Tripura

West Tripura

CC/31/2016

Sri Kajal Das Roy. - Complainant(s)

Versus

Life Insurance Corporation of India. - Opp.Party(s)

Mr.A.L.Saha. Mr.K.Nandi, Sumi Datta.

09 Aug 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSSAL FORUM
WEST TRIPURA :  AGARTALA

CASE   NO:   CC- 31 of 2016

Sri Kajal Das Roy,
S/O- Lt. Samarendra Das Roy,
West Pratapgarh,
P.S. A.D. Nagar,
West Tripura.                .…...Complainant.

     VERSUS

Life Insurance Corporation of India,
Agartala Branch No-1,
Paradise Chowmuhani,
Hospital Road Extension,
P.S. West Agartala,
West Tripura.                .........Opposite party.

      __________PRESENT__________

 SRI A. PAL,
PRESIDENT,
  DISTRICT CONSUMER  
DISPUTES REDRESSAL FORUM,
      WEST TRIPURA, AGARTALA. 

SMT. Dr. G. DEBNATH
MEMBER,
  DISTRICT CONSUMER 
DISPUTES REDRESSAL FORUM, 
  WEST TRIPURA,  AGARTALA.

SRI U. DAS
MEMBER,
  DISTRICT CONSUMER 
DISPUTES REDRESSAL FORUM, 
  WEST TRIPURA,  AGARTALA.

C O U N S E L

For the Complainant        : Sri Amritlal Saha,
  Sri Kajal Nandi,
  Smt. Sumi Datta,
                      Advocates.

For the O.Ps                 : Sri Nepal Majumdar,
                      Advocate.    

        JUDGMENT  DELIVERED  ON:  09.08.2016

J U D G M E N T
        This case arises on the petition filed by one Kajal Das U/S 12 of the Consumer Protection Act. Petitioner's case in short is that he purchased one Health Policy, 'Jeevan Arogya' from the Opposite Party, Life Insurance Corporation of India (in short LICI) having branch office at Agartala. Policy was valid from 16.05.2013 to 16.05.2044. Annual premium of Rs.3578.97/- was paid. After purchasing the policy petitioner suffered pain in the abdomen, went to the ILS Hospital, Agartala. There he was treated and Gall Bladder stone detected and by operation stone was removed. Total charge was Rs.50,000/-. Petitioner claimed the amount from the LICI. But the O.P. LICI refused to accept the claim and informed him that to get the benefit he will have to wait for 2 years as per condition and privileges of the LICI 'Jeevan Arogya' Policy. The condition of the LICI is that as per terms and conditions of the policy specific waiting period was given. For treatment of Gallbladder stone waiting period is 2 years. The petitioner is entitled  to get benefits of policy, treatment cost if the illness occurred after 2 years of purchasing the policy. On this point claim was repudiated. Petitioner being aggrieved by the action of the Opposite party filed this prayer before this Consumer Forum seeking redress as per section 12 of the C.P. Act. 
2.            Opposite party, LICI filed W.S denying the claim. It is contended that the policy holder was fully satisfied with the terms and condition and accepted the same. Option of ''Cooling Off'' allows the policy holder to return the policy and exit from it if he is not satisfied with the terms and conditions of the policy. The Policy condition was sent with the 'Welcome Kit'' and the petitioner within 15 days did not exit from the policy and accepted the terms. As per  terms of the treatment Surgery of Gall Bladder stones falls under specific waiting period of 2 years from the commencement of the policy.  No benefit of hospitalization and surgery is available if the treatment is within the 2 years from the date of commencement of the policy. The policy was taken on 2013. Treatment of gall bladder stone was on 07.09.2014. After 1 year 3 months from the date of commencement of the policy. As the 2 years period not completed so petitioner is not entitled to get the cost of treatment. 
3.            On the basis of contention raised by both the parties following points cropped up for determination;
            (i)Whether the terms and conditions of the policy put a bar to claim the treatment cost and compensation?
            (i)Whether the petitioner is entitled to get treatment cost and compensation?    
4.            Petitioner produced original LICI 'Jeevan Arogya Policy', discharge summary, copy of claim intimation given to the LICI. Petitioner also produced statement on affidavit of Kajal Das Roy, petitioner of the case. 
5.            O.P. on the other hand produced 'Jeevan Arogya' condition and privileges, copy of Insurance policy, hospital treatment history, claim form, communication, return of claim papers, application, forwarding, discharge summary, claim repudiation letter, proposal form for the health Insurance claim, return of health Insurance claim etc. total 22 documents which are exhibited and marked as Exhibit- A Series. O.P. also produced the statement on affidavit of Mahammad Ali Choudhury, Manager, administration, L.I.C. of India.
6.            On the basis of all these evidence we shall now determine the above points;
    Findings and decisions on point No. 1 and 2:
7.            In this case treatment and surgery of the petitioner in ILS Hospital is admitted. Petitioner was admitted and gone surgery on 2014. After Gall Bladder operation he was discharged on 09.09.2014. It was also admitted fact that cost of treatment was total Rs.50,000/-. Claim form duly filled up was received and through the correspondence date 11.08.15 LICI informed that as the specific waiting period in respect of treatment specified in list not covered. So, the claim was repudiated as nothing was payable under the policy, Senior Divisional Manager informed it Treatment and conditions of the 'Jeevan Arogya' policy is enshrined in the table-903. According to LICI the same booklet was sent to the petitioner and there he was given option to exit within 15 days if not satisfied with the terms and conditions.     
8.            We have gone through the booklet which is written in a microscopic alphabet. It is very difficult to read the writings in naked eyes. Firstly, in the Section-6 written it is that there shall be no general waiting period in case of hospitalization or surgery due to accidental bodily injury. There shall be a general waiting period during which no benefits will be payable in the event of hospitalization and surgery if that hospitalization or surgery occurred due to sickness. General waiting period shall be 90 days from the date of cover commencement in respect of each insured. There under specific waiting period is given. For the treatment of gall bladder stone specific waiting period shall be 2 years from the date of cover commencement. This booklet was sent to the petitioner as per contention of O.P. LICI. Learned advocate for the LICI argued that petitioner is to wait for 2 years to get the benefit from 16.05.13. If the operation was done after 16.05.15 then only the petitioner had been entitled to get the benefit. But the operation was done on 08.09.14 before completion of 2 years. So, petitioner is not entitled to get the benefit.    
9.            It is true that the terms and conditions is to be strictly followed. No benefit can be extended beyond the terms and conditions. But the question is whether the terms and conditions was projected before the policy holder while he purchased the policy. We have gone through the proposal form meticulously. In the proposal form there is no whispering about such terms and conditions. We have also gone through the original copy of LICI 'Jeevan Arogya'. In the policy nothing is written to support that the benefit will be available in case of treatment after 2 years of the commencement of the policy. In the policy certificate it is written that the policy bond condition & privileges of Jeevan Arogya is sent with the cards by 3rd party. TPA has sent with the name and address to the petitioner. Petitioner was requested to go through the terms and conditions and finally written ''cooling off'' provision  offers for a period of 15 days. But in the policy it is not written that the party can exit if not satisfied with the terms and conditions. 
10.            In this case the only points is in respect of  fulfillment of terms and conditions in respect of waiting period. The date of sending of 'Welcome kit' to the petitioner, date of receipt by him and opportunity to exit from the policy not clearly comes out from the evidence of the O.P. There is nothing before us to support that sufficient time and opportunity was given to the petitioner to exit from the policy if not satisfied with the terms and conditions. The terms and conditions were not projected to him while purchasing the policy. Such proposal also not given. Generally the waiting period is written 90 days from the date of commencement in respect of each policy. Again specific waiting period given for specific disease which is contradictory with the general waiting period. This terms and conditions is not statute. It is one sided and not signed by the petitioner after understanding the same. 
11.            Waiting period as written not satisfactorily explained to the petitioner. The process of exit from the policy not disclosed while giving proposal. In the 'Welcome kit' the condition and privileges were written in a microscopic alphabet illegible and can not be read over by naked eyes. Learned  advocate for the petitioner argued that the petitioner was not aware about such terms and conditions at any point of time. He paid the premium 2 times and was under the impression that he was covered by the policy. The matter of waiting period was disclosed to him only when he placed the claim before the LICI. This was shocking and it was deficiency of service by the LICI. We have considered the submission of both the parties and we consider that such terms and condition is contradictory and not binding on the petitioner who was kept in dark while purchasing the policy. This consumer court is to give redress to the person who is aggrieved by the deficiency of service of any authority or person. We therefore, consider that as such illegible terms and conditions can not put a bar on the claim of the petitioner and he is entitled to get benefit of the 'Jeevan Arogya Policy' and also get compensation for the deficiency of service by LICI. Both the points are decided accordingly. 
12.            In view of our above findings over the two points this petition is allowed. We direct the O.P. LICI to give all the benefits, treatment cost Rs.50,000/- to the petitioner as he paid the premium for the same. The person can not be deprived when he paid the premium for getting the service. This service was not provided and he was deprived for waiting period therefore, he is entitled to get compensation Rs.10,000/- also cost of litigation Rs.5,000/-. We therefore, direct the O.P. to pay benefits of the policy and Rs.50,000/- along with it compensation Rs.10,000/- and also litigation cost Rs.5,000/-. The amount is to be paid within 2(two) months if not paid it will carry interest @ 9% P.A.              

                  Announced.

SRI A. PAL
PRESIDENT,
DISTRICT CONSUMER  DISPUTES 
REDRESSAL FORUM,
WEST TRIPURA,  AGARTALA.

 

SMT. DR. G. DEBNATH,
MEMBER,
 DISTRICT CONSUMER DISPUTES 
REDRESSAL FORUM, 
WEST TRIPURA, AGARTALA    SRI U. DAS
MEMBER,
  DISTRICT CONSUMER 
DISPUTES REDRESSAL FORUM, 
  WEST TRIPURA,  AGARTALA.