DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SAHIBZADA AJIT SINGH NAGAR (MOHALI)

                                       Consumer Complaint No.525 of 2015                                                          Date of institution:  09.10.2015                                               Date of decision   :  08.02.2017

Prem Kumar Bansal son of Charan Dass, resident of HM-11, Phase-1, Mohali, Tehsil and District SAS Nagar (Mohali).

                                  ……..Complainant

                                        Versus

Life Insurance Corporation of India, Kharar- Landran Road, Ward No.6, Near Ambika Devi Mandir, Kharar, District Mohali through its Chief Manager.

                                                              ………. Opposite Party

Complaint under Section 12 of

the Consumer Protection Act.

Quorum

Shri Ajit Pal Singh Rajput, President                          Shri Amrinder Singh Sidhu, Member.

Present:    Shri Vijay Kumar, counsel for the complainant.

                Shri Lovedeep Sareen, counsel for the OP.

ORDER

By Ajit Pal Singh Rajput, President

                Complainant, Prem Kumar Bansal has filed this complaint against the Opposite Party (hereinafter referred to as the OP) under Section 12 of the Consumer Protection Act. The brief facts of the complaint are as under:

2.             The complainant purchased health insurance policy from the OP on 28.05.2011 for a term of 25 years. At the time of purchase of the policy, a thorough medical checkup was got done by the OP and thereafter the policy was issued to him. In October, 2013 the complainant went in for routine check up to a cardiologist as he was suffering difficulty during brisk walk in the morning. The ECG and Echo tests were normal but TMT test was mildly positive. For complete check up the complainant went to Max Hospital in November, 2013 and after the check up the complainant was found suffering from blockage of one of the arteries of heart and two stents had to be inserted in the artery to make it working again. Before going to Max Hospital, the complainant duly informed about procedure to be carried out on him. Thereafter when the procedure was conducted and stents were inserted the complainant again informed the OP and also sent the relevant papers of his treatment to the OP.  However, the OP vide letter date 08.01.2014 repudiated the claim on the ground that the complainant had pre-existing disease. The complainant informed the OP that he was not suffering from any pre-existing disease and had not been taking any kind of medication for any such disease. The complainant again supplied record of his treatment to the OP vide letter dated 21.01.2014 followed by reminder dated 09.02.2014.  The complainant also contacted Max Hospital and the concerned doctor vide letter dated 11.02.2014 modified defect of previous disease from 10 years by stating that it was a typographical error. The OP sent letter dated 10.03.2014 to the Max Hospital  and the hospital vide letter dated 10.04.2014 in which the concerned doctor Dr. Sudheer Saxena specifically mentioned that it was not a case of any pre-existing disease and it was only due to typographical mistake in the discharge summary while typing the word 10 years instead of 10 days.  However, again the OP repudiated the claim vide repudiation letter dated 26.08.2014 on the ground that in this case only one artery is being stented (with 2 stents) as such the claim is not payable. It was further mentioned in the letter dated 26.08.2014 that the claim was payable where 2 or more arteries are stented. The complainant approached the Insurance Ombudsman who also rejected the claim of the complainant by granting liberty to move any Forum or court. At the time of issuance of policy, the OP had specifically conveyed to the complainant that in case of any trouble, full reimbursement would be given to the extent of policy amount i.e. upto Rs.4.00 lakhs to the complainant and upto Rs.2.00 lakhs to Mrs. Kiran Bansal, wife of the complainant.  The complainant had paid Rs.5,00,725/- to the hospital and the complainant is claiming Rs.4.00 lakhs from the OP under the policy.  Thus, nonpayment of the insured sum under the policy is unfair trade practice on the part of the OP.     Hence this complaint for giving directions to the OP to pay him insured sum of Rs.4.00 lakhs alongwith interest @ 12% per annum from 14.11.2013 till realisation; to pay him Rs.2,00,000/- for harassment and mental tension and Rs.25,000/- as litigation expenses.

3.             The complaint is contested by the OP by filing reply, in which it has raised certain preliminary objections, inter alia, that the complainant had submitted the duly signed proposal form after fully understanding the terms and conditions of the policy; the OP has acted strictly as per terms and conditions of the policy; the complaint is gross abuse of process of law and is liable to be dismissed with costs. On merits, the OP has pleaded that the policy documents were supplied to the complainant well within time and terms and conditions of the policy were well explained to him. The claim was reeducated by the TPA on the ground of pre-existing disease as mentioned in the discharge summary issued by the hospital. The complainant approached the OP and informed that it was not a case of pre-existing disease but it was due to typographical mistake that it was written HTN since 10 years instead of 10 days. Upon this the OP sent letter dated 10.03.2014 to the Max Hospital and Dr. Sudhir Saxena informed that the complainant was not a previously K/C of DM or hypertension and was detected to be hypertension about 10 days. It was a typographical error in his discharge summary made by junior doctor.  After this the OP admitted claim of the complainant  and paid him an amount of Rs.2200/- for HCB (Hospitalization cash benefit) and rejected MSB (Major Surgical benefits) as it is payable in that case where two or more arteries are stented as per terms and conditions of the policy but in the case of the complainant only one artery was stented with two stents. Denying other averments of the complainant, the OP has prayed for dismissal of the complaint.

4.             In order to prove the case, the complainant tendered in evidence affidavit Ex. CW-1/1; copies of policy Ex.C-1; letter dated 08.01.2014 Ex.C-2; letter dated 21.01.2014 Ex.C-4; letter dated 09.02.2014 Ex.C-4; letter of Max Hospital to the OP Ex.c-5; letter dated 10.03.2014 by LIC to Max Hospital Ex.C-6; letter of Max Hospital to the OP Ex.C-7; letter dated 26.08.2014 Ex.C-8; order dated 08.07.2015 of the Insurance Ombudsman Ex.C-9; bill dated 14.11.2014 Ex.C-10 and discharge summary Ex.C-11.  In rebuttal the OP tendered in evidence affidavit of Ms. Hemlata, Manager (L&HPF) Ex.OP-1/1; copies of proposal form Ex.OP-1; terms and conditions Ex.OP-2; report Ex.OP-3; repudiation letter Ex.OP-4; order of Insurance Ombudsman Ex.OP-5 and discharge summary Ex.OP-6.

5.             It has been argued by learned counsel for the complainant that firstly the OP had rejected the claim of the complainant on the ground of non disclosure of pre-existing ailments. Thereafter, on receipt of clarification from the Max Hospital, that it was due to typographical mistake in the discharge summary wherein period of 10 years was mentioned as against actual period of 10 days, the OP again refused the claim on the ground that only one artery was affected i.e. two stents had been inserted in one artery and the treatment was not covered under the policy. Learned counsel has argued that at the time of purchase of the policy, the complainant was not made aware about this Exclusion clause and now the OP cannot derive any benefit from the exclusion clause. The complainant was given only four pages of the policy. The detailed terms and conditions Ex.OP-2  containing ‘Major Surgical Benefits’  on the basis of which the OP has repudiated the claim of the complainant was never supplied by the OP to the complainant alongwith the cover note of the policy. In support of his contention, he has relied upon the decision of Hon’ble Haryana State Consumer Disputes Redressal Commission, Panchkula in Star Health and Allied Insurance Co. Ltd. vs. Asha & Others, 2015(1) CLT 590, wherein it has been held that it is the duty of the insurance company to prove that these terms and conditions were explained to the insured when the cover note was issued. It is nowhere mentioned therein that the insured was explained about this exclusion clause.

6.             On the other hand, the learned counsel for the OP has argued that on both the occasion the claim of the complainant was rightly repudiated. After clarification from the Max Hospital, the OP processed the claim of the complainant again and found that he was only entitled for reimbursement of Rs.2200/- for HCB (Hospitalization cash benefit) and rejected the claim for MSB (Major Surgical benefits) as it was payable in that case where two or more arteries are stented but in the case of the complainant only one artery was stented with two stents.

7.             We have gone through the pleadings, evidence and written arguments and heard the oral submissions addressed by the learned counsel for the parties. We are of the opinion that the OP is not justified in repudiating the claim of the complainant. Firstly, the OP repudiated the claim of the complainant on the ground of pre-existing ailment.  Then on receipt of clarification of period of pre-existing ailment, the OP again repudiated the claim on the ground that case where two or more arteries are stented but in the case of the complainant only one artery was stented with two stents.  The complainant has pleaded specifically that he was not explained the terms and conditions of the policy by the OP or its agent at the time of purchase of policy nor any such terms and condition were supplied except for the first four pages. The OP has not produced any document showing that the terms and conditions of the policy were duly explained to the complainant before its purchase and the same were duly provided to the complainant. Thus, in view of the aforesaid case law in Star Health and Allied Insurance Co. Ltd. vs. Asha & Others (supra) we hold that the complainant is entitled to claim the sum assured under the policy and the OP is deficient in service in not honouring the claim of the complainant.

9.             Accordingly, we direct the OP to pay to the complainant an amount of Rs.4,00,000/- (Rs. Four Lakhs only) i.e. the sum assured under the policy. We also find that the complainant is entitled to a sum of Rs.25,000/- (Rs. Twenty five thousand only) on account of mental agony due the negligent act of the OP and litigation cost of Rs.10,000/- (Rs. Ten thousand only).   The present complaint stand allowed.            

                The OP is further directed to comply with the order of this Forum within 45 days from the date of receipt of this order, otherwise the OP shall be liable to pay 9% interest per annum on the total cost awarded.

                The arguments on the complaint were heard on 02.02.2017 and the order was reserved. Now the order be communicated to the parties. Copy of the order be sent to the parties free of cost and thereafter the file be consigned to the record room.

Pronounced

Dated: 08.02.2017    

                                          (A.P.S.Rajput)                  

President

(Amrinder Singh Sidhu)

Member