Punjab

Rupnagar

CC/21/68

Ashok Kumar - Complainant(s)

Versus

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

Sh. Chetan Kumar Gupta, Adv.

06 Sep 2022

ORDER

BEFORE THE DISTT. CONSUMER DISPUTES REDRESSAL COMMISSION, ROPAR

 

                       Consumer Complaint No. : 68 of 22.09.2021

                        Date of decision                    :    06.09.2022

 

Ashok Kumar aged about 61 years son of Walati Ram, resident of Ward No.6, Model Town, Kurali, District SAS Nagar (Mohali) 

                                                        ......Complainant

                                             Versus

1. Life Insurance Corporation of India Limited, through its Branch Manager, Ropar, District Rupnagar
2. Branch Manager of Life Insurance Corporation of India Limited, Ropar, District Rupnagar   

 

   ...Opposite Parties

 

                        Complaint under Consumer Protection Act

QUORUM

 

                        SH. RANJIT SINGH, PRESIDENT

                        SMT. RANVIR KAUR, MEMBER

 

ARGUED BY

 

 

Sh. Chetan Kumar Gupta, Adv. for complainant

Sh. Narinder Kumar, Adv. counsel for O.Ps

 

                                           ORDER

              SH. RANJIT SINGH, PRESIDENT

 

The present order of ours will dispose of the above complaint filed under Consumer Protection Act, by the complainant against the Opposite Parties on the ground that
the complainant is a policy holder issued by opposite parties bearingNo.160856109 on 28.8.1995 for a period of 25 years till 28.8.2020. The complainant is an old policy holder and he has been paying his premium 6536/- (half yearly) regularly and has never claimed for himself before, from opposite parties or any other insurance group. The complainant had a problem of chest pain and discomfort in the beginning on February 2020. On 08.02.2020, it was emergency hence he was immediately admitted to PGI on same day in cardiology department. Operation was conducted on same day. On next day i.e. 09.02.2020, he was discharged. The complainant is not a doctor and has no knowledge of medical procedure. Doctors are PGI conducted best course of treatment. Precutaneous coronary intervention, also known as angioplasty, was done and the same is not considered a major surgery. The complainant sent opposite parties all the required details, bill, prescriptions and documents like PAN Card, Adhar Card etc. However, vide letter dated 01.12.2020, the opposite parties rejected the claim of the complainant. The complainant immediately wrote to the opposite parties asking the reason of rejection. Opposite parties vide letter dated 24.12.2020, informed the complainant that his claim has been rejected as contingency of angioplasty is not covered under terms and conditions of the plan. Repudiation of claim of complainant is arbitrary illegal, null and void. The OPs are bound by the terms and conditions of agreement and liable to pay claim.  Thus, alleging deficiency in service, the complainant sought the following relief against the Ops:-

1. The letter dated 1.12.2020 and 24.12.2020 may kindly be declared as null and void
2. To pay the claim amount of Rs.1,50,000/- (50% SA of 3 Lakh) along with interest @ 18% per annum and burdened with special costs.
3. Opposite parties may be directed to pay litigation charges Rs.50,000/- .
4. To payRs.5,00,000/- on account of mental agony, pain and suffering and harassment.
5. Any other relief which this Hon’ble Court may deem fit may also be granted, in the interest of justice.

2.      In reply, the Ops No.1 & 2 has filed taking preliminary objections; that the present complaint is not maintainable; that the complainant has not approached the Hon’ble Commission, with clean hands and suppressed the material facts; that the complainant has no locus standi to file the present complaint; that the complainant has no cause of action to file the present complaint against the answering OPs; that the answering Ops reserve their right to amend the written reply as and when a new fact comes into the knowledge of the answering OPs; that the answering OPs do not admit and denies all allegations made in the complaint and the complainant must be put to strict proof of the allegations except those which are specifically admitted. On merits, it is stated that the complainant had purchased the insurance policy from the OPs under half yearly mode of premium of Rs.6536/-. Date of commencement of risk under the policy was 28.8.1995 and sum assured under the policy was Rs.3,00,000/-. The complainant had taken loan for Rs.2,90,000/- against the policy in question on 07.02.2014. The policy in question was matured on 28.8.2020 and in this regard a letter dated 23.07.2020 was issued by the answering OPs in good faith after following the due process of law and requested the complainant to submit the documents, which were required to initiate maturity benefit/claim. After submission of required documents by the complainant, the maturity benefit/claim has already been paid by the answering OPs to the complainant on 05.01.2021 vide voucher No.M/20202021/002155, after deducting the loan amount of Rs.2,90,000/- and interest on loan of Rs.2,60,028/- as per terms and condition of the policy in question. Now nothing is due against the answering OPs.   Thus, alleging no deficiency in service on the part of the OPs and prayed for dismissal of the present complaint.

3.      The learned counsel for the parties have tendered certain documents in support of their version and closed the evidence.

4.      We have heard the learned counsel for the contesting parties and have gone through the record file, carefully and minutely.

5. It is pertinent to mention here that the medical procedure taken by the complainant is not covered as per the terms and conditions of the policy. In para No.4 of the complaint, the complainant himself admitted that Percutaneous Coronary Intervention also known as angioplasty was one at PGI, Chandigarh. But as per terms and conditions of the insurance policy, angioplasty is not covered under the policy and same is specifically excluded from the purview the policy. 

6.  The learned counsel for the OPs has placed on record the order of the case titled as Life Insurance Corporation of India Vs Abdul Salim, decided on 26.08.2011, wherein it is held that complainant underwent angioplasty with stent for which he had to pay a total amount of Rs.1,15,000/-  . Claim declined by insurer on the ground that the disease for which the complainant had filed claim was not covered under the insurance policy. Complaint was allowed by the District Forum and petition directed to pay 50%of the assured amount. State Commission dismissed the appeal of insurer- Claim for angioplasty was specifically bypass surgery has to be done- While there is also a provision that insurer can pay 50% of the amount assured to insured who files claim for medical treatment, but that will only be admissible in respect of treatment for the disease specifically mentioned in the policy and cannot cover the disease which are not stated or are contract between the parties- Once the terms and conditions of policy are accepted are binding on both the parties.

7. From the perusal of the file, it reveals that before the filing of the present complaint, OP issued a letter dated 23.07.2020 to the complainant as Ex.OP4 but the complainant never replied the said letter. Thereafter, the insurance company paid Rs.3,19,672/- as full and final payment against the policy in question through NEFT dated 05.1.2021. 

8. In view of the above discussions, we feel, that complainant is not able to convey his complaint or allegations against the OPs clearly. In such, peculiar situation, we are not able to grant any relief to the complainant. Therefore, the complaint stands dismissed. However, no order as to cost. Free certified copies of this order be sent to the parties, as per rules. The files be consigned to record room.

 

ANNOUNCED                                                                                       (RANJIT SINGH)

Dated.06.09.2022                                                 PRESIDENT
 

 

                                               

                                                               (RANVIR KAUR)

                                                                                   MEMBER