complainant from any doctor. There may be various reasons of cough with expectoration because  the same may be due to some allergy or the same may be bronchitis or like that. But disease of bronchitis or of allergy is not such a disease as well denude the insured from getting medical claim through. As complainant or her dependent not shown to be aware of symptoms of illnesses or of pains of Tumor earlier to the diagnosis after admission of the complainant in PGI, Chandigarh, on 4.12.2012 and as such, repudiation of claim due to pre-existing condition is highly improper and unjustified. Rather, surgery on complainant was performed on 7.12.2012 is a fact borne from Ex.R3=Ex.C32. Diagnosis of Carcinoid Tumor was shown to be done for the first time during admission of the complainant on 4.12.2012 to 22.12.2012 in PGI, Chandigarh as revealed by Ex.R3=Ex.R32 and as such, there was no suppression of fact by the complainant qua pre-existing illnesses, symptoms or disease in question. When such knowledge to the complainant or her dependents was not attributable, then certainly they could have not disclosed about the same to the OPs at the time of purchase of the policy in question. So, rejection of the claim is illegal and unjustified and as such, complainant entitled to compensation for mental pain, agony and harassment to the tune of Rs.10,000/- along with litigation expenses of Rs.5000/- and OPs must reconsider the claim of the complainant within 30 days from the date of receipt of copies of order.

8.                Therefore, as a sequel to the above discussion, complaint allowed with the direction to OPs to reconsider the claim of the complainant within 30 days from the date of receipt of copies of order. That exercise of reconsideration must be completed within 45 days and thereafter, payment of due amount( if any found) be made to the complainant within 30 days of the order to be passed by the OPs with interest @7% p.a. from the date of filing of the complaint namely 23.02.2015 till payment. Compensation of Rs.10,000/- and litigation expenses of Rs.5000/- allowed in favour of the complainant and against OPs. Compliance of these directions be made within 30 days from the date of receipt of copies of the order. Copies of order be made available to the parties free of costs as per rules.

9.                File be indexed and consigned to record room.

 

          (Babita)                (Sat Paul Garg)                         (G.K. Dhir)

Member                 Member                                   President

Announced in Open Forum

Dated:01.02.2016

Gurpreet Sharma.