BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 07 of 2020
Date of Institution : 07.01.2020.
Date of Decision : 21.11.2023.
Vikas Bansal (aged about 38 years) son of Sh. Jawahar Lal Bansal, House No.23, A-Block, New Anaj Mandi, Sirsa.
……Complainant.
Versus.
1. Life Insurance Corporation, LIC Building, Old M.C. Market, Sirsa through its Senior Manager/ Manager.
2. Life Insurance Corporation, Divisional Office, SCO 3, 4, 5, Sector-1, UDA Rohtak Haryana through its Divisional Manager.
3. Genins India Insurance TPA Ltd. D-34 Ground Floor, Sector 2 Noida, Uttar Pardesh- 201301 through its Senior Manager/ Authorized person.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act, 1986.
Before: SH. PADAM SINGH THAKUR …………PRESIDENT
MRS.SUKHDEEP KAUR………………MEMBER.
SH. OM PARKASH TUTEJA………….MEMBER
Present: Sh. Ajay Bansal, Advocate for complainant.
Sh. S.K. Puri, Advocate for opposite parties no.1 and 2.
Opposite party no.3 already exparte.
ORDER
The present complaint has been filed by complainant under Section 12 of the Consumer Protection Act, 1986 (after amendment u/s 35 of the Consumer Protection Act, 2019) against the opposite parties (hereinafter referred as OPs).
2. In brief, the case of the complainant is that agent of op no.1 approached to the complainant and informed about the newly launched LIC policy i.e. LIC Jiwan Arogya (Table 903) and also informed that complainant and his family members will be secure from all type of medical treatment, surgery etc. The complainant after understanding the benefits of said policy agreed to purchase the same by covering other family members and had also paid premium of Rs.5382/-. The ops no.1 and 2 issued policy no. 178980880 in favour of complainant. It is further averred that from 08.06.2011 to 29.11.2018 the complainant deposited half yearly premium amount of Rs.5382/- each with the ops though few time complainant got deposited the premium with permissible penalty duly approved and accepted by ops no.1 and 2. That policy was issued on 22.11.2011 after fulfillment of all required formalities including medical check up etc. It is further averred that complainant faced few medical issues and went to the Sigma Hospital, Sirsa where Dr. G.S. Gupta MBBS MS Surgeon examined him on 08.11.2018 and advised for detail investigation. That ultrasound of complainant was got conducted from Dr. Vishal Garg Radiologist in which it was found that he is suffering from Fatty liver Gr-1 and right inguinal hernia and as such he was advised for surgery of Inguinal Hernia. The complainant was admitted to the hospital on 09.11.2018 and after operation was discharged on 10.11.2018. That total claim of Rs.27,272/- was lodged with the op no.1 on 03.12.2018 with all required formalities like discharge summary, bills, investigation report etc. and he was assured that his claim has been referred to the higher authorities for approval but for the first time in the month of January, 2019 he came to know that his claim has been referred to op no.3 for clearance purpose which was a matter of surprise because complainant neither approved nor engaged and not having any concern with op no.3. The complainant entered into a privity of contact with ops no.1 and 2 who are responsible and legally bound to indemnify their liability. It is further averred that complainant on the request of ops no.1 and 2 fulfilled the requirement of op no.3 as per letter dated 05.01.2019. That from the said letter, the complainant smelled out from the query put by op no.3 that they are authorized for repudiation of the claim who are seems to be predetermined against the claim of complainant and the act of op no.3 could easily be analyzed from their query which was as follows “that as per the record policy revived on 09.03.2012, 02.08.2023 and 22.08.2014, please confirm UW decision and status of good health declaration on above mentioned dates”. It is further averred that this was matter of surprise because this type of work solely belongs to the ops no.1 and 2 and had the policy not revived in a regular course of manner, then what was the need for imposing penalty upon the complainant and now imposing the query in a technical manner with the sole intention to decline/ repudiation of the claim directly covers the op no.3 in deficiency in service, negligence and participating in unfair trade practice. That complainant again contacted with the ops no.1 and 2 and inquired about the pending claim and was again shocked to see the letter issue by op no.3 to op no.2 dated 18.01.2019 recommending the repudiation of his claim with the observation that “37 years male presented with the complaint of pain and swelling, right inguinal region since two years, diagnose as case of right inguinal Hernia and treated surgically for the same. As per policy record, policy revived on 22.08.2014 existing terms and as per treatment record, history of hyper tension since five years is noted. Evidence of pre-existing disease/ condition/ treatment prior to date of revival is observed and treatment/ surgery done is not listed under major surgery benefit list, hence the claim is being rejected under HO1 and MO1”. That in the end lines of this impugned letter the op no.3 has written that original claim file is being forwarded for final opinion. Thereafter, the op no.2 in a stereo manner and on the basis of impugned observation mentioned in letter dated 18.01.2019 issued another impugned repudiation letter dated 25.01.2019 which is also wrong and illegal because hyper tension and sugar are life style disease and the second reason that surgery not listed in the allowed surgeries is not the ground for repudiation of claim as there has not been any specific endorsement on the policy nor this alleged issue was ever disclosed to the complainant at any point of time from the year 2011. It is further averred that ops are legally bound to settle and make the payment of claim lodged by the complainant and though as per the policy the risk of insured persons had shown to be up to Rs.two lacs but complainant has lodged claim of Rs.27272/- only and ops have caused unnecessary harassment and mental agony to the complainant. Hence, this complaint.
3. On notice, ops no.1 and 2 appeared and filed written version raising certain preliminary objections regarding maintainability, cause of action, locus standi, suppression of true and material facts and that policy was issued by ops’ company on the basis of the information provided by the life assured in the proposal form. Since the information was established to be incorrect by ops’ company, hence the ops’ company was well within its rights to repudiate the said claim of complainant. It is further submitted that since the answering ops have acted within the four corners of the statutory provisions, no case of deficiency in services can be said to have arisen and as such present complaint is not maintainable before this Commission and complainant is estopped by his own act and conduct from filing the present complaint.
4. On merits, it is submitted that claim of complainant being not covered under the terms of policy has been rightly repudiated by the ops. That every insurance including the health insurance policy is a contract bound by conditions and rules. Unlike other life insurance policy the health insurance policy of LIC provides fixed benefits on occurrence and treatment of certain diseases excluding some diseases and some periods of occurrences after commencement of policy or revival of policy. Any evidence of pre existing disease will prevent the benefit of policy to the claimant. Every health insurance claim is considered for payment or rejection only if the premiums are upto date at the time of admission in hospital. Therefore continuity in premium payment is basic and first condition for consideration of processing of claim. But it does not solely qualify the claimant to receive the payment. It is further submitted that repudiation letter is clearly stating the reason of repudiation as per rejection code HO1 and MO1 and claim has been rejected in a legal sense and as per opinion of TPA. The treatment records shows the history of diabetes since five years and evidence of pre existing disease/ conditions/ treatment prior to date of revival is observed and treatment/ surgery done is not listed under major surgery benefit list, hence the claim is rejected under HO1 & MO1. The patient has been diabetic since six years and every revival of the policy is de-novo insurance of existing lapsed policy and policy is revived on the basis of declaration of Good Health by the policy holder. If anything adverse is disclosed, the policy is not revived or revived with different terms. That each proposer in the health insurance policy has to specifically declare any type of medical condition which he has at the time of taking the policy or at the time of revival of the policy and he has willfully concealed the status of his pre existing disease. It is further submitted that there are 14 questions under the heading – Health Details and Medical Information- of the proposal form of this policy filled in and signed by the claimant/ policy holder, which facts itself falsify the claim of complainant and facts concealed by the complainant/ policy holder. All other contents of complaint are also denied to be wrong and prayer for dismissal of complaint made.
5. OP no.3 failed to appear despite notice sent through registered cover and as none appeared on behalf of op no.3 after stipulated period, therefore, op no.3 was proceeded against exparte.
6. The complainant in evidence has tendered his affidavit Ex.C1 and copies of documents i.e. policy Ex.C2 (containing pages 1 to 92) consisting repudiation letters dated 18.01.2019, 25.01.2019, premium receipts, medical record, bills and receipts.
7. On the other hand, ops no.1 and 2 have tendered affidavit of Ms. Sunita Matta Manager (Legal) as Ex.R1, history of premium transaction Ex.R2, repudiation letter dated 25.01.2019 Ex.R3.
8. We have heard learned counsel for the parties and have gone through the case file.
9. Admittedly the complainant had purchased health insurance policy i.e. LIC’s Jeevan Arogya (Table 903) policy from ops no.1 and 2 from 08.06.2011 against payment of half yearly premium of Rs.5382/- as is evident from policy Ex.C2 and under the said policy complainant and his family members i.e. his wife Smt. Arti, daughter Matisha and son Jayant were insured and covered. There is also no dispute of the fact that complainant has paid premium amounts of Rs.5382/- in half yearly installments though with some penalty for late payment of premiums up to 29.11.2018 and said fact is also proved from the premium receipts placed on file by the complainant alongwith policy Ex.C2. The premium on 09.03.2012, 02.08.2013 and on 29.08.2014 have been accepted by the ops with some penalty after their due approval. From the medical record placed on file by complainant, it is also evident that on 09.11.2018 complainant was admitted in the Sigma Hospital, Sirsa where he was operated for Inguinal Hernia and was discharged on 10.11.2018 and complainant lodged claim of Rs.27,272/- spent on his above said surgery and treatment alongwith all requisite documents i.e. bills/ receipts, discharge summary and investigation reports but the ops have repudiated the claim of complainant vide two letters dated 18.01.2019 and 25.01.2019 referring Code HO1 about pre-existing illness irrespective or prior medical treatment or advise and code MO1 which says that surgeries not listed in the allowed surgeries. However, we are of the considered opinion that ops have wrongly and illegally repudiated the genuine claim of the complainant. First of all the ops have failed to prove on record any pre existing disease to the complainant. Secondly the ops have been accepting the premium amounts from the complainant though at three occasions with some penalty and the ops have failed to prove on record that at any time the policy was in lapsed condition and for revival of the policy the complainant had to fulfill above said requirements. Since the policy was not in lapsed condition at any point of time, therefore, ops cannot take the plea that insured has to specifically declare any type of medical condition at the time of revival of the policy. Further more, the late premiums were received by ops on 09.03.2012, 02.08.2013 and on 29.08.2014 whereas the complainant was operated in the month of November, 2018. The ops have not proved on record that they ever asked the complainant to complete formalities at the time of receiving premiums with penalty. The ops have also failed to prove on record that complainant ever concealed the factum about his health from the ops and in this regard ops have not relied any document to prove any concealment by the complainant. Moreover, the disease of Diabetes is a life style disease and ops have not proved on record that any terms and conditions of the policy were ever conveyed or explained to the complainant and as such the ops have also wrongly repudiated the claim of complainant on the ground that surgery is not listed in the list of surgeries which are allowed by them because no such list was ever supplied to the complainant. The sum insured amount was of Rs. two lacs and complainant has submitted his claim for only meager amount of Rs.27,272/- i.e. after paying huge premium amounts to the complainant as complainant has been paying premium amounts of Rs.5382/- each in half yearly installments from 08.06.2011 and has paid the same up to 29.11.2019 but despite the huge payment of premium the ops have repudiated the claim of complainant on mere technicalities. The complainant has been paying insurance premiums under health insurance policy and therefore, after lapse of more than seven years the ops cannot take the plea that surgery of Inguinal hernia is not listed in the list of surgeries and no list was ever supplied to the complainant. As such non payment of the genuine claim of complainant clearly amounts to deficiency in service and unfair trade practice on the part of ops and the ops have caused unnecessary harassment to the complainant. The repudiation of the claim of complainant is hereby set aside.
10. In view of our above discussion, we allow the present complaint and direct the opposite parties to pay the claim amount of Rs.27,272/- alongwith interest at the rate of @6% per annum from the date of filing of present complaint i.e. 07.01.2020 till actual realization to the complainant within a period of 45 days from the date of receipt of copy of this order. We also direct the ops to further pay a sum of Rs.10,000/- as compensation for harassment and Rs.5000/- as litigation expenses to the complainant within above said stipulated period. The prime liability to comply with this order will be ops no.1 and 2. A copy of this order be supplied to the parties as per rules. File be consigned to the record room.
Announced: Member Member President,
Dated: 21.11.2023. District Consumer Disputes
Redressal Commission, Sirsa.
