BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL COMMISSION, JALANDHAR.

Complaint No.295 of 2018

      Date of Instt. 17.07.2018

      Date of Decision:12.05.2022

Manjit Kaur, aged 46 W/o Noora Singh, 160 Ranjeet Enclave, Cantt Road, Jalandhar-144022.

..........Complainant

Versus

1.       Life Insurance Corporation of India (LIC) Branch Office Unit-2, Jeevan Raksha, Opposite District Admn. Complex, Rajinder Nagar Jalandhar City-144001 through its Sr. Branch Manager.

2.       Life Insurance Corporation of India (LIC) Divisional Office, Jeevan Prakash, Model Town Road, Jalandhar-144001, through its Senior Division Manager.

3.       Life Insurance Corporation of India (LIC), Health Insurance Division No.4, 1898, OASIS Plaza, Tilak Road, ABIDS, Hyderabad-500001 (Andhra Pradesh) through its Officer In-Charge.

4.       E-MEDITEK (TPA) Services Limited, Corporate Office, Plot No.677, Udyog Vihar, Phase V, Gurgon, Haryana through its Authorized Signatory.

….….. Opposite Parties

Complaint Under the Consumer Protection Act.

Before:        Dr. Harveen Bhardwaj             (President)

                   Smt. Jyotsna                            (Member)

                   Sh. Jaswant Singh Dhillon       (Member)   

Present:       None for the Complainant.

                   Sh. S. C. Sood, Adv. Counsel for OPs No.1 to 3.

Order

Dr. Harveen Bhardwaj (President)

1.                The instant complaint has been filed by the complainant, wherein he has alleged that the complainant allured and induced by tempting and lucrative advertisement circulated across the country by introduction unique LIC Health Protection Plus (Table No.902) policy fell into trap of OP No.1 going with its sweet words believing gentlemen professional assurance was taken in and on inducement by its authorized agent/representative obtained LIC health Protection Plus (Table No.902) canvassing persuasion and inducement for complainant herself as per particulars given here under:-

That OP No.1 covered risk insured for Sum Assured Rs.4,00,000/- under Health Related Benefits under Health Insurance Policy Plan (Supra) against following health risks:

(i)                Hospital Cash Benefit. (HCB)

(II)              Major Surgical Benefit. (MSB)

Besides reimbursement of domiciliary treatment expenses.

                   OP No.1 issued Policy No.133275222 dated 10.02.2011 in small mini micro print which cannot be read by naked eye. The conditions and privileges and Major Surgical benefit for undergoing Surgery in a hospital due to accidental injury or sickness covered during the period after date of commencement and exclusion clause/s were not ever issued/delivered or communicated in writing to the complainant by OPs during the whole policy period. The purported Annexure II LIC’s Health Protection Plus (Table No.902) policy of list of Surgical Procedure and Benefit on Hospitalization were also not issued/delivered alongwith policy document and as such are not part of insurance policy in question. There was no ground or reason or occasion for not issuing conditions and privileges, exclusion clauses, surgical procedure and benefit on hospitalization covered under the policy nor specified anywhere in policy document. Even otherwise such terms and conditions and exclusion clause were not ever explained to the complainant insured and she cannot be bound by terms and conditions and exclusions clauses/ The complete details of reimbursement of Rs.5000/-, drastic deductions and basis of arbitrary and malafide assessment of Rs.5000/- and reasons to decline reimbursement of full amount of Mediclaim Rs.35,293/- preferred have not given though it enjoins upon OPs to provide all such details transparent and fair and not sketchy and laconic. The complainant covered under Health Insurance Policy was hospitalized in Modern Hospital, Jalandhar as in patient with complaint of bleeding P/V was diagnosed as DUB, Bulky uterus, fibroid, underwent LAVH with B/I, Salpingioopherecotmy. The complainant remained hospitalized from 06.10.2016 to 09.10.2016. After discharge on 09.10.2016 from the hospital after surgical treatment/operation, the complainant preferred mediclaim in the prescribed claim form. All bills and other documents submitted by the complainant to the OPs. The purported Annexure II of LIC’s Health Plus Plan 902 of list of Surgical Procedure and Benefit on hospitalization were also not issued/delivered alongwith policy documents and as such are not part of insurance policy in question. There is no ground or reason or occasion for not issuing conditions and privileges, exclusion clauses, surgical procedure and benefit on hospitalization covered under the policy nor specified anywhere in policy document. Even otherwise, such terms and conditions and exclusion clause were not ever explained to the complainant insured. All the requirements and formalities whichever were asked for completed and complied with for quick settlement and reimbursement of health insurance mediclaim for full total claim amount of Rs.35,293/. To utter dismay and anguish of the complainant, OP No.2 vide cryptic letter dated 06.01.2017 printed in small and fine print inter alia stating the claim has been processed and settled for Rs.5000/- as stated therein. Ironically and interestingly there was no whisper in respect of deductable clause and denying reimbursement for full amount. From the information and documents provided vide letter dated 30.11.2017 in response to RTI application dated 17.10.2017 under Section 6(1), it was revealed that in fact claim was processed recommended for approval by TPA OP No.4 though as per HIR 2016, TPA has no competence and jurisdiction in respect thereto. OP No.2 on ill advised of OP No.4 issued letter dated 06.01.2017 in routine and mechanical manner as stated ante. The drastic reduction of claim amount was arbitrary, malafide, unreasonable and unjustified. The mediclaim was not hit by any such hidden clause/condition unknown kept under mat was not binding on the complainant in any manner. OPs could not bind down the complainant to provision of policy of which the complainant was not ever made aware. This itself is sufficient to saddle with the charge of deficiency in service and unfair trade practice as envisaged under the provisions of the Consumer Protection Act, 1986 as amended upto date on the part of the OPs. The OPs are guilty of deficiency in rendering service, negligence and unfair trade practice in unilateral and arbitrary for drastic reduction of the claim amount of Consumer Protection Act, 1986 and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay mediclaim of health insurance policy amount of Rs.35,293/- minus Rs.5000/- alongwith interest @ 12% from the date of payment to the hospital upto the date of actual payment to the complainant. Further, OPs be directed to pay compensation of Rs.25,000/- for causing mental tension and harassment to the complainant, Rs.5500/- as litigation expenses and Rs.1000/- on account of fee of Rs.200/- for making complaint, postal charges and expenses for typing, Photostat and stationary etc.

2.                Notice of the complaint was given to the OPs, who filed its joint written reply and contested the complaint by taking preliminary objections that the complainant is stopped by her own act, conduct and acquiescence to file the present complaint. The complainant has suppressed the material facts from this Commission. The complainant has admitted that the date of commencement of the policy was 08.02.2011 and as such, the complainant in order to make wrong case have wrongly stated that the conditions and privileges and major surgical benefit for undergoing surgery in a hospital due to accidental injuries or sickness covered during the period after date of commencement and exclusion clauses were not ever issued or communicated in writing to the complainant. At the time of issuance of the policy, the terms and conditions were supplied to the complainant. The policy was issued on 08.02.2011 and the complainant never written a letter and never protested and never challenged that the terms and conditions were not received by the complainant. The complainant cannot take the advantage of his own wrong. The OP is a public undertaking and after lapse of seven years it is very simple to state that the complainant did not get the terms and conditions. It is further averred that the complainant was allured and induced by temping and lucrative advertisement circulated across the country. These allegations allured to be stated before the Consumer Commission. Let the matter be decided by the Civil Court by putting these allegations and for non-receipt of the terms and conditions i.e. exclusion clause, the terms and conditions are always part and parcel of the policy which has been placed by the complainant himself on the record. It is further averred that the LIC’s Health Protection Plus Plan is a fixed benefit plan and not medi-claim policy. On merits, the factum with regard to taking the policy by the complainant is admitted and it is also admitted that the hospital cash benefit and major surgical benefit are covered under this policy, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.

3.                Rejoinder to the written statement filed by the complainant, whereby reasserted the entire facts as narrated in the complaint and denied the allegations raised in the written statement. 

4.                In order to prove their respective versions, both the parties produced on the file their respective evidence.

5.                We have heard the learned counsel for the OPs No.1 to 3 only as none has appeared on behalf of the complainant since last so many dates and have also gone through the case file very minutely.

6.                It has been admitted and proved by the complainant that the complainant purchased LIC’s Health Protection Plus (Table No.902) policy from the OP w.e.f. 10.02.2011 further renewed till 2017. During the validity of the above said policy, the complainant was diagnosed as DUB, Bulky uterus, fibroid and menorrhagia, Belly uterus C, Uterine fibroid and underwent LAVH with B/I, Salpingioopherecotmy. She remained admitted in the hospital from 06.10.2016 to 09.10.2016. She was diagnosed with the above said diseases as per Ex.C-10 and the discharge slip has been proved by the complainant as Ex.C-11. For the entire treatment, the complainant spent Rs.35,293/-. The complainant filed a claim for the above said amount of mediclaim of Rs.35,293/- on 29.10.2016, vide Ex.C-12, but the OPs reimbursed only Rs.5000/-. The policy has been proved by the complainant as Ex.C-1, Medical examination report Ex.C-5, Special Biochemical Test Ex.C-6, Haematology Test Ex.C-7, Routine Urine Analysis Ex.C-8, ECG Report Ex.C-9. The complainant has also proved on record the details and bills for the expenses incurred on her treatment Ex.C-14 to Ex.C-22. It has been alleged that the denial of genuine claim of the complainant is wrong and it proves the deficiency in rendering services, negligence and unfair trade practice in arbitrary manner by the OPs. It has also been alleged that the terms and conditions were never supplied to the complainant and the policy dated 10.02.2011 is in small mini micro print, which cannot be read by naked eye. The complainant is not in the knowledge of the exclusion clauses nor the same was ever explained to the complainant, therefore the repudiation letter is alleged to be illegal.

7.                The OPs have proved on record two documents i.e. LIC’s Health Protection Plus conditions and privileges Ex.O-1 and Claim Requirement Letter Ex.O-2. The OPs have relied upon the law LIC Vs. Ramphal and Jeet Kamal Vs. LIC, decided by the Hon’ble National Consumer Disputes Redressal Commission.

8.                The contention of the OPs is that the terms and conditions were duly sent and delivered to the complainant. The surgery got done by the complainant does not fall in the list of surgical procedures mentioned in the terms and conditions of the policy. It is not disputed that the complainant purchased the policy in the year 2011 and at that time, as per the complainant, she was not supplied with the terms and conditions and the print of the policy was very mini and was not readable. The complainant never protested or requested to the OPs to provide the elaborate terms and conditions to her nor this fact has been proved by the complainant that she ever made any request to the OPs. The policy was purchased in the year 2011. She was admitted in the hospital in 2016 i.e. after five years and during these five years, no efforts were ever made by the complainant to get the terms and conditions of the policy. Thus, this contention of the complainant that she was never supplied with the terms and conditions and was not explained about the exclusion clause, is not tenable as in Ex.C-1, it has been mentioned at Page No.2 that “the Welcome Kit contains your Policy Bond. Conditions & Privileges under your Health Protection Plus Policy. The health cards for you and your family members covered under this policy will be sent to you by the TPA (Third Party Administrator), Health Card serves as an identity card and will be useful to you at the time of claiming benefits under the policy. The TPA will send you the details of his contact, name and address. This is also available at your service branch office.

                   We urge you to go through the conditions and privileges under the policy and familiarize yourself with various benefits and conditions available to you and the other members covered.”

9.                It is admitted and proved that the claim was filed for Rs.35,293/- and the claim was settled for Rs.5000/- only. Perusal of Ex.O-1, which are the conditions and privileges to the purchasers of LIC’s Health Protection Plus show that the surgery underwent by the complainant is not covered and is not mentioned in the list of surgical procedures.    It has been held by the Hon’ble National Commission, in a case Revision Petition No.2640 of 2016, titled as “Jeet Kamal Vs. LIC & Anr.” that the conditions of the insurance policy are equally applicable on the parties beyond the conditions of the insurance policy, the claim cannot be provided. It has further been held by the Hon’ble National Commission in the above said case that as per the terms and conditions of the policy Ovarian Cancer is not one of the surgical procedure covered by the said insurance company, therefore the claim cannot be granted. In the present case also the treatment taken by the complainant and the surgery underwent by the complainant is not covered in the list of surgical procedures mentioned in the list of schedule of policy. Therefore, no claim can be granted to the complainant as the claim has already been settled by the OPs as per the rules and terms and conditions of the insurance policy and accordingly, the complaint of the complainant is hereby dismissed with no order of costs. Parties will bear their own costs. This complaint could not be decided within stipulated time frame due to rush of work.

10.              Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.

Dated          Jaswant Singh Dhillon    Jyotsna                Dr.Harveen Bhardwaj     

12.05.2022         Member                          Member           President