BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, JALANDHAR
Complaint No.119 of 2017
Date of Instt. 26.04.2017
Date of Decision: 16.03.2021
Suresh Kumar Dhir, aged about 50 years, s/o Sh. Raj Kumar, resident of C/o H.No. 313, Panj Peer, Near Sita Mata Mandir, Neem Wali Gali, Jalandhar.
..........Complainant
Versus
1. Life Insurance Corporation of India, Yogakshema, Jewan Bima Marg, Post Box No. 19953, Mumbai 400021 though its Managing Director.
2. Life Insurance Corporation of India, Jeewan Parkash, City B O IV, Ground Floor P B No. 148, Divisional Office, Model Town Road, Jalandhar-144001 through its Divisional Officer.
3. Life Insurance Corporation of India, Branch 2, Unit II, Jiwan Jyoti Building, Opposite Tehsil Complex, Jalandhar through its Senior Branch Manager.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Sh. Kuljit Singh (President)
Smt. Jyotsna (Member)
Present: Sh.R. K. Bhandari, Advocate Counsel for complainant.
Sh.M.S Sachdev, Advocate Counsel for OPs.
Order
Kuljit Singh (President)
1. The instant complaint has been filed by the complainant, against OPs on the averments that the agent of OPs contacted him in the month of May 2011 and explained the benefits of Health Medical Insurance of Life Insurance Corporation of India and he also elaborates the plans and there privileges of Health Medical Insurance and he further explained that in case of hospitalization immediate cash benefit will be given to the insurer at the time of hospitalization. The agent of Ops in order to prove himself also arranged the meeting of the complainant with his Development Officer and he found that at the time of meeting with Development Officer, the Development Officer narrated the similar version as that of the agent, but he further added that the premium of the said insurance policy is to be paid for at least continues period of five years from the date of commencement of the said medical insurance policy and then policy will cover the health benefit of the insurer for the period of 31 years from the date of its commencement. Thereafter, on the assurance of OPs, he purchased LIC Health Protection Plus having Table No. 902 from OP no.3 on 10.05.2011 having policy no.133280920 with the installment premium of Rs.750/- per month. The complainant thereafter made the payment of all installment premiums to OPs without missing any monthly installment premium up to June 2016. The complainant in the month of June 2016 contacted his Development Officer and he informed him that he had paid the monthly installments premium for five years and now he can stop the payment as per the policy. The complainant accordingly stopped paying the monthly installments premium to OPs. In the month of January 2017 the complainant went to Bhavnagar Gujarat for his business purpose. In the morning of 23.01.2017 at about 6.00 PM suffered pain on his left arm numbness and then he immediately rushed to HCG Hospital Bhavnagar with help of his close relative. He has suffered a severe paralysis attack and he was immediately admitted in the hospital and remain admitted in ICU for three days and thereafter complainant was shifted to the room and after some recovery in the health of complainant, he was discharged from the said hospital on 28.01.2017. He spent Rs.1,00,000/- on his treatment. At the time of discharging from the HCG Hospital on 28.01.2017, he received a bill of Rs.77,709/- having bill no.BILL0000068285 which was duly paid by him. After discharging from the said hospital, he was not able to move his left arm and left leg completely and thereafter he started his treatment from Sharda Medical Centre Tehsil Nalagarh, District Solan (HP) which was having specialization in Paralysis patient to get the immediate recovery and after 5-6 appointments with the said doctor, he is able to move freely at his own and he also spent more than Rs.50,000/- on his treatment from the said doctor. In the month of March 2017, the complainant contacted OP no.3 and made request about the claim of his health insurance policy. The official of the OP no.3 gave claim intimation form and hospital treatment form to the complainant and told him that this form is to be filled in by the hospital authority or by the concerned doctor, who treated the complainant. The complainant along with the claim intimation form and hospital treatment form went to HCG Hospital Gujarat and gave the said form to them then doctor who treated the complainant, filled the Hospital Treatment Form and also signed the said form along with the stamp of the said Hospital. Thereafter, the complainant went to the official of OP no.3 and submitted the said form along with application for medical claim dated 31.03.2017. Then official of OP no.3 told the complainant that they will forward the claim application letter of the complainant along with other supporting documents to the Divisional Office i.e. to OP no.2 and then decision will be taken by them. After few days, the complainant received phone call from office of OP no.2 that they will not do anything for the complainant and further told him to contact his branch office i.e. to OP no.3. The official of OP no.3 badly treated the complainant and told him that they can only give a sum of Rs.11,000/- to him but the complainant spent Rs.1,50,000/- on his treatment. OP no.3 returned the claim intimation form to the complainant and told that they cannot do anything more for the complainant. The act and conduct of OPs are illegal and against the laws of natural justice. There is deficiency in service and unfair trade practice on the part of OPs. Therefore, he has filed the present complaint and prayed that the OPs be directed to pay bills of HCG Hospital amounting to Rs.77,709/- along with expenditure of Rs.50,000/- incurred on his treatment at Sharda Medical Centre, District Solan, besides Rs.50,000/- as compensation for mental harassment and Rs.5500/- as cost of litigation.
2. Upon notice, OPs appeared and filed written reply and contested the complaint of the complainant by raising preliminary objections that the complainant has got no locus standi to file the present complaint. The complaint is not maintainable. The complaint is liable to be dismissed. On merits, it was averred that in the month of May 2011 explained the benefits of Health Medical Insurance of Life Insurance Corporation of India at the time of hospitalization. It is incorrect that the Development Officer added that premium of the said insurance policy is to be paid for at least continues period of five years from the date of commencement of the said medical insurance policy and then policy will cover the health benefits of the insurer for the period of 31 years from the date of its commencement. The policy and its contents were duly explained to the complainant and after admitting the contract and contents therein, policy was finalized and proposal given by complainant was accepted and policy was commenced on 10.05.2011. It was denied that complainant suffered pain on his left arm or then he immediately rushed to HCG Hospitals. It was also incorrect that complainant spent more than Rs.1,00,000/- on his treatment in the said hospital. The present policy is not mediclaim policy rather it is an investment-cum-Health Insurance Policy whereas NAV of the policy is returned to the policy holder on the policy anniversary immediately after attaining the age of 75 years. The said policy is for certain fixed benefits irrespective of medical expenses incurred on specified surgeries. Rest of the averments of the complainant was denied by OPs, and they prayed for dismissal of the complaint.
3. The complainant has tendered in evidence his affidavit Ex.C-A along with copies of documents Ex.C-1 to Ex.C-14. On the other hand, OPs tendered in evidence affidavit of Vijay Gill Manager Health Insurance as Ex.OP-A along with copies of documents Ex.OP-1 to Ex.OP-9.
4. We have heard learned counsel for the parties and have also gone through the record of the case very carefully.
5. The complainant has tendered in evidence his affidavit Ex.CA in support of his case. He alleged that he purchased LIC Health Protection having Table No.902 from OP no.3 on 10.05.2011 having policy no. 133280920 with installment premium of Rs.750/- per month. The complainant paid all the installment premiums to OPs. He further alleged that he suffered a pain on his left arm on 23.01.2017 and admitted in HCG Hospital Bhavnagar District Gujarat. He has suffered a severe paralysis attack and admitted in the hospital and discharged from the said hospital on 28.01.2017. He alleged that he spent Rs.1,00,000/- on his treatment. After discharging from the said hospital, he was not able to move his left arm and thereafter he came back to Jalandhar and started his treatment from Sharda Medical Centre District Solan. In the month of March 2017, he contacted OP no.3 and made request about claim of his health insurance policy. But OPs failed to pay the claim amount to complainant, which he has incurred during the time of his treatment. Ex.C-1 is copy of insurance policy issued in the name of the complainant. Ex.C-2 is copy of status report of the policy. Ex.C-3 is copy of terms and conditions of the policy. Ex.C-4 is copy of history of premium transaction. Ex.C-5 is copy of passbook. Ex.C-6 is copy of letter regarding medical claim addressed to LIC by complainant. Ex.C-7 is copy of letter dated 31.03.2017. Ex.C-8 is copy of claim intimation form. Ex.C-9 is copy of Hospital Treatment Form. In this document, the date of admission is mentioned as 23.01.2017 in the HCG Hospital and date of discharge is mentioned as 26.01.2017. Ex.C-10 is copy of impatient bill for payment of Rs.22,710/-. Ex.C-11 is copy of discharge summary of the complainant. In this document, the diagnosis is mentioned as “Acute onset left Hemiparesis (UL>LL) with left UMN Facial Paresis.” Ex.C-12 is copy of prescription slip issued by Sharda Medical Centre. Ex.C-13 is copy of payment receipt.
6. To refute this evidence of the complainant, OPs relied upon affidavit of Vijay Gill Manager as Ex.OP-A in support the case of OPs. This witness stated that the contractual obligation has arisen between the parties. The policy in question is purely Health Insurance Plan governed by the terms and conditions of the policy. The policy is totally based on contract and is not mediclaim policy, so only the fixed amounts are to be granted. Ex.OP-1 is copy of the proposal form. Ex.OP-2 is copy of insurance policy. Similarly, we have also examined other documents Ex.OP-3 to Ex.OP-9 on the record.
7. It is an established fact that the complainant purchased the policy in question i.e. LIC Health Protection Plus having Table No. 902 from OP no.3 on 10.05.2011 having policy no. 133280920 with premium amount of Rs.750/- per month. This fact is clear from copy of insurance policy Ex.C-1 on the record. The date of commencement of the policy is mentioned in this document as 10.05.2011 and due date of payment of last premium is mentioned as 10.04.2032. The complainant suffered pain on his left arm and he rushed to HCG Hospitals Bhavnagar on 23.01.2017 and discharged from the said hospital on 28.01.2017. The complainant got the treatment during the currency period of the policy. The treatment given by the above said hospital is as “Acute onset left Hemiparesis (UL>LL) with left UMN Facial Paresis.”, this fact is clear from policy document Claim Intimation Form Ex.C-8 placed on the record. As per record, the complainant has suffered a severe paralysis attack and he was immediately admitted in the hospital and remains admitted in ICU for three days and thereafter complainant was shifted to the room and after some recovery in the health of complainant, he was discharged from the said hospital on 28.01.2017. The sub clause b of Clause 2 HEALTH RELATED BENEFITS terms and conditions of the policy Ex.C-3, as under :
b. In case of Hospitalization in the intensive care unit of a Hospital : Two times the Applicable Daily Benefit reckoned under clause 2(i)(a) and its sub clauses above for each conditions period of 24 hours or part thereof (after having completed the 48 hours as above) provided any such exceeds a continuous period of 4 hours of Hospitalization in the Intensive Care Unit of a Hospital during any period of Hospitalization necessitated solely, by reason of the said Accidental Bodily injury or sickness shall be payable. In the present case, the complainant has also admitted in ICU for three days and thereafter complainant was shifted to the room and after some recovery in the health of complainant, he was discharged from the said hospital on 28.01.2017. Thus, the disease of the complainant covered under the policy. The complainant fell ill during the currency period of the policy. The terms and conditions binding on both the parties and no one wriggle out from the same. The complainant paid all the installments in time to OPs, this fact is clear from History of Premium Transaction Ex.C-4 placed on the record. The complainant alleged in his complaint that he spent Rs.1,00,000/- on his treatment in the HCG Hospital Bhavnagar Gujarat. He further alleged that he also spent more than Rs.50,000/- on his treatment. But the complainant has placed on record the bill for payment of Rs.77,709/- which was issued from HCG Hospital. Except this bill, the complainant has not produced on record any bill. We do not agree with the submissions of the OPs in this case. The insurance companies collect the premiums from the insured and find ways to decline the claims without any valid reasons. This fact is settled by Hon’ble Punjab and Haryana High Court at Chandigarh in case titled as New India Assurance Company Limited versus Smt. Usha Yadav and others reported in 2008(3) RCR (Civil) Page 111 held as under:-
“It seems that the insurance companies are only interested in earning the premiums and find ways and means to decline the claims. All conditions which generally are easily understood by a person at the time of buying any policy. The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay cost of Rs.5000/- for luxury litigation being rich.”
From perusal of entire record of the case and after hearing submissions of counsel for the parties, we are considered opinion that the complainant is entitled for Rs.77,709/- as per copy of bill of HCG Hospitals Ex.C-10 produced by the complainant A Unit of Healthcare Global Enterprises Ltd, this document is of the complainant and he himself placed on record. The complainant is also entitled for the amount of Rs.4,000/- as per bill dated Ex.C-13 on the record.
8. In the light of our above detailed discussion, we partly allowed the complaint of the complainant and directed the OPs to pay Rs. 81,709/- to complainant on account of expenditure on his treatment. The complainant is also entitled for Rs.15,000/- as compensation and litigation expenses. The opposite parties are also directed to deposit Rs. 5,000/- as costs in the Consumer legal Aid Account maintained by this Commission.
9. The compliance of the order be made within 45 days from receipt of copy of this order.
10. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room after due compliance.
Announced in open Commission
16th of March 2021
Kuljit Singh
(President)
Jyotsna
(Member)
