Haryana

Yamunanagar

CC/156/2013

Kewal Krishan S/o Mulakh Raj - Complainant(s)

Versus

Life Insurance Co. - Opp.Party(s)

Harvinder Aneja

24 Oct 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, YAMUNA NAGAR AT JAGADHRI.

 

                                                Complaint No.156 of 2013.

                                                Date of Institution:26.2.2013.

                                                Date of Decision: 24.10.2017.

 

Kewal Krishan s/o Sh.Mulakh Raj, age 50 years, r/o H.No.1050, Barrack No.31, Camp, Yamuna Nagar.

                                                                                                …Complainant.

                                Vs.

1.     Life  Insurance Co. Health Protection Plus Plan situated opposite Madhu Petrol Pump, Jagadhri road, Yamuna Nagar through its Branch Manager.

2.     Life Insurance co. Health Protection Plus Plan, Marketing Manager, 489 Model Town, Karnal.

…Respondents.

 

                                Complaint under section 12 of the

                                Consumer Protection Act.

CORAM:     SH.SATPAL………..PRESIDENT,

                    SH.S.C.SHARMA,         MEMBER.

                    SMT. VEENA RANI SHEOKAND, MEMBER.

 

Present:     Sh.Harvinder Aneja, Adv. for complainant.

                 Sh.Rajiv Gupta, Adv. for OPs.

 

ORDER:     (SH.SATPAL PRESIDENT)

 

1.             The complainant has filed this complaint under section 12 of the Consumer Protection Act against the respondents (hereinafter the respondents shall be referred as OPs).

2.             Brief facts of the complaint as alleged are that the agent of the Ops contacted the complainant and shown many plans regarding health of complainant and assured that in case the complainant was hospitalized, then the Ops will pay 100% of all expenses as per the bills of the hospital.  Upon the assurance of the Ops, the complainant paid Rs.25,000/- of first installment and at that time the Ops issued policy No.177451437, dated 6.10.2010 valid up to 6.10.2037 because a person was to be insured up to 75 years after paying three installments of Rs.25,000/- each and complainant paid three installments without any default.  In the month of December-2012, the complainant suffered some heart problem and he firstly approached to Kapil Hospital as well as Santosh Hospital and Dashmesh Hospital and thereafter approached to Max Health Care Super Specialty Hospital on 02.01.2013 where the complainant was hospitalized and angiography was done.  The complainant was discharged on the same day and paid Rs.10,700/-.  As per the report of angiography, the complainant was advised for angioplasty as his arteries were blocked up to 90%.  Thereafter, on 5.1.2013 the complainant was admitted in the hospital and angioplasty was performed by the doctors and during this period the complainant was hospitalized up to 7.1.2013 and following treatments were given to the complainant:

PTCA stenting of LCx lesion

AO Processur:130/90 mm of Hg

Final diagnosis:

        Successful PTCA and Stenting of LCx Lesion Done. 

Recommendation:

        Medical Management.

                The complainant was discharged on 7.1.2013 and at that time total amount paid by complainant was Rs.4,57,361.02 paise through IPID No.4823.  Thereafter, the complainant submitted all the documents/history with the Ops and lodged a claim of Rs.4,57,361.02ps+Rs.10700/- i.e.Rs.4,68,061.02 paise.  After verification, the Ops passed the claim of Rs.2,00,000/- and the amount was paid through cheque No.475164, dated 31.1.2013 by the Ops.  The complainant was astonished to receive the cheque which was sent by post and the Ops had not given the full bill of the hospital charges i.e. Rs.4,68,061.02 paise as per the commitment of the Ops.  Thereafter, the complainant approached the Ops with the request to pay the total amount of Rs.4,68,061.02 paise as per hospital bills, but of no use, which amounts to deficiency in service on the part of the Ops and prayed for acceptance of complaint by directing the Ops to pay Rs.2,68,061.02 paise alongwith interest and to pay Rs.1,00,000/-  as compensation for mental agony, harassment and financial loss. 

3.             Upon notice, the Ops appeared and filed their written statement by taking some preliminary objections alleging therein that the complaint is not maintainable against the Ops ; there is no deficiency in service on the part of the Ops.  On merits, admitted the fact regarding taking of insurance policy No.177451437 under LIC’s Health Plan, Health Protection Plus under table No.902 by the complainant.  The Policy in question was issued on 6.10.2010 valid up to 6.10.2026 and complainant paid three premiums against the said policy.  The policy in question cover the health claim as per the terms and conditions of the Insurance Policy and the different percentage of difference surgical benefit is payable of the sum assured ranging from 40% to 100% as per the list of surgical procedure shown in the LIC’s Health Protection Plus conditions and privileges.  The life assured had undergone Coronary Angioplasty with stent implantation and submitted the claim papers amounting to Rs.4,57,364/-, on receipt of the claim papers, the claim was processed as per terms and conditions of the Insurance Policy.  As per the surgical benefit payable under the policy in question for Coronary Angioplasty with stent implantation (Two or more Coronary Arteries) 40% of the sum assured is payable.  As per the insurance policy in question, the sum assured is Rs.5,00,000/- therefore, the Ops as per policy conditions paid Rs.2,00,000/- i.e. 40% of the sum assured to the complainant/insured vide cheque No.475164, dated 31.1.2013 within a period of just one month from taking of treatment by life assured. The claim has been settled legally and justifiably and there is nothing to be astonished by the complainant on receipt of cheque of Rs.2,00,000/-.  There is no deficiency in service on the part of the Ops and prayed for dismissal of compliant.

4.             To prove the case, ld. counsel for the complainant tendered into evidence affidavit of complainant as annexure C.X, documents such as copy of policy as annexure C.1, settlement receipt as annexure C.2, copy of discharge summary as annexure C.3, copies of record of hospitals along with test reports as annexure C.4 to C.14, copy of cheque of Rs.2,00,000/- as annexure C.15 and closed the evidence on behalf of the complainant.

5.             Ld. counsel for the Ops tendered into evidence affidavit of Shri Surinder Kumari Patlani A.O. as annexure RW/A, documents such as copy of policy as annexure R.1, copy of proposal form as annexure R.2 and closed the evidence on behalf of Ops.

6.             We have heard the learned counsel for the parties and gone through the pleadings as well as documents placed on the file. 

7.             After hearing ld. Counsel for both the parties and on perusal of record, it has been found that the complainant purchased the LIC Health Protection Plus Plan (Table-902) for a sum assured of Rs.5,00,000/- and deposited three continuous premium of Rs.25,000/- to the Ops.  It is also not disputed that the complainant fell ill and had undergone Coronary Angioplasty with stent implantation in Max Hospital, Mohali and a medi-claim of Rs.4,57,364/- was submitted by the complainant and an amount of Rs.2,00,000/- was paid by the Ops to the complainant as per policy conditions.  The controversy between the parties is that whether the complainant is entitled for remaining amount of Rs.2,57,364/- which was incurred by the complainant on his treatment. 

                The version of the complainant is that at the time of purchasing of policy in question, the Ops had assured that in the eventuality of illness of the complainant,  the Ops-insurance company will pay all the expenses i.e. 100% of hospitalization charges because the limit of the policy was Rs.5,00,000/- but the Ops company paid only Rs.2,00,000/- to the complainant and withheld the remaining amount, which is illegal.  Ld. Counsel for the complainant submitted case law reported in 2015(1) CLT page 590 (Haryana State Commission) titled as Star Health & allied Insurance Co. Ltd. Vs. Asha & others, wherein the Hon’ble State Commission held that ”Insurance policy-Terms and conditions-Exclusion clause-Held-It is the duty of the insurance company to prove that these terms and conditions were explained to the insured when cover note was issued-No where mentioned therein that the insured was explained about this exclusion clause-With very small letters clauses, warranties, endorsement, etc. are mentioned-Insurance policy is issued by the company lateron-It is well settled that the company, who is taking specific plea about repudiation of any claim is to prove that the exclusion clause was explained to the consumers-When the Ops have failed to prove this fact they cannot derive any benefit from this exclusion clause.”  Similarly, ld. Counsel for the complainant has also relied upon the case law reported in 2000(1) CPJ page 1 (SC) titled as M/s. Modern Insulators Ltd. Vs. Oriental Insurance Co. Ltd., wherein the Hon’ble Supreme Court held that “Appellant in its affidavit filed confirmed that it was supplied only with cover note and schedule of policy-Other terms and conditions containing exclusion clause not communicated-Exclusion clause did not form part of contract of insurance-Respondent cannot claim benefit of said exclusion clause-Finding of National Commission not tenable in law.”  Ld. Counsel for the complainant also relied upon the case law reported in 2001(1) RCR (Civil) page 347 (SC) titled as Life Corporation of India Vs. Asha Goel; 2016(4) CLT page 372 (State Commission, U.T., Chandigarh) titled as S.B.I. General Insurance Co. Vs. Balwinder Singh Jolly & others; 2015(2) PLR page 75 (P&H High Court) titled as Oriental Insurance Co. Ltd. Vs. Naresh Sharma & others and 2005(1) CLT page 88 (P&H High Court) titled as Vidya Vs. Life Insurance Corporation of India, wherein the similar question of law has been discussed.    

                On the other hand, the plea of the Ops is that the policy in question cover the Health Claim as per terms and conditions of insurance policy and the different percentage of different surgical benefit is payable of the sum assured ranging from 40% to 100% as per the list of surgical procedure shown in the condition and privileges.  As per the surgical benefit payable under the policy in question for Coronary Angioplasty with stent implantation, 40% of the sum assured is payable and as per insurance policy in question, the sum assured is Rs.5,00,000/-, therefore, the Ops company as per policy conditions paid Rs.2,00,000/- i.e. 40% of the sum assured to the complainant on 31.01.2013 without any delay and as such, the complainant is not entitled for the whole amount incurred on his treatment as per terms and conditions of the policy in question.

                We have perused the document Annexure-R1, which is LIC’s Health Protection Plus Conditions and Privileges, the clause-II i.e. Major Surgical Benefit is reproduced as under:-

                “In the event of an insured under this policy undergoing any specified surgery in a hospital due to Accidental Bodily injury or Sickness first occurring or manifesting itself after the Date of Cover, Commencement and during the cover period, then, subject to terms and conditions of this policy, the Benefit Amount, reckoned as the percentage of the sum assured as mentioned in the Surgical Benefit Annexure against the specified surgery performed, shall be payable by the Corporation.”  

                  Meaning thereby, the Ops company is liable to pay only the percentage of sum assured as mentioned in the Surgical Benefit Annexure against the specified surgery performed.  We have also perused the list of Surgical Benefit Annexure (Annexure-R1) wherein it is clear that in the event of Coronary Angioplasty with stent implantation (Two or more coronary arteries must be stunted), then the insurance company is liable to pay 40% of the sum assured.  In the present case, the sum assured was of Rs.5,00,000/- and as such, the Ops company is liable to pay 40% of the sum assured in the event of Coronary Angioplasty with stent implantation.  The Ops-insurance company had already paid Rs.2,00,000/- to the complainant, meaning thereby, 40% of the  sum assured for which the company is liable.  It is also relevant to mention here that it is well settled law that both the parties to an agreement are bound to abide by the terms and conditions contained in the agreement and none of the parties can travel beyond the stipulated/prescribed terms and conditions of the agreement.  The Hon’ble National Commission in LIC of India Vs. Giriraj Mehta in revision petition No.3123 of 2008 vide judgment dt. 25.05.2010 has held that “the Courts should give true import of terms and conditions of policy, without making any addition or even stretching those terms and conditions”.  In the present case, the complainant in his pleadings nowhere alleged that the Ops-insurance company did not supply the terms and conditions of the policy.  The authorities submitted by ld. Counsel for the complainant are not disputed but not applicable to the facts and circumstances of the present case.  Hence, there is no deficiency on the part of Ops.            

8.             Thus, as a sequel of above discussion, we find no merit in the complaint of the complainant and the same is hereby dismissed with no order as to costs.  A copy or order be supplied to the parties free of cost.  File be consigned to the record-room.

Announced in open Court:24.10.2017.

                                                                (SATPAL)

                                                                PRESIDENT

 

(VEENA RANI SHEOKAND)             (S.C.SHARMA)

MEMBER                                             MEMBER.