Before the District Consumer Disputes Redressal Forum, Rohtak.
Complaint No. : 182.
Instituted on : 28.03.2011.
Decided on : 16.03.2015.
Ashok Kumar Bansal s/o Sh. Janki Dass Bansal R/o Shop No.20, Anaj Mandi, Sampla District Rohtak.
………..Complainant.
Vs.
- Life Insurance Corporation of India, Divisional Office, SCO 3,4,5 SECTOR-1, HUDA, Rohtak.
- E-Meditek Solution Ltd. 45, Nathupur Road, DLF Phase-III Gurgaon-122002(HR) India.
……….Opposite parties
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.JOGINDER KUMAR JAKHAR, PRESIDENT.
MS. KOMAL KHANNA, MEMBER.
Present: Sh.G.K.Lalit, Advocate for the complainant.
Sh.S.P.Gulati, Advocate for the opposite parties.
ORDER
SH. JOGINDER KUMAR JAKHAR, PRESIDENT :
1. The present complaint has been filed by the complainant with the averments that he had taken a mediclam policy from the opposite party no.1 vide policy no.176985397 on 30.06.2009 and opposite party no.1 appointed the opposite party no.2 as his TPA vide UHID No.201939100014330. It is averred that the complainant was hospitalized on 23.08.2010 to 25.08.2010 in Handa Nursing Home, New Delhi due to stone in left uretiric for which he had to bear Rs.30437/- as treatment expenses. The opposite party were duly intimated by the complainant vide claim form dated 4.9.2010 with a request to pay the insurance claim amount and the complainant furnished all the requisite documents and completed all the formalities. It is averred that the complainant received a letter dated 29.12.2010 from the opposite party as per which the claim of the complainant was repudiated on the ground that complainant’s hosptialisation period is less than 52 hours. It is averred that complainant requested the opposite party many times to settle the genuine claim of the complainant and also served a legal notice dated 12.02.2011 but of no use. It is averred that the act of opposite parties is illegal and amounts to deficiency in service. As such, it is prayed that opposite parties may kindly be directed to pay the treatment expenses of Rs.30437.60/- along with alongwith interest, compensation and litigation expenses to the complainant.
2. On notice opposite parties appeared and filed their written reply submitting therein that the policy no.176985397 is not a mediclaim policy as mentioned but it is Health insurance policy named ‘Health Plus’ under table 901. The policy has been taken from LIC Bahadurgarh Branch The FUP is 06.2011. It is averred that the as per claim forms submitted by the complainant on 04.09.2010, the period of Hospitalization is from 09.00 A.M. on 23.08.2010 to 10.00AM on 25.08.2010. It is averred that as per the policy conditions, for claiming the ‘Hospitalization Cash benefit. Apart from other conditions, the hospitalization has to be for a minimum continuous period of 52 hours and in the said claim of complainant the hospitalization was not for a minimum continuous period of 52 hours, so the claim was rightly repudiated vide letter dated 29.12.2010. Hence the repudiation was justified and lawful. It is thus prayed that the complaint may kindly be dismissed with costs.
3. Both the parties led evidence in support of their case.
4. Ld. Counsel for the complainant in his evidence has tendered affidavit Ex.PW1/A, documents Ex.P1 to Ex.P23 and has closed his evidence. On the other hand ld. Counsel for the opposite parties has tendered affidavit Ex.R1, documents Ex.R2 to Ex.R5 and has closed his evidence.
5. We have heard ld. counsel for the parties and have gone through the material aspects of the case carefully.
6. In the present case insurance and hospitalization of complainant in the hospital w.e.f. 23.08.2010 to 25.08.2010 is not disputed. After the hospitalization, complainant vide claim form Ex.P2 had lodged the claim with the opposite party for a sum of Rs.30437.60/- but the same has been repudiated by the opposite parties vide letter Ex.R5 on the ground that “The total hospitalization period is less than 52 hours”. To prove their case opposite parties have placed on file terms and conditions of the policy enclosed with policy Ex.R2.
7. After going through the file and hearing the parties it is observed that the claim of the complainant has only been repudiated on the ground that the claim of the complainant for the payment of Hospitalization/Major Surgical Benefits has been repudiated by the opposite parties on the ground that the total hospital period is less than 52 hours. But this condition of 52 hours is not mentioned in the policy i.e. neither under the head hospital Cash benefit or Major Surgical benefits. Moreover it is not proved on file that the terms and conditions of the policy were supplied to the complainant. In this regard Hon’ble National Commission in 2014(2)CLT 305 titled as The Oriental Insurance Co. Ltd. Vs. Satpal Singh & Others has held that: “Onus to proof that terms and conditions of the policy were supplied to the insured lies upon the insurance company” and as per 2013(1)CLT 589 titled as New India Asurance Co. Ltd. Vs. Pabbati Sridevi & Others Hon’ble National Commission has held that: “Terms and conditions therein, not communicated to the insured-Whether can be used by Insurance Company-No-Held that the terms and conditions were never issued to the insured-Policy is in the nature of standard, printed documents. There is nothing to show that its contents were part of the policy document issued to the insured-Terms and conditions in insurance policy cannot be rely upon by insurance company”.
8. After going through the file, hearing the parties and above referred case law which are fully applicable on the facts and circumstances of the case, it is observed that the repudiation of claim by the opposite parties is illegal and amounts to deficiency in service and the complainant is entitled for the claim amount as per bills Ex.P15 to Ex.P19 amounting to Rs.30437.60/-. On the other hand law cited by ld. Counsel for the opposite parties referred in Legal Digest April 2013 titled as Life Insurance Corporation of India Vs. Niwas Bansal is not applicable on the facts and circumstances of the case.
8. In view of the aforesaid discussion and findings it is directed that opposite parties shall pay the amount of Rs.30438/-(Rupees thirty thousand four hundred thirty eight only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e. 28.03.2011 till its actual realization and shall also pay an amount of Rs.2200/-(Rupees two thousand two hundred only) as litigation expenses to the complainant maximum within one month from the date of announcement of this order failing which the awarded amount shall carry interest @ 12% p.a. from the date of order. Complaint is allowed accordingly.
9. Copy of this order be supplied to both the parties free of costs.
10. File be consigned to the record room after due compliance.
Announced in open court:
16.03.2015.
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Joginder Kumar Jakhar, President
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Komal Khanna, Member.
