DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, CAMP COURT AT AMRITSAR, PUNJAB.

 

Complaint Case No : RBT/CC/2018/212

Date of Institution : 27.03.2018/29.11.2021

Date of Decision : 05.07.2022

Mr. Mandeep Singh s/o Sh. Bhagat Singh R/o H. No. 802, Garden Colony, Bahmaniwali Road, Patti, District Tarn Taran.    …Complainant

Versus

Life Insurance Company of India Limited (LIC) Through its Chairman/ Managing Director/Principal Officer Through its Branch Office at District Shopping Complex, Ranjit Avenue, Amritsar through its Branch Manager.

…Opposite Party

Complaint U/S 12 and 13 of The Consumer Protection Act

Present: Sh. Deepinder Singh Adv counsel for complainant.

Sh. Vikram Puri Adv counsel for the opposite party. 

Quorum.-

1. Sh. Ashish Kumar Grover : President

2. Sh. Navdeep Kumar Garg  : Member

(ORDER BY ASHISH KUMAR GROVER PRESIDENT):

    The present complaint has been received by transfer from District Consumer Commission, Amritsar in compliance of the order dated 26.11.2021 of the Hon'ble State Consumer Disputes Redressal Commission, Punjab, Chandigarh. The complainant filed the present complaint under Section 12 and 13 of the Consumer Protection Act against Life Insurance Company of India, Amritsar. (in short the opposite party). 

2. The facts leading to the present complaint as stated by the complainant are that the complainant got LIC Jeevan Arogya mediclaim insurance for himself and his wife from opposite party covering the risk period 13.10.2012 to 13.10.2043. 

3. It is further alleged that the wife of the complainant Harinder Kaur fell ill and was to be hospitalized and taken treatment at Rajiv Gandhi Cancer Institute from 12.8.2014 to 13.8.2014, 25.8.2014 to 26.8.2014 and 25.11.2014 to 6.1.2015 and the treatment cost of the said hospitalization came to be more than Rs. 2 lacs. The opposite party was immediately informed about the said hospitalization and the treatment taken thereof as the said policy was issued on cashless basis and sum insured for the medical benefit is Rs. 2 lacs so the complainant is entitled for the claim of Rs. 2 lacs. But the opposite party repudiated the claim of the complainant on the frivolous grounds vide letter dated 30.11.2017 that the wife of the complainant was on anti-depressant drugs which was wrong. The complainant earlier made the complaint and opposite party in their written version taken the objection of non submission of certain documents regarding the said claims and complainant provided the required documents to the opposite party but even then they repudiated the genuine claim of the complainant. The complainant paid premium of Rs. 11,240/- to the opposite party vide cheque No. 000004 dated 13.10.2017 but the opposite party arbitrarily did not get the same encashed and continued the said policy against the provisions of law. The act of the opposite party is deficiency in service and unfair trade practice. Hence, the present complaint is filed seeking the following reliefs.-

1) The opposite party may be directed to pay  the amount of Rs. 2 lacs alongwith interest at the rate of 12% per annum from the date of filing of the claim till realization. 

2) To pay Rs. 50,000/- on account of compensation for mental agony and harassment. 

3) To pay adequate litigation expenses.

4) Any other relief to which the complainant is found entitled. 

4. Upon notice of this complaint, the opposite party filed written statement taking preliminary objections that the complainant has not come to this Commission with clean hands and concealed material facts from this Commission. The complainant has no cause of action to file the present complaint. 

5. On merits, the opposite party submitted that the policy is a health insurance policy with the defined fixed benefits as per leave of HCB (Hospital Cash Benefit) chosen by the life assured. The policy Jeewan Arogya taken by the complainant is not a cashless policy and also not a reimbursement policy. The claim of the complainant has rightly been repudiated. It is admitted that policyholder remained admitted in Rajiv Gandhi Cancer Insitute, Delhi from 12.8.2014 to 13.8.2014, 25.8.2014 to 26.8.2014 against which discharge summary and final hospital bills have been submitted. However, the complainant had not submitted the documents in support of admission in hospital from 25.11.2014 to 6.1.2015 despite sending reminder letter by the opposite party. The claims in respect of above mentioned two hospitalizations have rightly been repudiated by the opposite party vide letter dated 30.11.2017 on the ground that as per the period of hospitalization is less than 28 hours nothing is payable in respect of both the claims as per the policy conditions. Not only this both the claims have been repudiated under pre existing disease clause wherein treatment has been taken for the disease which is pre existing at the time of taking the policy or the policy has been obtained by concealment of facts. The discharge summary dated 24.6.2014 clearly shows that the patient had history of taking anti depressant for five years which goes prior to the date of taking policy on 13.10.2012. Further, no renewal premium is acceptable under policy as the policy has become null and void as was conveyed to the policyholder vide repudiation letter dated 25.3.2017 in respect of other claim under the same policy. There is no deficiency in service on the part of the opposite party. Lastly, the opposite party prayed for the dismissal of the present complaint.  

6. In support of his complaint, the complainant tendered into evidence his affidavit Ex.C-1, copy of repudiation letter Ex.C-2, copy of cheque Ex.C-3 and closed the evidence. 

7. To rebut the case of the complainant, the opposite party   tendered in evidence affidavit of Rajinder Kumar Ex.OP-1, copy of policy Ex.OP-2, copy of proposal form Ex.OP-3, copy of repudiation letter dated 30.11.2017 Ex.OP-4, copy of claim rejection letter dated 30.11.2017 Ex.OP-5, copy of patient discharge summary issued by Rajiv Gandhi Cancer and Research Centre Ex.OP-6, copy of hospital treatment form Ex.OP-7 and closed the evidence.  

8. We have heard the learned counsel for the parties and gone through the record on the file. 

9. The opposite party admitted that the complainant purchased the policy Ex.OP-2 from the opposite party for himself and his wife for the period from 13.10.2012 to 13.10.2043. It is also admitted by the opposite party that the complainant submitted claim form of his wife for treatment taken from Rajiv Gandhi Cancer Institute, Delhi. It is also admitted by the opposite party that they have repudiated the claim of the complainant vide letter Ex.OP-4. 

10. We have carefully perused the repudiation letter dated 30.11.2017 Ex.OP-4. The opposite party repudiated the claim of the complainant on two grounds. Firstly, they have repudiated the claim on the ground of pre-existing illness irrespective of prior medical treatment or advise. The discharge summary dated 24.6.2014 of the hospital clealy shows that the patient had history of taking anti depressant for 5 years which goes prior to taking of policy on 13.10.2012. But in our view if the patient had history of taking anti depressant for 5 years, it has no link with the present Cancer disease of patient Harinder Kaur. The opposite party not produced any evidence to prove that due to these anti depressant medicines the disease of cancer occurred in the patient. So, this ground of repudiation is baseless and unreasonable.

11. Secondly, they have repudiated the claim on the ground that hospitalization period less than 28 hours for both the admissions. It is admitted by the opposite party that the patient wife of the complainant had taken the treatment from 12.8.2014 to 13.8.2014, 25.8.2014 to 26.8.2014 and 25.11.2014 to 6.1.2015. From the discharge summary Ex.OP-6 it is also proved that patient date of admission was 12.8.2014 and date of discharge was 13.8.2014, so from the admission of opposite party and record on the file it is proved that the patient had admitted in hospital for  at least one night every time. So, this ground of repudiation is also unreasonable and baseless. In this way, the opposite party repudiated the claim of the complainant on baseless grounds, which is deficiency in service and unfair trade practice on their part. It is admitted by the opposite party that they have not accepted the renewal premium of the policy, as the policy has become null and void. But in our view the opposite party had not renewed the policy of the complainant on unreasonable and baseless grounds. The complainant has not filed medical bills on the file. The complainant mentioned in the complaint that complainant earlier made the complaint regarding the said claims and opposite party in their written version taken the objection of non submission of certain documents regarding the said claims and complainant provided the required documents to the opposite party and opposite party repudiated the genuine claim of the complainant on the frivolous grounds. On the other hand the opposite party admitted in the written version that the complainant had supplied the medical bills and treatment record of 12.8.2014 to 13.8.2014 and 25.8.2014 to 26.8.2014. the opposite party further mentioned in the written version that the complainant had not submitted the documents in support of admission in the hospital from 25.11.2014 to 6.1.2015 despite sending reminder letters by the opposite party. The opposite party has not produced any evidence to prove that the complainant had not submitted the documents with regard to treatment dated 25.11.2014 to 6.1.2015. The opposite party mentioned in written version that reminder letters were sent to complainant but opposite party has not produced any reminder letter in evidence. It is established that complainant had submitted all treatment record and medical bills with the opposite party. The opposite party has also not denied the sum insured amount of Rs. 2 lacs in written version. 

12. In view of the above discussion, present complaint is partly allowed and opposite party is directed to pay the amount of Rs. 2,00,000/- to the complainant alongwith interest at the rate of 6% per annum from the date of filing of present complaint till actual realization. The opposite party is further directed to renew the policy of the complainant with all the benefits after taking premiums from non renewal. The opposite party is also directed to pay Rs. 3,300/- to the complainant as compensation for mental tension and harassment and Rs. 2,200/- as costs and litigation expenses. Compliance of this order be made within the period of 45 days from the date of the receipt of the copy of this order. Copy of the order will be supplied to the parties by the District Consumer Commission, Amritsar as per rules. File be sent back to the District Consumer Disputes Redressal Commission, Amritsar. 

ANNOUNCED IN THE OPEN COMMISSION:

        5th Day of July 2022

 

            (Ashish Kumar Grover)

            President

              

(Navdeep Kumar Garg)

Member