BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 104 of 2013
Date of Institution : 22.4.2013
Date of Decision : 1.3.2016
Prem Kumar son of Sh.Banarsi Dass, r/o House No.2734, Mamera Road, Ward no.11, Ellenabad, District Sirsa.
….Complainant.
Versus.
- Life Insurance Corporation of India, Branch Office, Sirsa through its Branch Manager.
- Life Insurance Corporation of India, Divisional Office, Rohtak, SCO No.3-4-5, Sector-1, HUDA, Rohtak, District Rohtak.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SMT.GURPREET KAUR GILL ………PRESIDING MEMBER.
SHRI RAJIV MEHTA ……MEMBER.
Present: Sh.JBL Garg, Advocate for the complainant.
Sh.O.P.Sihag, Advocate for the opposite parties.
ORDER
In brief, the complainant purchased LIC Health Protection Plus Plan (Table 902) policy from opposite party no.1 bearing No.178982869 dt. 27.7.2011 with sum assured of Rs.4,00,000/-. The date of maturity of the policy was 27.1.2031. The complainant continued making payment of insurance premium regularly to opposite parties. At the time of purchase of insurance policy, the complainant was got medically check up and all the requisite forms were duly got filled up from the complainant by the against of op. As the complainant was found as medically fit person in enquiry by the respondents, therefore, he was issued the abovesaid insurance policy. On 31.5.2012, the complainant was got admitted in Heart and General Hospital, 7, Vivekanand Marg, C-Scheme, Jaipur with complaint of chest pain, where he was surgically operated upon and was discharged on 3.6.2012. A sum of Rs.2,21,850/- was incurred by the complainant on his treatment. Thereafter, the complainant lodged his claim with the respondents under the abovesaid policy, but the same was repudiated vide letter dt. 28.7.2012 on the grounds that (i) pre-existing illness irrespective of prior medical treatment or advice; (ii) surgery not listed in the allowed surgeries as per policy condition. Hence, the present complaint for payment of claimed amount of Rs.2,21,850/- alongwith interest, besides damages for compensation and litigation expenses etc.
2. Opposite parties in their reply have admitted the purchase of the insurance policy by the complainant. It is pleaded that the Major Surgical Benefit Sum Assured is Rs.400,000/-. For principal insured i.e. Sh.Prem Kumar, the date of expiry of hospitalization Cash benefit and Major Surgical Benefit is 27.7.2041. The benefits payable are fixed subject to the claim being as per the terms and conditions of the policy. The complainant was required to disclose the past details of hospitalization/treatment/illness/pathological tests/health conditions etc. in the proposal form. Due to good faith, the declarations given by the complainant about his health conditions in the past were believed true and similarly, it was believed that he had not undergone any illness/treatment in the past. In the event of Accidental Bodily injury or sickness first occurring or manifesting itself after the date of cover commencement and during the cover period, as per policy conditions the following benefits are payable upon hospitalization of the insured person subject to the terms and condition, waiting period and exclusions of the policy: 1. Hospital cash benefit; 2. Major Surgical Benefit. The complainant was hospitalized at Heart and General Hospital, Jaipur from 31.5.2012 to 3.6.2012. He claimed for both the benefits i.e. Hospital Cash Benefit and Major Surgical Benefit. His claim was processed for Hospital Cash Benefit and after claim evaluation rejected the claim on the said grounds. Hence, the claim is not admissible as per policy conditions and there is no deficiency of service on the part of the respondents.
3. Both the parties have led their evidence in the form of affidavits and documents. The complainant has tendered in evidence Ex.C1-his affidavit; Ex.C2-repudiation letter; Ex.C3-claim intimation form; Ex.C3/A-Claim form; Ex.C4-Claim discharge Form; Ex.C5-Hospital Treatment Form; Ex.C6 and Ex.C7—particulars of policy; Ex.C8 to Ex.C12 and Ex.C14 to Ex.C17-OPD receipts; Ex.C13-final bill; Ex.C18-proposal form; Ex.C19 and Ex.C20-form of Health Plus Plan no.901 regarding health details and Medical Information; Ex.C21-proposal form-Addendum for bank details; Ex.C22-details of existing health insurance policies; Ex.C23-medical examiner’s confidential report; Ex.C24-Blood Sugar Tolerance report; Ex.C25-Routine Urine Analysis; Ex.C26-electrocardiogram whereas the respondents have tendered Ex.R1-affidavit of Sh. R.C.Mathur, Manager; Ex.R2-summary of the claim processing; Ex.R4-repudiation letter; Ex.R5-rejected claim data sheet; Ex.R6-particulars of policy; Ex.R7-prescription slip of Jain hospital; Ex.R8-policy terms and conditions; Ex.R9-to Ex.R18-medical bills; Ex.R19-policy details.
4. We have gone through the record of the case carefully and have heard learned counsel for both the parties.
5. In this case, fact of issuance of insurance policy to the complainant by the Ops is admitted. Fact of treatment and hospitalization is also admitted by the Ops. However, they denied to reimburse the hospital charges to the complainant for his treatment on the ground of not intimating the pre-exist disease at the time of proposal. It is further pleaded that on the good faith and declarations given by the complainant about his health conditions in the past believed true. Similarly it was believed that he had not undergone any illness/treatment in the past. But, from the hospital treatment issued by the treating hospital authority, complainant was declared suffering from hyper tension since 1-1/2 years. Further, as per the case of the Ops, his case has not been fallen for the major surgical benefits.
6. From the above, it is clear that treating hospital authorities found the complainant suffering from hyper tension since 1-1/2 years. However, there is no evidence on the record to establish the fact that he was suffering from any type of heart disease for which he had been issued undergone coronary Angioplasty with stent implantation in one artery (LAD) only. In our view, the fact that he has any kind of heart disease was not in the knowledge of complainant before diagnosing by the hospital authorities of Jaipur where his Angioplasty has been taken. In these circumstances, question of concealing the pre-disease does not arise. In our view, denying of reimbursement of the hospital charges to the complainant amounts to deficiency in service on the part of the Ops. Accordingly, we held the Ops guilty for their deficient service. Under the provisions of Section 14 of the Consumer Protection Act, 1986, we direct the Ops to pay sum of Rs.2,21,850/- to the complainant alongwith interest @ 9% p.a. from the date of institution of this complaint i.e. 22.4.2013 till payment. Ops are also directed to pay cost of litigation amounting to Rs.3000/- to the complainant. Compliance of this order be made within 45 days, failing which the complainant will be entitled to initiate the legal proceedings u/s 25& 27 of Consumer Protection Act. Copy of this order be supplied to the parties free of cost. File be consigned to record room after due compliance.
Announced in open Forum. Presiding Member,
Dated: 1.3.2016. Member. District Consumer Disputes
Redressal Forum, Sirsa.
