Haryana

Ambala

CC/414/2016

Harvinder Singh - Complainant(s)

Versus

LIC - Opp.Party(s)

G.S.BAWA

30 May 2018

ORDER

 

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AMBALA

 

                                                                      Complaint case no.        :  414 of 2016

                                                          Date of Institution         :  07.11.2016

                                                          Date of decision    :   30.05.2018

 

 

Harvinder Singh aged 50 year, son of Sh. Sawan Singh r/o House No.2099/2, Mohalla Guru Nanakpura, Ambala City.

……. Complainant.

 

 

1.       L.I.C. of India, through its Manager, LIC, Building near Head Post Office, Aggar Sain Chowk, Ambala City.

2.       The Manager, LIC of India, Health Insurance, Divisional Office, 489, Model Town, Karnal.

 

 ….…. Opposite Parties.

 

Before:        Sh. D.N.Arora, President.

                   Sh. Pushpender Kumar, Member.

Ms. Anamika Gutpa, Member.           

         

 

Present:        Sh. G.S.Bawa, counsel for complainant.

                    Sh. Dev Batra, counsel for OPs.

 

 

ORDER:

                   In nutshell, brief facts of the present complaint is that the complainant has taken a Health Policy vide no.1716103565 dated 30.04.2008 of LIC’s Health Plus Plan with expiry date of 30.04.2030 from Health Insurance, Ambala and all the documentations with regard to taking of the aforesaid policy and completed in the office of OP No.1 at Ambala City and as per the Health Plan, the complainant had been paying Rs.15,000/- annually as he has purchased  LIC Health Plus Profit Policy. There is no limitation for repaying the insurance amount to the complainant and whatsoever the amount shall be spent by the complainant at his would be treatment that amount without any deduction along with interest shall be paid to his against the bills. The complainant suffered heart problem and he got himself checked from MAX HEALTH CARE and also orally intimated to the OP in this regard. He was operated twice i.e. firstly in the month of Jan.2016 and second in the month of July, 2016 by the Doctors of the MAX Hospital as detailed above and the stunts were inserted and the Max Hospital has charged a sum of Rs.3,59,345/- in the month of Jan.2016 and another  amount of Rs.2,32,740/- were received by the Max Hospital in the month of July,2016 and the complainant has paid a total sum of Rs.5,92,085/- to the Max Hospital, Mohali against the receipts and all the dealings and receipts were deposited with the OP for the repayment to the complainant, but inspite  of given aforesaid assurance and the repayment of Rs. 5,92,085/- the OP has made a meager amount payment of Rs.80,000/- only so far and the remaining amount of Rs.5,12,085/- is yet to be paid by the OP which is the legally enforceable liability of the OP. A legal notice dated 08.10.2016 by regd. Post was given to the OP No.2.           Thus, the complainant has suffered economical loss and financial loss. Hence, the present complaint.

2.               Upon notice, OPs have appeared and filed written statement and learned counsel for the OPs stated that as reported by the complainant he was diagnosed Acute IWMI, HTN, Hyperurecimia, CAD-TVD and was treated surgically by PTCA with stent to LAD/RCA in MAX Super specialty hospital during hospitalization period from 12.01.2016 to 14.1.2016. As per out records the complainant has lodged the claim for the treatment taken in Jan.2016 wherein he claimed Rs.3,59,345/-. No claim allegedly taken on  July 2016 for Rs.2,32,740/- was ever reported to our office, but even otherwise the same was not payable in view of above terms  & conditions  & the claimant was paid Rs.80,000/- for Major Surgical Benefit and nothing was payable for hospital cash benefit as the hospitalization period was less than 52 hours. As per terms & conditions of the policy 40% of the MSB covered is payable for the treatment taken which is Rs.80,000/- and it has already been paid and HCB is not payable for the first 48 hours of hospitalization. So, there is no deficiency in service on the part of OPs and prayed for dismissal of the present complaint.

3                 To prove his version complainant tendered his affidavit as Annexure C-X & C-Y along with documents as annexure C-1 and C-15 and close his evidence. On the other hand, Counsel for the OPs tendered affidavit as Annexure R-X along with documents as Annexure R-1 & R-13 and close their evidence.

4.                We have heard both the counsels of the parties and carefully gone through the case file. It is admitted fact that the complainant had taken a Health Policy vide no.1716103565 dated 30.04.2008 of LIC’s Health Plus Plan with expiry date of 30.04.2030 from Health Insurance, Ambala. During the policy period, the complainant suffered heart problem and got admit in the Max Health Care Hospital. The complainant has alleged that he was operated twice in the month of Jan, 2016 & second time in the month of July, 2016 and stents was inserted and the Max Hospital charged Rs. 3,59,345/- in month of June, 2016. The complainant has paid the amount of Rs.2,32,740/- in the month of July, 2016 for second time and he further taken the plea that the Ops have paid only Rs.80,000/- and rest of the amount has been declined. At the time of the arguments, the counsel for the complainant moved an application for giving the direction to the OP to produce the original policy file. Reply filed by the Ops. We observed that the complainant failed to prove any relevancy to summoning the policy file when all relevant documents already on the record. Hence, the application filed by the complainant for summoning the original file is hereby dismissed.

5.                          It is clear from the treatment record Annexure C-3 to Annexure C-5, the complainant was admitted in the hospital on 30.07.2016 at 9.15P.M.  and diagnosed a case of Coronary Angiography, CAG, via Right Radial Route, revealed  Triple Vessel disease, Post PTCA, Patent Stents  to RCA & Proximal-Mid LAD which PTCA with Stent to LAD was done on 30.07.2016 and discharged on 31.07.2016. It is proved from the above treatment record that the complainant was admitted on 30.07.2016 at 9.15 P.M. and discharged on 31.07.2016 and remained admitted in the hospital less than 52 hours and nothing under the Hospital Cash Benefit  is payable  and case of the complainant does not cover under the above said benefits (Hospital Cash Benefit Limits).  

6.                          Now, question arises whether the surgery done to the complainant covered under major surgery benefit limit. As per the terms and conditions Annexure R-13 it was the duty of the complainant which type of the surgery was under taken by the complainant with regard to Cardio- vascular system. Admittedly the surgery under taken by the complainant was not major surgery as per the list of the surgical procedure. It is mentioned that major surgery of Arota the amount is payable 100% sum assured, CABG(two or more coronary arteries must be bypassed) via open chest surgery  the amount is payable 100% sum assured, Valve Replacement using  mechanical prosthesis via open chest surgery the amount is payable 100% sum assured, Pericardiotomy/Pericardectomy done in chronic constrictive pericarditis amount is payable 100% sum assured, Open chest surgery for repair of any of the heart valves the amount is payable 100% sum assured.

7.                          In view of the above Cardio-vascular system (surgical benefit list as mentioned above) now question arises whether the complainant is entitled for 100% of the assured amount. It is not a case of the complainant that he has been operated open chest surgery for repair any heart valves which may entitle 60% of the assured amount. The case of the complainant is that stents were inserted in the Max Hospital. Hence, the surgery taken by the complainant has been rightly considered by OP by releasing 40% of the assured amount as per terms and conditions of the policy and amount for surgery can be released once for all surgery in the insured period. On the other hand counsel for the complainant argued that the terms and conditions has not been issued to the complainant so the terms and conditions Annexure R-13 is not binding on the right of the complainant and he is entitled 100% of assured amount but it is not a plea of the complainant in the complaint that terms and conditions has not been supplied. So such plea is not tenable. As such this Forum has not found any deficiency on the part of the Ops for treating the claim of the complainant. So, the present compliant is hereby dismissed with no order to costs. Copy of the order be sent to the parties concerned, free of costs, as per rules. File after due compliance be consigned to record room.

Announced on :30.05.2018

                                               

 

 

(PUSHPENDER KUMAR)     (ANAMIKA  GUPTA)           (D.N. ARORA)

            Member                               Member                                 President