D.O.F:14/06/2019
D.O.O:30/03/2022
IN THE CONSUMER DISPUTES REDRESSAL FORUM, KASARAGOD
CC.No.112/2019
Dated this, the 30th day of March 2022
PRESENT:
SRI.KRISHNAN.K : PRESIDENT
SRI.RADHAKRISHNAN NAIR.M: MEMBER
SMT.BEENA.K.G : MEMBER
Sunny George
Narippara House
Bandadka Post – 671541 : Complainant
Kasaragod
(Adv: Vijayan Kodoth)
And
LIC of India
Kasaragod Branch : Opposite Party
Kozhikode Division
(Adv: A. Radhakrishnan)
ORDER
SRI.RADHAKRISHNAN NAIR.M: MEMBER
The complaint is filed under section 12 of the Consumer Protection Act, 1986 (as amended).
The facts of the case in brief is that the complainant took the insurance policy, namely, Jeevan Arogya scheme of the Opposite Party and was remitting the premium amount promptly. The complainant who is a rubber tapping labourer, while doing the tapping work, fell down and the tapping knife piearsed in to his left hand by cutting the muscle and nerves and thereby lost the mobility of left thumb.
The complainant was treated at AJ Hospital, Mangalore for 6 days from 14.12.2018 to 19.12.2018 as inpatient and undergone operation and plastic surgery spending an amount of Rs.65,000/- as hospital bill. He incurred a total expense of Rs.85,000/-, including misceIIanious expenses.
The complainant filed a claim petition as per insurance policy but the Opposite Party sanctioned only Rs. 7,000/-. The Complainant is entitled for the entire amount of treatment expenses. But the Opposite Party sanctioned only a meagre amount, which amounts to service deficiency on their part. Hence this complaint is filed seeking direction to the Opposite Party to pay Rs.2, 00,000/- as compensation and cost.
The opposite party entered appearance and filed written Version.
As per the written version of the Opposite Party, it is admitted that they have issued an insurance policy to the complainant under Jeevan Arogya scheme with policy No.797930385.
1). Hospital cash benefit (HCB) : If you or any of the insured lives covered under the policy is hospitalised due to Accidental Body Injury or Sickness and the stay in hospital exceeds a continuous period of 24 hours, within the cover period, then subject to terms and conditions Daily Benefit (ADB) is payable by the corporation.
The proposer has the option to choose the amount of initial daily benefit .This arithmetically increase @ 5% every year up to 50 % called Applicable Daily Benefit (ADB). This is payable under the Hospitalisation cash benefit. No claim bonus @ 5 % of ADB is added to all benefits after every 3 years.
ll). Major Surgical Benefit (MSB) : - In the event of an Insured under this plan, due to medical necessity, undergoing one of the surgeries defined in Major Surgical Benefit Annexure, within the cover period in a hospital due to Accidental Bodily Injury or Sickness, the respective benefit percentage of the Major Surgical Benefit Sum Assured, as specified against each of the eligible surgeries mentioned in Major Surgical Benefit Annexure, shall be paid by the corporation regard less of the actual cost incurred.
III) Day Care Procedure Benefit : In the event of an Insured under this Plan undergoing any specified Day Care Procedure mentioned in the Day Care Procedure Benefit Annexure due to medical necessity, a lump sum amount equal to 5 (five) times the Applicable Daily Benefit shall be paid, regardless of the actual costs incurred.
IV). Other Surgical Benefit : In the event of an Insured under this Plan, due to medical necessity, undergoing any Surgery not listed under Major Surgical Benefit or Day Care Procedure Benefit, causing the Insured’s Hospitalization to exceed a continuous period of 24 hours within the Cover Period, then, a daily benefit equal to 2 (two) times the Applicable Daily Benefit shall be paid for each continuous period of 24 hours or part thereof provided any such part stay exceeds a continuous period of 4 hours of Hospitalization.
So the benefits available under the policy are clearly mentioned in the policy document. The initial daily Benefit chosen by the complainant as per policy is Rs.1000/-. On each policy year, an amount equal to 5 % of the daily benefit has been added to arrive the applicable daily benefit. Also no claim benefit @ 5 % of initial Daily Benefit chosen is added, after 3rd and 6th year since no claim is availed on the policy in last 6 years.
The Complainant had preferred a claim under the policy on 28.12.2018 as per the discharge sumary from AJ Hospital Manglore. The claim was settled under the Day care procedure and an amount of Rs.7,000/- was given to the complainant The amount arrived as follows :-
Initial daily benefit chosen - Rs.1000/-
Date of commencement of the policy - 10.08.2012
Date of Hospitalisation /claim - 14.12. 2018
Period for Auto increase of 5 % - 6 years
Applicable daily benefilt arrived after after 6 year - Rs.1,000 + (1,000 x 5 % x 6) = Rs.1,300/- Period for claiming No claim Bonus @ 5 % - 2 times (For each 3 years) Eligible amount of No claim Bonus - Rs.1,000 + (1,000 x 5 % x 2) = Rs.100/- Applicable daily benefit eligible - Rs 1300+ Rs. 100/- = 1400/-As per policy conditions Day care procedural benefit payable - Rs.1400 x 5 = Rs .7,000/-.
The medical bills for Rs.61,634 / - was submitted by the complainant but since the Jeevan Arogya plan is an insurance policy and not a mediclaim policy, only prefixed benefits are payable.
There is no service deficiency on the part of the Opposite Party. The complaint is to be dismissed.
The complainant filed proof affidavit in lieu of chief examination and documents.
Ext. A1 to Ext. A5 are marked .The Ext - A1 is the Discharge Summary dated 19-02-2018 from AJHospital , MangIore , Ext - A2 is the Jeevan Arogya Health Insurance policy dated 10-08-2012.
Ext A3 is the Renewal premium receipt. dated 04 -08-2017, Ext. A 4 is the copy of Medical bill dated 19.12.2018 from AJ Institute of Medical Science, Manglore. Ext. A5 is the Hospital treatment form.
The opposite party's Manager Legal and Housing property finance filed proof Affidavit in lie u of Chief examination and marked documents as Ext. B1 and Ext. B4 series. Ext B1 is the proposal form of the Complainant. Ext.B2 is the copy of the Policy. Ext. B3 is the payment letter, Ext. B4 series are the claim form documents.
Based on the pleadings and evidence of the rival parties in this case the following issues are framed for consideration.
1. Whether the complainant is entitled for any amount towards the insurance benefit?
2. Whether there is any service deficiency on the part of any of the opposite party?
3. If so, what is the relief?
For convenience, all these issues are considered together.
Here the specific case of the complainants that he took the insurance policy, namely, Jeevan Arogya scheme of the Opposite Party and was remitting the premium amount promptly. The complainant, who is a rubber tapping labourer, while doing the tapping work, fell down and the tapping knife piearsed in to his left hand by cutting the muscle and nerves and thereby lost the mobility of left thumb. The complainant was treated at AJ Hospital, Manglore for 6 days from 14.12.2018 to 19.12.2018 as inpatient and undergone operation and pastic surgery spending an amount of Rs.65,000/- as hospital bill. He incurred a total expense of Rs.85,000/- , including misceIIanious expenses. The complainant filed a claim petition as per insurace policy but the Opposite Party sanctioned only Rs. 7,000/-. The Complainant is entitled for the entire amount of treatment expences. but the Opposite Party sanctioned only a meagre amount, which amounts to service deficiency on their part.
The Opposite Party's version is that benefit available under the policy are clearly mentioned in the policy document. The initial daily Benefit chosen by the complainant as per policy is Rs.1000/-. On each policy year, an amount equal to
5 % of the daily benefit has been added to arrive the applicable daily benefit. Also no claim benefit @ 5 % of initial Daily Benefit chosen is added, after 3rd and 6 th year since no claim is availed on the policy in last 6 years. The Complainant had preferred a claim under the policy on 28.12.2018 as per the discharge sumary from AJ Hospital Manglore. The claim was settled under the Day care procedure and an amount of Rs.7,000/- was given to the complainant The amount arrived as follows :-
Initial daily benefit chosen - Rs.1000/-
Date of commencement of the policy - 10.08.2012
Date of Hospitalisation /claim - 14.12. 2018
Period for Auto increase of 5 % - 6 years.
Applicable daily benefilt arrived after after 6 year - Rs.1,000 + (1,000 x 5 % x 6) = Rs.1,300/-
Period for claiming No claim Bonus @ 5 % - 2 times (For each 3 years)
Eligible amount of No claim Bonus - Rs.1,000 + (1,000 x 5 % x 2) = Rs.100/-
Applicable daily benefit eligible - Rs 1300+ Rs. 100/- = 1400/-
As per policy conditions Day care procedural benefit payable - Rs.1400 x 5 = Rs .7,000/-
The medical bills for Rs.61,634 / - was submitted by the complainant but since the Jeevan Arogya plan is an insurance policy and not a medi claim policy, only prefixed benefits are payable.
Here the Document Ext. A 2 the Discharge Summary shows that the complainant had sharp cut in jury Left hand - 1st WEB Space Laceration with FPL Tendon Injury.
It also shows that the patient had under gone the surgical procedure, namely , ''Left hand 1st web space wound exploration /repair of FPL/thenar muscle done under BB ". As per the version of the Opposite Party, the benefits under the Jeevan Arogya policy are the following :
Hospital cash benefit (HCB), Major Surgical Benefit (MSB),. Day Care Procedure Benefit, Other Surgical Benefit etc. It means that the insured persons who took the Jeevan Arogya policy is entitled for all or any of the above benefits, according to the nature of his case and as per the terms and conditions of the policy.
The complainant states that he got injured from work place and was treated in Mangalore hospital for 6 days as in patient. He had undergone a surgery and spent about Rs.85,000/- for treatment. He produced Ext. A4 , the hospital bill showing an amount of Rs.61,634 /- + Rs .3,878/- =Rs .65,512/-.His further case is that he took the policy on the promise of the agent of the Opposite Party that entire hospital expenses will be sanctioned. The Opposite Party didn't disputed the accident and the treatment of the complainant. Also there is no dispute regarding the quantum of hospital expenses incurred by the complainant.
The Opposite Party argues that the amount can only be sanctioned only as per the terms and conditions of the policy. As per the terms and conditions, the complainant is entitled for Rs. 7,000/- . They have discribed a calculation in the written version, as per which how they arrived at Rs 7,000/-.
As per the calculation of Opposite Party, the complainant is only entitled for the benefit under the head Day care procedure benefit. Since the complainant had chosen Rs 1,000 a initial daily benefit, the Opposite Party calculates with that amount and some small multipliers and shows that the complainant is entitled for Rs.7,000/- even though he paid a total amount of Rs.61,634 /- + Rs .3,878/- =Rs .65,512/-at the hospital.
The Opposite Party says that the calculation is based on some procedures mentioned in policy annexure. But the Opposite Party has not produced a copy of that annexure for perusal. The Document Ext .B2, the copy of the policy conditions is not clear and readable.
Further there is no evidence to show that a copy of the above policy condition was issued to the complainant at the time of taking the policy. Also there is no evidence to show that the complainant had signed the above one sided terms and conditions.
It is very interesting to note that the calculation schedule as described in the written Version is seen to be erroneous. It is written that "Eligible amount of No claim Bonus - Rs.1,000 + (1,000 x 5 % x 2) = Rs.100/- " . This is apparently erroneous . Here the correct amount shall be Rs. 1,100/- not Rs. 100 /-. So, the final amount to be Rs. 1,300 + Rs.1,100/-= Rs . 2,400/-Rs. 2,400/- x 5 = Rs . 12,000/-.
So as per the correct calculation, the complainant is entitled for Rs. 12,000/- in this head and there is a balance of Rs.5,000/- to be paid to the complainant.
All this imply that the opposite party was purposefully trying to calculate in such a way so as to minimize the insurance benefit amount and defeat the complainant.
Health insurance is an agreement whereby insurance company agrees to undertake to guarantee of compensation for medical expenses, in case the insured falls ill or meets with an accident which leads to hospitalization of the insured.
It is of no use or purpose, if the insurance company is not ready to bear the genuine hospital expenses of the insured, who got injured in an accident. Denial of such benefit on technical grounds, and by adopting erroneous calculation is illegal and against the concept and perspective of consumer protection law.
Here the opposite party has no dispute regarding the validity or coverage of insurance policy of the complainant. Also no pleading that the complainant's case is falling under exclusion clause of the policy conditions.
So considering the facts and circumstance of the case, this commission is of view that in addition to Rs 5,000/- , being the balance amount in Daily benefit mentioned earlier, the complainant is entitled for the hospital bill amount of Rs.61,634 /- + Rs .3,878/- =Rs .65,512/- towards insurance benefit.
Since the Opposite Party didn't pay the above amount in time, there is service deficiency on the part of them, due to which the complainant suffered mental agony. Therefore the Opposite Party is liable to pay compensation for that. This commission hold that Rs.10,000/- will be a reasonable amount of compensation.
ln the result, the complaint is allowed in part and the Opposite Party is directed to pay a total amount of Rs. 70,512/- with 8% interest per annum from 14.06.2019, the date of complaint till payment, to the complainant .The Opposite Party is also directed to pay Rs.10,000/- (Rupees Ten thousand only) towards Compensation and Rs.5,000/-(Rupees Five thousand only) towards the costs.
Time for compliance is 30 days from receipt of the copy of the Judgement.
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Exhibits
A1- Discharge summary
A2- Jeevan Arogya Health insurance
A3- Renewal premium receipt.
A4- Medical bill
A5- Hospital treatment form.
B1- Proposal form
B2- Copy of the policy
B3- Payment letter
B4- claim form
Witness Examined
Pw1- Sunny George
Dw1- P.S Sathyanarayannan
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Forwarded by Order
Assistant Registrar
Ps/
