Punjab

Sangrur

CC/564/2017

Parmod Kumar - Complainant(s)

Versus

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

Sh.S.S.Mann

12 Apr 2018

ORDER

 

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR

                             

                                                                                           Complaint no. 564                                                                                       

                                                                                             Instituted on:  25.10.2017 

                                                                                             Decided on:    12.04.2018

 

Parmod Kumar aged about 52 years son of Om Parkash resident of Patti Tabo Mori, VPO Sheron, Tehsil Sunam, District Sangrur.  

                                                …. Complainant.      

Versus

1. LIC of India through its Divisional Manager Divisional Office, Railway Road, Sangrur District Sangrur.
2. Manager Marketing, LIC of India, Divisional Office,  Jeevan Parkash, Sector 17-B, Chandigarh. 

                                                  ….Opposite parties.

 

 

FOR THE COMPLAINANT:       Shri S.S.Mann  Advocate                          

 

FOR  THE OPP. PARTIES  :         Shri Amit Goyal, Advocate

                 

 

 

Quorum

                            

 

Sarita Garg,  Presiding Member

Vinod Kumar Gulati, Member

                 

 

ORDER:  

 

 

Sarita Garg, Presiding Member

 

1.             Parmod Kumar, complainant has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that  he got himself insured from Op no.1 vide policy number 164687605 dated 14.02.2011 and deposited premium of Rs.30000/-  half yearly with OP no.1 . In the month of November 2014, the complainant suffered pain in his left hip and  got replaced his left hip from Cheema Medical Complex, Mohali on 3.6.2015.  On 7.11.2015  the complainant submitted his claim  of Rs.1,92,000/- with OP no.1  and on 13.1.2016 the OP no.1 sent a letter to the complainant  vide which the OP no.1 repudiate the claim . On 2.2.2017 the OPs issued a letter  wherein they required to provide  the history and duration  of smoking and alcohol certified by treating doctor but the OPs had not reimbursed the medical claim of the complainant so far.    Thus, alleging unfair trade practice on the part of OP, the complainant has sought following reliefs:- 

i)      OP be directed to reimburse the medical bill i.e. Rs.1,92,000/- along with interest @18% per annum  till realization,

ii)     OP be directed to pay to the complainant a sum of Rs.25,000/- on account mental agony and harassment and  Rs.15000/- as litigation expenses.

2.             In reply filed by the OPs, it is specifically denied that OPs assured the complainant that LIC will indemnify the complainant in case of any accident or expenditure of hospitalization and medicines.  The policy in question is not a medi- claim policy rather same  is a fixed benefit policy and has no link with the amount of expenditure actually incurred by  the life assured and the amount actually  payable under the policy. The complainant was repeatedly requested  by the TPA  to provide  history of Osteoarthritis and Hypertension certified  by the treating doctor but the complainant failed to  provide the same. Thereafter letter dated 13.01.2016 was sent by the OPs to complainant informing him  that despite  of repeated reminders, documents have not been supplied but still claim could be considered again if he fulfills the requirement and ultimately the claim  of the complainant was repudiated  vide letter dated 22.03.2017.  Thus, there is no deficiency in service on the part of the Ops.   

3.             The complainant has tendered documents Ex.C-1 to Ex.C-14 and closed evidence. On the other hand, OPs have tendered documents Ex.OP-1 to ExOP-27 and closed evidence.

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

5.             It is an admitted fact between the parties that the complainant had taken the policy in question bearing number 164687605  from the OPs and it is further admitted that during the subsistence of the  insurance policy the complainant got replaced  his left hip from Cheema Medical Complex Mohali on 3.6.2015  where he spent an amount of Rs.1,92,000/-  on the treatment. But, the grievance of the complainant is that the OPs did not settle the claim despite his best efforts and submission of the documents to the OPs. On the other hand, the stand of the Ops is that the complainant did not submit the documents which were required for settlement of the claim such as history of Osteoarthritis and Hypertension certified by the treating doctor.  During arguments, the learned counsel for the complainant has handed over the set of documents to the learned counsel for the OPs and a copy of the same documents has also been placed on record.    

 

6.             Accordingly, in view of our above discussion, we allow the complaint partly and direct the OPs to settle the claim of the complainant within a period of 45 days of receipt of copy of the order and also intimate their decision to the complainant under registered letter. It is made clear that it will be open for the complainant to approach this Forum again, if he remains unsatisfied from the decision of the OPs. Under the circumstances, the parties left to bear their own costs. A copy of the order be supplied to the parties free of cost. File be consigned to records in due course.  

                Announced

                April 12, 2018

 

 

 

 

                 (Vinod Kumar Gulati)       ( Sarita Garg )                                                                                                                                                                                                                        

Member                                                 Presiding Member