JUDGEMENT
The present complainant by filing this complaint has submitted that he purchased one LIC’s Jeevan Arogya non linked health insurance plan of Rs.3,00,000/- each for himself, his wife and his son paying Rs. 16,052/- as first year premium and on payment of that first premium he received the policy document through speed post being No. EW 339443918 IN having commencement of policy w.e.f. from 25.09.2013.
On 16.11.2013 evening suddenly felt chest pain and uneasiness and immediately the complainant rushed to Calcutta Medical Research Institute where after initial examination doctors admitted him in the ICCU for further treatment under Dr. Dhiman Kahali and on 21.11.2013 he was released from the said hospital with a written advice to do CAG immediately.
Accordingly on 11.12.2013 he was admitted at Nightingale Hospital in ICCU to do the CAG under Dr. Ghosh Dastidar, where the doctors found three blockages in different arteries of complainant’s heart and was released from the said hospital on 12.12.2013 with a written advice to do the PTCA in LAD and RCA immediately.
To do the above said treatment complainant’s wife went door to door of his friends and for collecting money finally on 15.12.2013 night he was admitted to Apollo Gleneagles Hospital under Dr. Suvro Banerjee where two stents were successfully placed and he was released from there on 19.12.2013 and the said discharge summary of the said hospital along with original claim forms was submitted to LIC by the complainant.
It is alleged by the complainant that no document is required except the hospital discharge summary for any reimbursement claim, but at the time of submission of the claim for the above treatment he was given number of forms which required stamp and signature from all the three hospitals and his photograph and many supporting documents. Accordingly complainant filled up all the forms very carefully and despite doctor’s strict restriction the complainant had to travel from hospital to hospital with his ill health and request person to person to get those forms stamped and signed and ultimately on 17.01.2014 the complainant submitted all the claims along with all relevant documents to LIC office but after a few days, he received a letter Ref. No. H041/KMDO-1/H.I/122, dated 06.02.2014 from LIC asking for some more documents and clarification and on 12,02.2014 he sent a clarification letter to their Sr. Divisional Manager (H.I.) LIC Office through their agent giving all the details, but LIC office again verbally asked for the medical details recorded at CMRI Hospital at the time of emergency treatment as documents for first commencement of disease.
Again he travelled and ultimately collected the documents and submitted it to LIC office on 20.02.2014. But after a few days he received three letters dated 23.03.2014 from LIC authorized TPA Medicare on 25.03.2014 stating that as per LIC’s advice all claims are denied under LIC’s Clause No. WO3 because the claims are within 90 days from the commencement date of the policy. On 08.04.2014 complainant sent a email to their responsible officers asking for the clarification as to why his claim was denied when there is no such clause mentioned in the policy bond and why he was harassed unnecessarily asking for so many documents which he had to collect from different hospitals with such ill health but there was no response from the op.
Subsequently on 23.05.2014 complainant received a letter issued by LIC Manager but surprisingly this time also the letter date was 07.04.2014 and speed post date was 22.05.2015 after 15 days stating that as per terms and conditions of the said policy under clause WO3. Again he resent email on 28.04.2014. But unfortunately there was no response from the LIC. So, on 09.05.2014 he sent his complaint letter to them through speed post but there was no response.
Further on 23.05.2014 he received a letter from LIC signed by their Manager HI giving the same excuse but not the answer/clarification sought for by the complainant and in the present speed post date was 22.05.2015 and in the above situation complainant has filed this complaint and there is no mention if it arises within 90 days from the date of commencement and no claim shall be entertained and complainant thinks in the name of non-linked health plan actually they are making the poor people fool, so that after harassment people will give up the hope and LIC enjoy money like the cheat funds.
So, in the above circumstances, complainant has prayed for redressal and for directing the op to release the entire claim amount.
On the other hand op by filing written statement submitted a receipt of the first yearly premium of Rs. 16,052/- from the complainant the policy being Policy No. 495956420 was issued to the complainant with commencement dated of 25.09.2013 and in this policy there are two beneficiaries i.e. wife and son of the complainant and each members have opted initial daily cash benefit of Rs. 3,000/- and as per policy condition this Major Surgical Benefit (MSB) in this particular case is 40percent of the sum assured of Rs. 3,00,000/- and this policy was dispatched by speed post on 08.10.2013 by article number EW339443918 IN along with policy bond and the conditions and privileges under the Jeevan Aroyga plan had been sent to the complainant and complainant has already disclosed the policy bond and the letter which specifically states regarding the sending of the welcome kit along with the terms and conditions.
As per conditions and privileges which was sent to the complainant along with the policy bond, specifically stated that there will be a general waiting period of 90 days from the date of commencement of the policy at page no.4 caluse-6 under the heading Waiting Period was known to the complainant but the complainant deliberately decided to avoid mentioning of such conditions in the petition because it will go against his contention. It is further submitted that in the policy bond of LIC’s Jeevan Arogya itself, it is specifically mentioned that this policy of assurance shall subject to the conditions and privileges attached herewith and also this policy offers the policyholder the option of cooling off provision for a period of 15 days from the date of receipt of the same.
Subsequently complainant was hospitalized for double vessel coronary artery disease on 16.11.2013 for the first time and release there on 21.11.2013 thereafter he was again admitted on 11.12.2013 to 12.12.2013 and lastly on 15.12.2013 to 19.12.2013 and all those admissions and treatments in hospital in hospital were done within a period of 90 days from the date of commencement of the policy. So, in view of the above policy conditions, the complainant is not entitled to get such benefit for which the same was refused or rejected but the allegation of the complainant is baseless and without any foundation.
Decision with reasons
On in depth study of the entire complaint and the written version including the terms and conditions of the LIC Jeevan Arogya Plan No. 903 and also the argument as advanced by the Ld. Lawyers, it is clear that the present disputed policy was purchased by the complainant on 25.09.2013 on payment of premium and as per policy bond, conditions and privileges under the Jeevan Arogya Plan, no doubt complainant is entitled to get benefit of the hospitalization charges for his treatment etc. But as per Clause-6 (waiting period) it is found that the general waiting period shall be 90 days from the date of covering of commencement of the policy in respect of the each insured. So, as per terms and conditions of that policy, the insured is entitled to get benefit of the hospitalization charges only after completion of 90 days from the date of commencement of the policy.
But in this case it is clear that complainant was admitted to ICCU for treatment on 16.11.2013 and was discharged on 21.11.20123. Now we shall have to consider whether the period of treatment of the complainant was within the waiting period of 90 days from the date of commencement of the policy or not. So, in this regard we have gone through the policy document wherefrom we find that the commencement of the policy was on and from 25.09.2013. Then 90 days shall be covered on 24.12.2013 and if complainant would be treated in any hospital after 24.12.2013, in that case as per policy condition, complainant was entitled to get the benefit of Jeevan Arogya policy benefit. But in the present case complainant is not entitled to get any benefit of the said policy in view of the fact that complainant was admitted within the waiting period i.e. 90 days from the date of commencement of the policy and practically it was within two months from the date of commencement of the policy.
So, in view of the above position no doubt rightly the op repudiated the claim of the complainant as per terms and conditions of the policy and in this regard legally there is no negligence, deficiency or negative attitude on the part of the op for repudiating the claim. Further considering the policy, it is clear that complainant was supplied a Welcome Kit of the policy conditions. But anyhow that has not been submitted by the complainant and at the same time complainant received the said policy but did not report to the op that he did not receive the kit of the condition at any moment. But from the complainant’s own version in the complaint it is clear that complainant is aware of the terms and conditions of the policy because he purchased it from the agent and agent supplied papers and he was satisfied and then purchased the policy.
So, in view of the above findings we are convinced to hold that there was no laches on the part of the op for repudiating the claim and no doubt by speed post on 07.04.2014 op reported the reason for rejection of the claim on the ground of hospitalization within 90 days from the date of commencement of the policy and after giving much importance of the personal submission of the complainant in respect of the fact that this condition was not informed to the complainant. But in this respect we are very much anxious about such allegation. But after consulting the entire papers and materials on record, it is found that the said allegation against the op is completely baseless, probably he was allured by the agent for getting such benefit only for the purpose entered into hospital for treatment and he purchased this policy and thereafter he entered into hospital for treatment and other purpose.
Another factor is that from the discharge summary and other papers, it is clear that he has been suffering from heart trouble prior to purchasing that policy and that was suppressed. So, in view of the above findings we are convinced to hold that complainant has miserably failed to prove any sort of laches on the part of the op and at the same time complainant and ops are completely governed and guided by the terms and conditions of the policy and in this regard this Forum has no power to give any exceptional benefit or no relaxation can be made on the ground of equity or whatever it may be and as per findings of National Commission ruling reported in 2013 (4) CPR 165 NC supports that view. But anyhow in some cases it is found that Forum is exceeding its jurisdiction and violating the position and judgement of the Supreme Court. But we are not in a mood to violate the judgement of Supreme Court and National Commission whatever it may be and this Forum has no doubt entered into the deep of the consumer dispute for realize that op did not deceive the complainant by any means when terms and conditions of the policy speaks specifically provides that present insured is entitled to benefit of hospitalization benefit only after expiry of 90 days from the date of commencement of the policy.
But fact remains that complainant entered into hospital within nine months within the commencement of the policy for which the benefit as per terms and conditions of the policy and that repudiation on the part of the op is no doubt legal, valid in the eye of law for which the complaint fails.
Hence, it is
ORDERED
That the complaint be and the same is dismissed on contest against the op but without any cost.
