The complainant purchased a LIC Health Protection Plus Policy -Table No. 902-on 06-08-2010 and OP received premium of Rs. 10,000.00 as per table and the OP also issued a Health Protection Plus Policy including his wife Baisakhi Chakraborty and the date of expiry of the said policy is 06-08-2048. At the time of policy, the OP LIC received all relevant documents with photographs and identity proof, age proof documents and have also issued Health Card for the principal policy holder, Sanjoy Chakraborty, but after expiry of two years from the date of opening that policy, the OP did not issue any Health Card in the name of his wife and minor daughter, instead demanded Rs. 12,000.00 as yearly premium which the complainant deposited with all papers in August 2013. OP LIC issued premium receipt in favour of the complainant, but did not issue any Health Card in the name of the wife and daughter as per table. The wife of the complainant unfortunately being serious ill, was under treatment at Tata Medical Centre, Rajarhat, Kolkata and spent Rs. 3,15,375.00 for the first time and Rs. 1,12,552.00 during the second time – in total Rs. 4,27,932.00 for the treatment of his wife. The complainant submitted all the documents including treatment sheets, doctors- opinion, medical vouchers etc. to the OP on 18-06-2013 and 19-12-2013, but the OP did not arrange to disburse medical benefit to the complainant. After two months the complainant made a written representation on 08-08-2013, but the OP did not settle his claim even after 5 months and instead the OP verbally informed that they forwarded his claim papers to the TPA and Chief Manager, LIC to settle his claim. As the OP withheld his legitimate claim unnecessarily, the complainant filed the instant case.
The OP denied all contents of the complainant and stated in their written version as well as in their WNA that the complainant-s case is not maintainable and that no correspondence was made by the complainant; that the claim amount will not be settled on the basis of actual expenses incurred but depending on the contingencies after hospitalization of the course of treatment and that under the terms and conditions of the policy the treatment only for duration of stay in hospital and surgery, if any can be allowed against the policy holder under Olan 902. OP prayed for dismissal of the case.
To substantiate his claim, complainant has filed photocopies of LIC-s Health Protection Plus Plan Table 902, receipt of first and last premium, Health Card issued in favour of the complainant, LIC-s letter dt. 10-09-2012, LIC-s letter dt. 10-09-2012, Claim Intimation Form, letter of LIC dt. 17-05-2013, written representation dt. 08-08-2013 of the complainant, letter issued by AAO -HI-, LIC, claim intimation form dt. 19-12-2013, Advocate-s letter dt. 19-12-2013 etc.
OP has not filed any document in support of their defense.
Points for discussion
- Whether there is any deficiency in service on the part of the OP.
- Is the complainant entitled to any relief as prayed for.
Decisions with reasons
Point nos. 1 and 2-
Both the points are taken up together for discussion.
The OP, in his written objection, states that the prayer of the complainant is not applicable in connection with the terms and conditions of Health Protection Plus Plan. According to the OP, under the terms and conditions of the policy, the treatment received only during the stay in hospital or surgery, if any can be allowed against the policy. They also stated that the amount of settlement of claim does not depend on expenses incurred, but claim is settled on the basis of treatment of the disease or surgery in accordance with enlisted surgery. As such, complainant is not entitled to any relief.
We have gone through all the papers and documents. The letter dt. 10-09-2012, issued by LIC to the complainant-policy holder goes to show that name of beneficiary Baisakhi Chakraborty and daughter Rimjhim Chakraborty have been included and the same will be given effect only after receipt of premium due for 08-2013. As such, the date of commencement of the medical-surgery benefits in the names of Baisakhi Chakraborty and Rimjhim Chakraborty is from 06-08-2013 to be effected. Treatment form filed by Baisakhi Chakraborty goes to show that she was admitted in the hospital on 04-03-2012. It is very clear from the letters vide reference no. 469-PS-Alterations-000014 and reference no. 469 -PS-Alterations-000015 that above inclusions will be effective only after the receipt of premiums which is due on 08-2013. As such, the complainant-policy holder is not entitled to any claim under the said Health Protection Plus Policy inasmuch as no deficiency in service on the part of the OP has been established, as alleged.
As such, both the points are disposed of against the complainant.
Hence, it is
ORDERED
That the instant case be and the same is dismissed on contest against the OP but without any cost.
