BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 124 of 2017
Date of Institution : 6.6.2017
Date of Decision : 27.2.2018.
- Mahesh Yadav (aged about 30 years) son of Ran Singh Yadav,
- Ran Singh Yadav (aged about 67 years) son of Sh. Ram Chander, both residents of 646- Ram Gali, Kirti Nagar, Sirsa.
……Complainants.
Versus.
- Branch Manager, Life Insurance Corporation C/o LIC Building, Opposite Spar Banquette Hall, Sirsa.
- Divisional Manager, L.I.C., Divisional Office, SCO-3, 4,5, Sec. 1, HUDA, Rohtak- 124001.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SH. R.L.AHUJA…………………………PRESIDENT
SH. MOHINDER PAUL RATHEE …… MEMBER.
Present: Sh. Ravinder Monga, Advocate for the complainant.
Sh. K.K. Relan, Advocate for opposite parties.
ORDER
The case of the complainants in brief is that complainants and their other family members are interested to secure them through some medical aid policies preferring health insurance. The complainants put their efforts for searching such type of health insurance policy from the newspaper, internet, advertisements etc. The complainants could not satisfy from the different health policies launched by different insurance companies some because of new company, some because of point of credibility in Indian market. That the ops being corporation group through their wide publicity in National, Regional, Local newspapers launching their new policies in the interest of general public. Out of which a LIC policy known as “Jiwan Arogya” (Table-904) was launched. The complainants after coming to know about the said policy keen to know about the features, benefits etc. The ops contacted with the complainants and explored their launched policy known as “Jiwan Arogya”. After going through the terms and conditions, the complainant no.1 purchased the said policy vide policy No.179909513 covering risks from 25.1.2016 to 25.1.2063. The ops prepared yearly installments of Rs.4158/- to be paid up to 25.1.2062. The ops before issuing the said policy in favour of complainant no.1 fulfilled all the required formalities including medical checkup etc. for the satisfaction of their norms and guidelines. It is further averred that at the time of receiving the LIC’s Jiwan Arogya policy, few terms and conditions were settled between complainant and ops in presence of complainant no.2 who is father of complainant no.1. That the complainant no.1 on 21.11.2016 suddenly felt problem in his body and due to critical condition, the complainant no.2 alongwith other family members immediately taken him to Medicare Hospital, Near Red Light chowk, Sirsa. Dr. Ramesh Dudi and Dr. Narbachan Singh got admitted complainant no.1 on 21.11.2016 and after giving treatment, medical care, required medical tests, diagnosis and was discharged on 30.11.2016. The intimation in this regard was duly given to the ops well within time. It is further averred that complainant no.1 after discharge from the hospital joined the duty and submitted his medical bills of Rs.69,317/- on 2.12.2016. The op no.1 verified the bills, treatment etc. by its own sources and sent the same to the office of op no.2 for clearance purpose. The complainant submitted all the original doctor’s bill, medical treatment detail, report of tests etc. and the original bills were submitted alongwith the claim form and other documents as required by the ops. That the complainant submitted the written application alongwith the bills and required documents and for a number of occasions inquired about the pending claim with the ops and every time he was asked to wait for a positive response as his papers have already been referred with the op no.2 who is final authority to decide the claim. It is further averred that complainant was shocked to receive alleged letter reference No.HI/CLM/ repudiation dated 8.3.2017 shown to be issued from the office of Manager, HI, Rohtak i.e. op no.2 wherein it was referred “We have reviewed the detail given in the claim forms and also various other reports given by you/ collected by the TPA/us in the course of verification/ investigation. We observe that your claim cannot be considered for admission and payment as per the terms and conditions specified in the policy, for the following reasons- Self inflicted injuries or conditions (attempt suicide) and/or use or misuse of any drug or alcohol), Hence we regret to inform you that your claim is repudiated and nothing is payable under the policy for the above referred hospitalization.” The complainant could not understand the exact reason of alleged repudiation of his claim. Even the alleged verdict given in the alleged letter seems to be self confusing version. There is no clear reason mentioned for repudiating the claim, every time the word written or itself found to be ambiguity created by ops, rather the same could be tantamount as predetermined decision written on stereo type letter without applying judicious mind and only with a view to deny the claim in a routine manner and same is liable to be quashed. The complainant went to the office of op no.1 and inquired about the alleged letter issue by op no.2 but op no.1 showed his inability to interfere into the decision of op no.2. That now after regular contacting with the ops, the complainant went to a conclusion that he had been defrauded, cheated by the ops who have adopted technicalities with a sole view to repudiate his claim. Though this is an admitted part that the LIC Jiwan Arogya Insurance Policy had been purchased by complainant on 25.1.2016 commencing the risk up to 25.1.2063. Moreover, the complainant successfully completed all the required formalities including medical examination as per the need and demand of the ops. The policy is being issued only after due satisfaction by the paneled doctor and the official of the ops. The ops have caused deficiency in service and adopted unfair trade practice towards the complainant. Hence, this complaint.
2. On notice, opposite parties appeared and filed written statement taking certain preliminary objections regarding maintainability, cause of action, concealment of material facts, no deficiency and that complainant did not avail the departmental remedy of filing representation against the repudiation of the claim, before the zonal office, New Delhi before filing this consumer complaint. On merits, while admitting the fact of purchase of policy by complainant, it is submitted that complainant himself admitted that after going through the terms and conditions he purchased this policy. So he was very much aware from the terms and conditions of the policy. The ops followed the terms and conditions of the policy. The claim of the consumer cannot be considered for admission and payment as per terms and conditions specified in the policy. The cause of repudiation as per repudiation code (H12) self afflicted injuries or conditions (attempted suicide), and/or the use or misuse of any drugs or alcohol and repudiation code (MII) same as H12. Remaining contents of complaint are also denied.
3. The parties then led their respective evidence by way of affidavits and documents.
4. We have heard learned counsel for the parties and have perused the case file carefully.
5. Learned counsel for complainants has contended that it is proved case of complainants that the complainant no.1 had taken a Jiwan Arogya policy from opposite parties vide policy No.179909513 covering risks from 25.1.2016 to 25.1.2063 and the ops prepared yearly installments of Rs.4158/- to be paid up to 25.1.2062. The complainant no.1 on 21.11.2016 suddenly felt problem in his body and due to critical condition, the complainant no.1 was taken to Medicare Hospital, Sirsa by complainant and his other family members where he got treatment and was discharged on 30.11.2016. The claim was lodged and the medical bills for Rs.69,317/- were submitted on 2.12.2016 but however, the claim of the complainant was repudiated arbitrarily and illegally for the reason self inflicted injuries or use of any drug or alcohol. The ops are under legal obligation to pay claim of the complainant and has relied upon judgments reported as 2000(1) CPC 358 titled as LIC Vs. Suresh Kumar (minor) (HSCDRC, Chandigarh), III (2004) CPJ 165, titled as UIIC Vs. Mehenga Singh (Uttranchal SCDRC) and 2008(3) CPJ 279, LIC vs. Satinder Kaur (SCDRC Punjab).
6. On the other hand, learned counsel for ops has strongly contended that complainant has no cause of action to file the present complaint and has not come to the Forum with clean hands. While making declaration in the proposal form, complainant has concealed fact that he was taking alcohol though during the course of investigation, he has been proved to be a chronic alcoholic. He suffered injuries on his person being a chronic alcoholic. Learned counsel for ops has further contended that it is proved fact as per report of the TPA E-Meditek Services Limited Ex.R3, the assured got treatment for ailment and was hospitalized due to chronic alcoholic pancreatitis and duodenal perforation. Further more, learned counsel for ops has referred Ex.R9 the statement of the relatives of the life assured which was recorded by the hospital authorities before conducting surgery on the person of complainant. This all proves that claim of complainant has rightly been repudiated by the ops on the basis of concealment of facts of taking alcohol. Ld. counsel for ops has relied upon judgment of the Hon’ble National Commission in case titled as Vinita Sethi vs. ICIC Prudential Life Insurance Company Ltd. & anr. Part No.XXXV October 2016 Volume-IV.
7. We have considered the rival contentions of the parties and have gone through the record and judgments relied upon by learned counsel for parties carefully.
8. The perusal of complaint reveals that complainants in order to prove their case have furnished affidavit of complainant no.1 Ex.C1, affidavit of complainant no.2 Ex.C2, copy of letter dated 8.3.2017 Ex.C3, copy of bill detail Ex.C4, copy of application Ex.C5, copy of policy Ex.C6 and copy of application Ex.C7. On the other hand, ops have furnished affidavit of Sh. Rajendra Singh Manager Ex.R1 and relied upon copy of letter dated 23.1.2017 Ex.R2, copy of report Ex.R3, copy of letter dated 11.3.2017 Ex.R4, copy of claim sheet Ex.R5, copy of policy details Ex.R6, copy of letter dated 6.3.2017 Ex.R7, copy of office note Ex.R8, copies of treatment record Ex.R9 to Ex.R11, and copy of status report of policy Ex.R12 and copy of laboratory test report Ex.R13.
9. The first contention of learned counsel for ops is that complainant has not submitted the original bill to the ops for settlement of the claim. The perusal of the record reveals that complainant has placed on record copy of document Ex.C4 with heading total bill detail from 21.11.2016 to 30.11.2016 and has mentioned bill numbers and the name of issuing concerns. The perusal of the letter Ex.R7 reveals that there is specific mention by Manager Health Insurance that they are in receipt of a HCB/MSB claim file/ papers as per details below and under heading documents, it has been specifically mentioned claim form, hospital treatment form, discharge summary, bill, lab reports, ultrasound report, daily treatment report and sent the same to the Branch Manager, E Meditek TPA Services Ltd. Chandigarh. So this letter clearly proves that bills, lab reports, ultrasound report and daily treatment report alongwith hospital treatment file and discharge summary were duly submitted by the complainant to the Manager Health Insurance who further submitted to the Branch Manager, E- Meditek TPA Services Ltd. So, this contention of learned counsel for ops appears to be devoid of any merit.
10. The second contention of learned counsel for ops is qua the repudiation of claim of complainant on the ground under the head repudiation code H12 self inflicted injuries or conditions (attempted suicide), and/or the use or misuse of any drugs or alcohol. The perusal of the evidence of ops reveals that they have relied upon the report of E-Meditek (TPA) Services Limited Ex.R3 but perusal of this report reveals that it does not bear the signatures of any authorized signatory nor the same has been self attested by any official of the LIC due to reason best known to the ops. The ops have not placed on record any affidavit of the concerned doctor who examined all the medical record of the complainant and came to any conclusion and submitted his detailed report in support of this report. The ops have further relied upon Ex.R9 report of the investigations but the ops have not furnished affidavit of Dr. Azad Singh regarding the diagnosis and treatment given by him to the complainant and regarding surgery if any conducted on the person of complainant. The ops have further not placed on record any specific evidence that the complainant was a chronic alcoholic and regarding disease which he suffered and for which he had undergone a surgery was a result of excessive alcohol. The ops have further not placed on record any terms and conditions of the policy on the basis of which they have repudiated the claim of the complainant. So, it appears from the evidence of ops that they have arbitrarily and illegally repudiated the claim of the complainant which clearly amounts to deficiency in service on the part of ops and further more said repudiation order is liable to be set aside.
11. In view of the above, we allow the present complaint, set aside the repudiation order/ letter and direct the opposite parties to settle and pay the claim of the complainant which may become payable as per terms and conditions of the policy to the complainant within a period of 30 days from the receipt of copy of this order. We also direct the ops to pay a sum of Rs.3000/- as composite compensation and litigation expenses to the complainant. In default, the ops shall be liable to pay interest @9% per annum on the amount of claim payable by ops to the complainant from the date of order till actual payment. A copy of this order be supplied to the parties free of costs. File be consigned to the record room.
Announced in open Forum. President,
Dated:27.02.2018. Member District Consumer Disputes
Redressal Forum, Sirsa.
