BEFORE THE DISTRICT CONSUMER DISPTUES REDRESSAL FORUM, KAITHAL.

Complaint no.15/14.

Date of instt.: 10/13.01.2014. 

                                                 Date of Decision: .2015.

Ramphal son of Sh. Tek Chand, age 48 years, resident of Village Sirsal, Tehsil Pundri, District Kaithal.

                                                        ……….Complainant.      

                                        Versus

1. Life Insurance Corporation of India Ltd. Kaithal, through its Branch Manager.

2. Life Insurance Corporation of India Ltd. Karnal, through its Regional Manager.

..……..Opposite Parties.

COMPLAINT UNDER SEC. 12 OF CONSUMER PROTECTION ACT, 1986.

Before:           Sh. Jagmal Singh, President.

                        Sh. Rajbir Singh, Member.

     Smt. Harisha Mehta, Member.

Present :        Sh. O.P.Sharma, Advocate for complainant.

Sh. Sudeep Malik, Advocate for the opposite parties.

                       ORDER

(JAGMAL SINGH, PRESIDENT).

                       The complainant has filed the present complaint under Section 12 of Consumer Protection Act, 1986, with the averments that he took the policy No.177933657 dt. 05.07.2012 for sum of Rs.1,00,000/- and the complainant paid premium/first instalment of Rs.7223/-.  It is alleged that in the month of June, 2013 the complainant felt some health problem, upon which the complainant consulted with the doctors and as per suggestions of the doctors, the complainant went to PGIMS Rohtak, where the tests of the complainant were conducted and observed that the complainant is suffering from Hepatitis-C and the doctors of PGIMS Rohtak told that the treatment of this disease is course of 42 injections and cost of one injection with other medicines is about Rs.7,000/- per injection and one injection will be injected in one week.  It is further alleged that the complainant visited the office of Ops and moved an application on 08.07.2013 and approached the Ops and told about the above-said disease and requested for financial help for the treatment under the above-said policy but the Ops declined the request of complainant vide letter No.H1/177933667/01/017 on 09.07.2013 and the Ops told that no amount can be considered for advance for the treatment of the disease.  It is further alleged that the complainant started his treatment for the above-said disease from P.G.I. M.S. Rohtak and the complainant spent Rs.70,000/- on the treatment of above-said disease.  It is further alleged that the complainant approached the Ops for reimbursement of the amount of treatment incurred by the complainant but the Ops flatly refused to pay the amount to the complainant.  This way, the Ops are deficient in service.  Hence, this complaint is filed.   

2.     Upon notice, the opposite parties appeared before this forum and filed written statement raising preliminary objections with regard to maintainability; cause of action; locus-standi; that the complicated question of law and facts are involved in the present complaint and for adjudication of which, only the Civil Court is the best platform; that there is no deficiency in service on the part of answering Ops as the policy in question is a fixed benefit Health Insurance Co. which covers hospitalization and surgical benefits as per terms and conditions of insurance policy and not OPD expenses.  Since the case of complainant was not covered either under category-I or category-II, hence, no question of payment of any amount under the policy arises and thus, the same was rightly declined.  On merits, it is submitted that the policy No.177933657 was issued in favour of complainant on 05.07.2012 with coverage of Sh. Ramphal with Hospital Cash Benefit of Rs.2,000/- and Major Surgical Benefit of Rs.2 lacs and coverage of Miss Bhawna, daughter of complainant with Hospital Cash Benefit of Rs.1,000/- and Major Surgical Benefit of Rs.1 lac with yearly premium of Rs.7223/-.  The other contents of complaint are denied and so, prayed for dismissal of complaint.    

3.     In support of his case, the complainant tendered in evidence affidavit Ex.CW1/A and documents Ex.C1 to C15 and closed evidence on 07.01.2015.  On the other hand, the Ops tendered in evidence affidavit Ex.R1 and documents Ex.R2 to R3 and closed evidence on 19.03.2015.  

4.     We have heard ld. counsel for both the parties and perused the case file carefully and minutely and have also gone through the evidence led by the parties.  

A copy of this order be sent to both the parties free of cost.  File be consigned to the record room after due compliance.

Announced.

Dt. .2015.

                                                                (Jagmal Singh),

                                                                President.

                (Harisha Mehta),     (Rajbir Singh),       

                        Member.         Member.