Punjab

Sangrur

CC/171/2017

Pawan Kumar Garg - Complainant(s)

Versus

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

Sh.Darshan Gupta

18 Aug 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

 

                                                               

                                                Complaint No.    171

                                                Instituted on:      24.04.2017

                                                Decided on:       18.08.2017

 

Pawan Kumar Garg aged 53 years son of Shri Roshan Lal, resident of Street No.2, Defence Avenue, Haripura Road, Sangrur.

                                                        …Complainant

                                Versus

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

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

                                                        ..Opposite parties.

 

For the complainant    :       Shri Darshan Gupta, Adv.

For OPs                    :       Shri Amit Goyal, Adv.

 

 

Quorum:    Sukhpal Singh Gill, President

                Sarita Garg, Member

                Vinod Kumar Gulati, Member

 

 

Order by : Sukhpal Singh Gill, President.

 

1.             Shri Pawan Kumar Garg, 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 Jeevan Arogya (Table 903) policy bearing number 165377990 in the year 2013 and has been regularly paying the premium under which the sum insured was for Rs.4.00 Lacs under mediclaim policy.  The complainant was hale and hearty and the time of getting the insurance policy.  The grievance of the complainant is that on 12.1.2015 he felt high fever and body pain and got treatment from Bansal Hospital, Sangrur and on the advice of the Doctor, on 7.5.2015 he went to Christian Medical College and Hospital Ludhiana for the better treatment, where he remained admitted from 7.5.2015 to 19.5.2015 and spent an amount of Rs.105106/- on his treatment besides other expenses of special diet boarding and travelling to the hospital.  Thereafter he lodged the claim with the OPs and submitted all the documents, but the OPs repudiated the claim of the complainant on 13.2.2017, which is said to be wrong and without any basis.  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 amount of Rs.1,05,106/- along with interest @ 12% per annum and further claimed compensation and litigation expenses.

 

2.             In reply filed by the Ops, preliminary objections are taken up on the grounds that the complainant has alleged that the policy in question is a mediclaim policy, whereas the policy in question is a fixed benefit policy and major surgical benefit under the policy is available only for the surgeries as per the list of surgeries mentioned in the policy terms and conditions. Apart from that legal objections are taken up on the grounds that the complaint is not maintainable, that the complainant has not come to the Forum with clean hands and that the complaint involves intricate questions of law and facts.  On merits, it is stated that the complainant obtained health insurance plan i.e. Jeevan Arogya vide policy number 165377990 from the Ops in the year 2013 and paid premium upto 2014. It is denied that the complainant obtained only policy.  It is stated that the policy in question was for Rs.4.00 Lacs only.   It is stated further that as per the discharge summary of the complainant issued by CMC Ludhiana, he is a known case of pancreatic diabetes, coronary artery disease and renal calculi, but he did not disclose this information while submitting the proposal form and has intentionally not provided the treatment record of the same to the TPA despite repeated requests.  The other allegations levelled in the complaint have been denied in toto.

3.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-16 copies of the documents and affidavits and closed evidence.  On the other hand, the learned counsel for the OPs has produced Ex.OP-1 to Ex.OP-11 copies of documents and affidavits and closed evidence.

 

4.             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 acceptance, for these reasons.

 

5.             It is an admitted fact between the parties that the complainant had taken the policy in question bearing number 165377990 from the Ops and it is further admitted that during the subsistence of the insurance policy the complainant remained admitted in Christian Medical College and Hospital Ludhiana for the period from 7.5.2015 to 19.5.2015, where he spent an amount of Rs.1,05,106/- 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 and duration of diabetes, pancreatitis, old renal calculi and coronary artery disease.  In the circumstances, we feel that ends of justice would be met if the complainant is directed to provide/submit the documents in his possession for settlement of the claim by the OPs.

 

6.             Accordingly, in view of our above discussion, we allow the complaint partly and direct the complainant to provide the documents whichever are in his possession within a period of 15 days under proper receipt and thereafter the OPs shall decide the claim within thirty days of the same and 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 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.

                        August 18, 2017.

                                                        (Sukhpal Singh Gill)

                                                                President

 

                                                             

                                                                (Sarita Garg)

                                                                    Member

 

 

                                                        (Vinod Kumar Gulati)

                                                                    Member