BEFORE THE DISTT. CONSUMER DISPUTES REDRESSAL COMMISSION, ROPAR
Consumer Complaint No. : 71 of 22.09.2021
Date of decision : 10.10.2022
Dharam Pal son of Sh. Dasondhi Ram, resident of House No.4, Gali No.3, Piara Singh Colony, Rupnagar, Tehsil & District Rupnagar
......Complainant
Versus
- Life Insurance Corporation through its Divisional Manager, Divisional Office, Chandigarh
- Branch Manager, Life Insurance Corporation of India Branch Office Giani Zail Singh Nagar, Rupnagar, Tehsil & District Rupnagar
...Opposite Parties
Complaint under Consumer Protection Act
QUORUM
SH. RANJIT SINGH, PRESIDENT
SMT. RANVIR KAUR, MEMBER
ARGUED BY
Sh. Dharampal, complainant in person
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 had purchased the Life Insurance Policy bearing No.163466578 on 10.3.2008 and was expired on 28.03.2021 for self and for his wife Smt. Promila. The complainant had been paying annual installments as was fixed by the OPs regularly without any fail in the terms and condition of the policy issued by the OPs. The OPs for the first few years informed the complainant of the unit purchased by the OPs out of the premium amount and thereafter has not informed the complainant about the amount of the complainant invested in the units in the terms of the policy. Wife of the complainant Smt. Promila diagnosed High Grade Carcinoma Endometrium after MRI dated 5.11.2020 and Biopsy dated 07.11.2020. TPA as required under the policy was informed by email as require by the policy well before start of treatment. Smt. Promila wife of the complainant was admitted on 24.11.2020 in Dr. Sodhi Health Care Multispecialty Hospita, # 1524, Sector 69, Mohali for Wertherim’s Hysterectomy by Dr. Vijay Bansal and discharged from hospital on 27.11.2020. On 03.12.2020, after surgery of the wife of the complainant suffered with abdominal pain, nausea, vomiting, poor oral intake. Dr. Vijay Bansal, after the lab report and abdominal scan dated 3.12.2020 advise3d on 4.12.2020 to admit in IVY Hospital for further management and evaluation and diagnosed with intestinal obstruction. After recovery, she was discharge on 7.12.2020. It is further alleged that after operation on 27.11.2020, Smt. Promila was referred to Dr. Jatin Sareen for Chemotherapy and she was admitted on 22.12.2020 to 24.12.2020, 12.01.2021 to 14.1.2021, 02.02.2021, 23.02.2021, 17.03.2021 etc. and during treatment before Dr. Jtain Sareeen on 19.2.2021 called by Dr. Vijay Bansal for next step and advise to take three more chemotherapy. The total six cycles of chemotherapy has been completed. Bill for a sum of Rs.4,76,946/- for treatment along with relevant document were submitted on 16.4.2021 duly received by the OP No.2 against No.49/16.04.2021. The OPs thereafter supplied claim intimation form and the complainant after completing the same to the OP No.2. The OPs thereafter has not settled the claim and paid the amount nor has intimated any shortcoming in the claim form till date in spite of representation dated 13.6.2021 and 02.09.2021. Thus, alleging deficiency in service, the complainant sought the following relief against the Ops:-
- To pay an amount of claim submitted by the complainant along with other benefits and to award a sum of Rs.50,000/- as compensation for suffering of the complainant and Rs.10,000/- as cost of the complaint or to grant any other relief which this Hon’ble Commission may deem fit and appropriate in the circumstances of the case in the interest of justice.
- In reply, the Ops No.1 & 2 has filed written reply taking preliminary objections; that the present complaint is not maintainable in the present form; that the complainant has not approached the Hon’ble Commission, Rupnagar, with clean hands and suppressed the material facts from the Hon’ble Commission; that the complainant has no locus standi to file the present complaint; 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. On merits, it is stated that the complainant had purchased a LIC Health Plus (Unit Linked Plan) bearing No.163466578, Plan Term 901/13/13, under yearly mode of premium for Rs.13,500/- Ms. Promila wife of the complainant was other inured under the policy. Date of commencement of risk under the policy was 28.3.2008 and sum assured under the policy was Rs.3,00,000/- and Daily Hospital Cash Benefit was Rs.1500/- per day as opted by the Life Assured himself and his spouse. The claim under the policy is based upon the certain percentage of sum assured as per lists/schedules of diseases and surgeries annexed with the policy bond. First unpaid premium was in the month of March 2021. Now the policy in question has already been matured on 28.3.2021. As on date, units available under the policy are 4578.764/- and the net asset value as on 28.03.2021 was Rs.28.0513/- per unit. The Genins India Insurance TPA Limited is the third party administration of the answering OPs. There is no deficiency in service on the part of the OPs. As the complainant has initiated two claims bearing numbers 10024460 and 10024461 respectively with the TPA of the answering OPs qua to the expenses incurred by the complainant on the hospitalization and treatment of his wife. The TPA of the answering OPs has already admitted the claim bearing No.10024460 of the complainant as per terms and conditions of the insurance policy bearing No. 163466578 and an amount of Rs.4500/- rightly paid to the complainant towards the expenses incurred for the hospitalization during period 24.11.2020 to 27.11.2020 against the amount claimed for Rs.1,37,529/- as per the terms and conditions of hte policy as the surgery of the insured is not covered under the plan of insurance. Same has been informed to the complainant by the TPA of the answering Ops vide letter dated 18.8.2021. It is further stated that second claim bearing No.10024461 of the complainant against policy bearing No.163466578, for claimed amount of Rs.42,543/- qua to the expenses incurred by the complainant for the hospitalization of his wife during the period from 4.12.2020 to 07.12.2020 has been rightly rejected by the TPA of the answering Ops vide letter dated 10.08.2021 on the grounds that the policy holder/complainant did not comply with the mandatory requirement called for and the claim was pending even after repeated reminders. Rest of allegations made by the complainant against the Ops have been denied and prayed for dismissal the complaint.
- 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. The policy in question is undisputed. In the present complaint, wife of the complainant was suffering from high grade carcinoma Endometrium (Uterus Cancer) but the in rebutting the claim of the complainant, the learned counsel for the OPs has placed on record Ex.C2 i.e. the terms and conditions of the policy in the said terms and conditions, the carcinoma (uterus cancer) is not covered under the insurance policy, which was purchased by the complainant. So, in these circumstances, the complainant is not entitled for sum assured.
6. It is pertinent to mention here that under the policy in question, the complainant has availed the daily cash benefits for Rs.1500/- per day. In the written reply filed by the OPs itself admitted that the Ops paid Rs.4500/- to the complainant as daily cash benefit for three days. OPs also admitted that they paid Rs.1,28,440/- against units. As far as the question of daily cash back is concerned, the OPs itself admitted that they paid Rs.4500/- per month. The complainant is placed on record the details of admission and discharge summary and as per this document, the complainant wife remained admitted in the hospital for 14 days and she is further entitled daily cash benefit as per terms and conditions of the policy. So, the complainant is entitled Rs.21000/- after deducting Rs.4500/- which was already paid by the Ops to the complainant.
9. In view of our above discussion, the complaint stands allowed partly. The Ops is directed to pay Rs.21,000/- along with interest @ 9% from the date of death of wife of the complainant till its realization as daily cash benefit, which is covered under the policy after deducting Rs.4500/- (already paid by the OPs). The complainant is also entitled Rs.50,000/- as compensation on account of physical harassment and mental agony. He is also entitled R.22,000/- as litigation expenses. 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.10.10.2022 PRESIDENT
(RANVIR KAUR)
MEMBER
