Punjab

Sangrur

CC/455/2017

Harinder Singh - Complainant(s)

Versus

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

Sh.Ajay K.Bansal

05 Mar 2018

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

                                                        

                                                Complaint No.    455

                                                Instituted on:      07.09.2017

                                                Decided on:       05.03.2018

 

 

Harinder Singh S/o Sh. Balwant Singh, resident of # 3, Punia Colony, Dhuri Road, Sangrur.

                                                        …Complainant

 

                                Versus

 

1.             Life Insurance Corporation of India (LIC) Jeevan Jayoti Building, Railway Road, Sangrur through its Manager.

2.             Life Insurance Corporation of India (LIC) through its Divisional Manager, Division Office, Jeevan Parkash Building, Sector 17 B, Chandigarh.

3.             S.P.Sharma, Development Officer, LIC Office, Railway Station Road, Sangrur.

                                                        ..Opposite parties.

 

 

For the complainant    :       Shri Ajay Bansal, Adv.

For Opp.party No.1&2:       Shri Amit Goyal, Adv.

For OP No.3              :       Shri Pawan Gupta, Adv.

 

 

Quorum:    Sukhpal Singh Gill, President

                Sarita Garg, Member

                Vinod Kumar Gulati, Member

 

 

Order by : Sukhpal Singh Gill, President.

 

1.             Shri Harinder Singh, complainant (referred to as complainant in short) has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the complainant availed the services of the OPs by getting LIC’s Health Protection Plus Plan (Table 902) vide policy number 165011429 on 31.3.2011 vide proposal number 18878 dated 26.3.2011 at annual premium of Rs.15,000/- and since then the complainant has been paying the premium of Rs.15,000/- regularly to the Ops and last policy was renewed upto 31.3.2017. It is further averred that before issuance of the insurance policy, the complainant was got medically examined from the empanelled doctor of the OPs.  The grievance of the complainant is that on 22.6.2016 the complainant felt problem of giddiness be nausea and headache since one week, as such he was got admitted in Dayanand Medical College and Hospital, Ludhiana where he remained admitted for six days and spent an amount of Rs.74,083/-.  Further on 9.9.2016, he was again admitted in Landmark Hospital, Chandigarh with the same problem, where he spent an amount of Rs.11,000/- and thereafter on 13.9.2016, the complainant was again admitted upto 13^th September, 2016 and again he spent an amount of Rs.54,585/- on his treatment and by this way, the complainant spent a total amount of Rs.1,75,000/- on his treatment besides travelling expenses. Thereafter the complainant submitted all the medical bills to the Ops for reimbursement of the amount of Rs.1,75,000/-, but all in vain and lastly the Ops repudiated the claim of the complainant vide letter dated 16.9.2016.  Thus, alleging deficiency in service on the part of the OPs, the complainant has prayed that the Ops be directed to pay to the complainant the claim amount of Rs.1,74,563/- along with interest @ 12% per annum and further claimed compensation and litigation expenses.

 

2.             In reply filed by OPs number 1 & 2, legal objections are taken up on the grounds that the complainant has not got any mediclaim policy, rather the same is a fixed benefit policy and Major surgical benefit are available under the policy as per the terms and conditions, that the complaint is not maintainable, that the complainant has not come to the Forum with lean hands and that the complainant has dragged the Ops into unwanted litigation. On merits, it is admitted that the complainants had obtained the policy in question and further it is stated that the terms and conditions of the policy are always sent with the policy.  It is admitted that the complainant had paid the premium till March 2016 and an annual premium of Rs.15,000/- has to be paid under the policy, but it is denied that the policy is for Rs.3,00,000/- rather the sum insured under the head Major Surgical Benefit is Rs.3.00 Lacs with initial Daily Hospitalisation Cash Benefit of Rs.1500/- which is to be paid strictly as per the terms and conditions of the policy. It is stated further that in the discharge summary of the complainant, it is specifically mentioned that the complainant is a known case of DM-Type II since 25 years and Hypertension since 10 years, but he did not disclose this information while submitting the proposal form and had obtained the policy by playing a  fraud with the OPs.  It is stated that since the complainant was not entitled to get any claim, as such it was repudiated vide letter dated 1.9.2016.  The other allegations levelled in the complaint have been denied in toto.

 

3.             In reply filed by OP number 3, the issuance of the policy by the OPs to the complainant is admitted. However, the other allegations levelled in the complaint have been denied in toto.  It is stated further that at the time of issuance of the policy, all the terms and conditions were explained to the complainant in details.

 

4.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-59 copies of documents and affidavit and closed evidence. On the other hand, the learned counsel for the OP number 1 and has produced Ex.OP1&2/1 to Ex.OP1&2/16 copies of the documents and affidavit and closed evidence. The learned counsel for OP number 3 has produced Ex.Op3/1 affidavit and closed evidence.

 

5.             We have carefully perused the complaint, version of the opposite parties and evidence produced on the file and also heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits dismissal, for these reasons.

 

6.             It is an admitted fact between the parties that the complainant is insured with the OPs number 1 and 2 under the LIC’s Health Protection Plan vide policy number 165011429 for the period upto 31.3.2017 by paying the requisite premium of Rs.15,000/- per year to the Ops, as is evident from the copy of the insurance policy on record as Ex.C-3.  It is further an admitted fact that the complainant took treatment from the hospitals such as Dayanand Medical College and Hospital Ludhiana as well as Fortis Hospital etc., where he spent a huge amount of Rs.1,75,000/- as claimed by the complainant.  The learned counsel for the complainant has contended that the Ops have wrongly and illegally repudiated the rightful claim of the complainant vide repudiation letter dated 1.09.2016, a copy of which on record is Ex.C-4 on the ground that since the complainant was having a pre-existing disease which is a known case of hyper tension since 10 years and known case of diabeties since 25 years and did not disclose the same in the proposal form.  It is worth mentioning here that a bare perusal of the insurance policy Ex.C-3 clearly reveals that the claim of Rs.3,00,000/- is only payable in case of Major Surgical Benefit (MSB).  But, in the present case, there is no such major surgery involved with the complainant.  There is nothing produced by the learned counsel for the complainant to show that it is a medical insurance policy, which covers all the medical expenses.  But, the policy shows that the claim of Rs.3,00,000/- is only payable in case of Major Surgical Benefit. Since, there is no such case involved in the present circumstances, we feel that the complainant is not entitled to get any relief from this Forum. 

 

7.             Accordingly, in view of our above discussion, we dismiss the complaint of the complainant. However, the parties are left to bear their own costs. A copy of this order be issued to the parties free of cost. File be consigned to records.

                        Pronounced.

                        March 5, 2018.

                                                        (Sukhpal Singh Gill)

                                                                President

 

                                                             

                                       

                                                                (Sarita Garg)

                                                                    Member

 

 

 

                                                        (Vinod Kumar Gulati)

                                                                    Member