Haryana

Kurukshetra

CC/234/2019

Kamal Sharma - Complainant(s)

Versus

Life Insurance Co - Opp.Party(s)

J.P.Gupta

18 Dec 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, KURUKSHETRA.

 

                                        Consumer Complaint No.234 of 2019.

                                        Date of instt.:10.6.2019. 

                                        Date of Decision:18.12.2019.

 

Kamal Sharma w/o Dr. Yoginder Kashyap, r/o H.No.436/1, Gobindpuri, Ladwa, District Kurukshetra.

                                                                …….Complainant.                                                    Versus

 

1. The Life Insurance Corporation of India (Health), P.O. Box No.106, “Jeevan Parkash”, 489, Model Town, Karnal-132001 through its Manager.
2. Ramesh Chander, Agent Code No.02538169, C/o Ramesh Medicose, near Maharaja Aggarsain Chowk, Ladwa, Kurukshetra.

 

        ….…Opposite parties.

 

Complaint under Section 12 of Consumer Protection Act.

 

Before       Smt. Neelam Kashyap, President.    

                   Ms. Neelam, Member.       

                   Shri Issam Singh Sagwal, Member.                                                   

Present:     Shri J.P. Gupta, Advocate for the complainant.

Ms. Meenakshi, Advocate for the opposite party No.1.

Opposite Party No.2 ex-parte.

           

ORDER

                                                                         

                    This is a complaint under Section 12 of the Consumer Protection Act, 1986 moved by complainant Kamal Sharma against LIC & other, the opposite parties.

2.             The brief facts of the complaint are that the complainant got insured herself vide policy No.177317769 type ORD, plan 902/99/13, mode yearly installment after paying premium of Rs.12,000/- P.A. w.e.f. 01.10.2010 to October 2022 and paid premiums regularly till 10/2018. She has not claimed any Medi-claim till date. She suffered severe backbone pain (spinal problem), so she was taken to Verma Hospital, Ladwa and the said hospital conducted some tests on 25.5.2018 and referred her to MMIMSR (Maharishi Markandeshwar Institute of Medical Science & Research), Mullana for urgent MRI whole spine and she spent Rs.5,000/- for MRI at Mullana. Verma Hospital referred her to Neuro Surgeon Fortis Hospital, Mohali (Pb.). She admitted in Fortis Hospital on 22.11.2018, where, she was operated upon and discharged on 27.11.2018 and paid Rs.2,39,200/- excluding transportation/attendant and other miscellaneous expenses like diet and follow up visits to the hospital etc. but the office of the OP No.1 had only transferred Rs.6300/- (for 3 days) in her account vide letter No.30/3/2019, though she remained admitted in the hospital for 5 days vide letter dated 23.1.2019. The OP No.1 directed her to submit a certificate from treating doctor conforming since when she is a known case of diabetes and hypertension supported by previous OPD prescription and/or investigation reports. The report dated 28.2.2019 of the treating doctor, has been submitted to the OP No.1, but still OPs had not cleared the bills till today. By not paying the expenses incurred by her in the treatment, the OPs are deficient in providing the services. Hence, this complaint.

3.             Upon notice, the opposite party No.1 appeared and filed written statement raising preliminary objections regarding maintainability; locus-standi; complaint is bad for mis-joinder and non-joinder of necessary parties; cause of action and jurisdiction. It is stated that as per record available with the OP No.1 to the extent that the Principle Insured Smt. Kamal Sharma got admitted in the Fortis Hospital, Mohali from 22.11.2018 at 5:59 PM to 27.11.2018 at 12:30 PM. The surgery performed upon the complainant as L4-L5 Spinal Canal Stenosis with listhesis (spine surgery) spinal decompression with TLIF is not covered under MSB (Major Surgical Benefits). Hence, MSB is not payable as specified in conditions 3 (II) (VII) of conditions and privileges in Policy Bond. This condition says that “No payment shall be made under the benefit for the operations performed, which are not listed in the Surgical Benefit Annexure”. However, HSB (Hospital Cash Benefit) was payable and an amount of Rs.6300/- has been paid as per terms & conditions of the policy. Further, admission in the hospital is completed for 5 days and HCB has been paid for 3 days after excluding 48 hours as per the policy condition No.3 (I) (i). This condition says “For every hospitalization, no benefit would be paid for the first 48 hours (2 days) of hospitalization regardless of whether the insured was admitted in a general or special ward or in an intensive care unit”. The payment has been made to the complainant as per condition No.2 (I) (a) of the policy. It being a health insurance policy the complainant is entitled only to fixed policy benefits as per policy terms & conditions and not the actual expenses incurred by the policy holder. There is no deficiency on the part of the OP No.1 and prayed for dismissal the present complaint with costs.

                Upon notice, none appeared on behalf of the OP No.2 before this Forum, therefore, he was proceeded against ex-parte vide order dated 16.7.2019.

4.             The complainant tendered affidavit Ex.CW1/A alongwith documents Ex.C-1 to Ex.C-26. On the other hand, learned counsel for OP No.1 tendered affidavit Ex.RW1/A alongwith documents Ex.R-1 to Ex.R-4.

5.             We have heard the learned counsel of the parties and carefully gone through the case file.

6.             The learned counsel for the complainant reiterated all the averments mentioned in the complaint. He argued that the complainant got insured herself from the OPs after paying premium of Rs.12,000/- P.A. w.e.f. 01.10.2010 to October 2022. He further argued that the complainant suffered severe backbone pain (spinal problem) and initially taken to Verma Hospital, Ladwa and thereafter referred to MMIMSR (Maharishi Markandeshwar Institute of Medical Science & Research), Mullana for urgent MRI whole spine and she spent Rs.5,000/- for MRI at Mullana. The complainant admitted in Fortis Hospital on 22.11.2018, where, she was operated upon and paid total Rs.2,39,200/-, but the OP No.1 had only transferred Rs.6300/- (for 3 days) in her account. The OP No.1 directed her to submit a certificate from treating doctor conforming since when she is a known case of diabetes and hypertension supported by previous OPD prescription and/or investigation reports. The report dated 28.2.2019 of the treating doctor, has been submitted to the OP No.1, but still OPs had not cleared the bills till today. In support of his contention, he placed reliance upon case law titled The Oriental Insurance Co. Ltd. Vs. Mahender & Anr., FAO No.5144 of 2018, date of decision 16.8.2018 (P&H).

7.             Contrary to it, the learned counsel for the OP No.1 has also reiterated all the contents mentioned in the reply. She argued that the surgery performed upon the complainant as L4-L5 Spinal Canal Stenosis with listhesis (spine surgery) spinal decompression with TLIF is not covered under MSB (Major Surgical Benefits). Hence, MSB is not payable as specified in conditions 3 (II) (VII) of conditions and privileges in Policy Bond. She further argued that HSB (Hospital Cash Benefit) was payable and an amount of Rs.6300/- has been paid as per terms & conditions of the policy. There is no deficiency on the part of the OP No.1. In support of his contention, she placed reliance upon case law titled Ekjot Singh Vs. E-Meditek Solution Ltd., Revision Petition No.4779 of 2012 in Appeal No.184/2012, d.o.d. 26.2.2016 (NC).

8.             Admittedly, the complainant had taken a health insurance policy bearing No.177317769 for the period from 01.10.2010 to 01.10.2022 vide policy Ex.R-1. The learned counsel for the complainant has mainly contended that the complainant got operated herself from Fortis Hospital, Mohali and spent Rs.2,39,200/-, but the OP No.1 had only paid only Rs.6300/- against that amount, whereas, on the other hand the learned counsel for the OP No.1 contended that the surgery performed by the complainant i.e. L4-L5 Spinal Canal Stenosis with listhesis (spine surgery) spinal decompression with TLIF does not cover under MSB (Major Surgical Benefits). From the internet, we have taken out about Spinal Stenosis Surgery i.e. “Spinal Stenosis surgery helps to reopen your spinal canal, the channel in your backbone that houses your spinal cord and other nerves”. The learned counsel for the complainant has drawn attention of this Forum towards “LIC’s Health Protection Plus Conditions and Privileges Ex.R-1/A and on its last page i.e. “Surgical Benefit Annexure”, sub-Clause “NERVOUS SYSTEM” of Clause “List of Surgical Procedures” is mentioned, which is relevant and reads as under:-       

List of Surgical Procedures	Percent of the Sum Assured
NERVOUS SYSTEM
Surgery to remove cerebral tumors (benign or malignant) and space occupying lesions requiring “craniotomy”	100%
Repair of Cerebral or, spinal Arterio- Venous Malformations and, Cerebral Aneurysms.	100%

 

                However, from the perusal of above sub-clause i.e. “Repair of Cerebral or, spinal Arterio- Venous Malformations and, Cerebral Aneurysms”, it is clear that the repair of Cerebral or spinal does fall within the domain of above said clause and since the complainant got performed the surgery of spine, therefore, the said surgery is covered under MSB (Major Surgical Benefits), whose claim is payable to the extent of 100%. In view of above facts & circumstances, we found no force in this contention of the OP No.1 that the spine surgery performed by the complainant does not cover under MSB (Major Surgical Benefits) of the policy in question. Hence, the OP No.1 has committed a mistake in refusing to pay the claim of the complainant on this very ground. Hence, the OP No.1 is deficient in providing the services. Since there are no specific allegations against the OP No.2 and even it has no role to play in the dispute in question, therefore, complaint qua OP No.2 is liable to be dismissed. The case law produced by the OPs is not applicable to the facts and circumstances of the present case being rested on different footings.

9.             Now the question which arises for consideration is what should be the quantum of indemnification. The complainant was insured for a sum of Rs.3,00,000/- against the policy in question. However, the complainant has produced medical treatment bills of Fortis Hospital, Mohali total amounting Rs.2,39,200/- from Ex.C1 to Ex.C23 on the case file respectively. So the OP No.1 is liable to pay the said amount to the complainant alongwith the compensation and litigation charges.

10.            In view of the aforesaid discussion, we hereby dismiss the present complaint against the OP No.2 and allow the same against the OP No.1 and direct the OP No.1 in the following manner:-

1. To pay the amount of Rs.2,39,200/- to the complainant.
2. To pay Rs.10,000/- as compensation for mental agony and physical harassment suffered by the complainant.
3. To pay Rs.5,000/- as litigation expenses.

 

                The OP No.1 is further directed to comply with the aforesaid directions within the period of 30 days from the date of communication of this order, failing which, the awarded amount shall carry interest @ 9% per annum from the date of order till actual payment and the complainant will be at liberty to initiate proceedings under Section 25/27 of the Act against the OPs. Certified copy of this order be supplied to the parties concerned, forthwith, free of cost, as permissible under Rules. File be indexed and consigned to the record-room, after due compliance.

Announced in open Forum:

Dt.:18.12.2019.                                                   (Neelam Kashyap)

                                                                        President.

 

 

(Issam Singh Sagwal),         (Neelam)       

Member                             Member.