Punjab

Rupnagar

CC/19/114

Sushma - Complainant(s)

Versus

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

In Person

04 Dec 2019

ORDER

THE DISTT. CONSUMER DISPUTES REDRESSAL FORUM, ROPAR

                                 Consumer Complaint No. 114 of 05.09.2019

                                 Date of decision                    :    04.12.2019

 

Sushma aged about 54 years, wife of Subhash Chand, son of Sh. Onkar Singh, resident of House No.93, Dashmesh Nagar, Ropar, Tehsil & District Rupnagar  

                                                                 ......Complainant

                                             Versus

1. Life Insurance Corporation of India, Rupnagar, Jeevan Jyoti Building, Giani Zail Singh Nagar, Rupnagar, through, through its Branch Manager.   

2. Sunita Rani agent of Life Insurance Corporation of India, Rupnagar, Jeevan Jyoti Building, Giani Zail Singh Nagar, Rupnagar (Agent code is 01294332)

           ....Opposite Parties

                                   Complaint under Section 12 of the                                                      Consumer Protection Act, 1986

QUORUM

 

                        SH. KARNAIL SINGH AHHI, PRESIDENT

                        CAPT. YUVINDER SINGH MATTA, MEMBER

ARGUED BY

 

Sh. Subhash Chand, authorized representative of complainant 

Sh. H.C. Verma, Advocate, counsel for O.P. No.1

Sh. Ashok Kumar, Authorized representative of O.P. No.2

                                           ORDER

              SH. KARNAIL SINGH AHHI, PRESIDENT

 

1. Sushma aged about 54 years, wife of Subhash Chand, son of Sh. Onkar Singh, resident of House No.93, Dashmesh Nagar, Ropar, Tehsil & District Rupnagar, through his authorized representative  has filed the present complaint seeking directions to the opposite parties to pay the claim amount of Rs.4,00,000/-  along with interest @ 12% per annum; to pay Rs.50,000/- as compensation; to pay Rs.10,000/- as litigation expenses.    
2. Brief facts made out from the complaint are that the complainant had purchased a LIC's Jeevan Arogya Policy bearing No.164997102 from O.Ps, he had paid Rs.226/- per month of the policy amount. The above said policy was fully covered for all types of diagnosis. In April, 2018, the complainant suffered with diagnosis Total Hip replacement and when she had gone at Shiwalik Hospital, Mohali, where she came to know about her total hip replacement diagnosis and after that doctor referred her to PGIMER. On 30.07.2018, she was admitted in PGIMER Chandigarh for treatment and during treatment and after conducting the operation, she was discharged from PGIMER on 27.8.2018. She spent Rs.3,80,000/- for her treatment along with other expenses. Thereafter, the complainant approached the O.Ps. for medical reimbursement and the O.Ps. repudiated her claim. Hence, this complaint. 
3. On notice, O.P. No.1 appeared through counsel and filed a written reply taking preliminary objections; that the complainant has no locus standi to file the complaint against the answering O.P; that this Hon'ble Court has no jurisdiction to entertain and try the complaint; that the complainant has no cause of action against the answering O.P. On merits, it is stated that a policy holder Smt. Sushma purchased Jeevan Arogya Plan having Policy No.164997102. The Jeevan Arogya Plan is fixed benefit plan and not a regular medi claim policy. A fixed amount is payable for Surgery or treatment undertaken which are covered under this policy subject to terms and conditions of the policy. There is no provision of reimbursement of expenses in this policy like other medi-claim policies. As per the Policy Conditions, if any, surgery or treatment is undertaken which has been occurred due to a Pre-existing disease (Hip Pain Since 10 years) before the commencement of the policy, the claim is not admissible and hence the claim of the complainant was recommended for repudiation of TPA. It is clearly evident from the records available that the previous history related to her disease was reported/narrated to the doctor by herself or through her attendant at the time of consultation of performing the surgery, this fact was never disclosed by the complainant in the proposal form at the time of taking the health insurance policy. Accordingly, the claim was rejected and repudiation letter dated 6.7.2019 was sent to the policy holder by registered post. Rest of the allegations made in the complaint have been denied and prayer has been made for the dismissal thereof. 
4. On notice, O.P. No.2 appeared through its authorized representative and filed a written reply taking preliminary objections; that the complaint is not maintainable against the answering O.P; that the complaint does not lie before the forum; that the complainant has no locus standi to file the present complaint; that the complainant has no cause of action to file the complaint; that the complainant has not approached this Hon'ble Forum with clean hands; that the complainant never made any alleged requests to the answering O.P; that the O.P. No.1 is solely liable for any kind of deficiency in service or to pay any kind of damage etc, as the answering O.P. was only agent of O.P. No.1. On merits, it is stated that the complainant has made a false and concocted story. The answering O.P. has explained all the details, terms and condition of the insurance policy to the complainant and it is the answering O.P. who was doing the job in the official capacity being the agent of O.P. No.1. Rest of the allegations made in the complaint have been denied and prayer has been made for the dismissal thereof. 
5.  On being called upon to do so, the authorized representative of complainant has tendered duly sworn affidavit of complainant Ex.C1 along with documents Ex.C2 to Ex.C4 and closed the evidence. The learned counsel for the O.P. No.1 has submitted duly sworn affidavit of Sh. Jai Bhagwan Bansal, Manager Legal Ex.OP1/A along with documents Ex.OP2/B to Ex.OP12/B and closed the evidence. The authorized representative of OP No.2 suffered a separate statement to the effect that his written reply be read as part and parcel of his evidence and closed the evidence. 
6. We have heard the learned counsel for the parties and have gone through the record of the file, carefully.
7. On behalf of complainant (Sushma) her husband filed authority letter to argue the matter on behalf of his wife. He made prayer that Sushma purchased Jeevan Arogya Policy from the O.P. and she has to pay Rs.226/- per month as EMI and subsequent she has been depositing monthly prescription regularly. In the month of April 2018, complainant suffered diagnosis of hip replacement and the replacement was made from the PGIMER on 27.8.2018. She spent Rs.3,80,000/- for the treatment including hospitalization expenses for medical/surgery treatment. After the recovery, when the complainant approached the O.Ps. for payment of the necessary expenses spent by her for medical treatment then the O.P. No.1 had vide his letter dated 6.7.2019, repudiated the claim with the remarks Pre-existing illness (Hip Pain). Sh. Subhash Chand (Authorized Representative) further made prayer that while declining the claim, O.P. no.1 did not rely upon any of the medical treatment of relief. Lastly by referring to the documentary evidence, prayed to allow the complaint with cost. 
8. Sh. H.C. Verma, counsel for O.P. No.1 argued that so far the issuance of the Jeevan Arogya Policy, EMI Rs.226/- per month and commencement of the policy w.e.f. June 2011 are the admitted facts. Complainant also approached to the O.P. No.1 with medical prescription, expenses etc incurred for her treatment in PGIMER. He also made prayer that there is no need to go in detail qua the expenditure but as per the proposal form filled up by the complainant through OP No.2 she has not supplied the correct picture on her body ailments. He relied upon Ex.OP2 and made prayer that proposal form furnished by the complainant is not in accordance to the medical status, rather she concealed the facts. Then counsel relied upon the repudiation letter dated 6.7.2019, copy of which is Ex.C2 and OP7. Referring the letter dated 6.7.2019, learned counsel pointed out there was pre existing illness (Hip Pain). So the claim has rightly been repudiated. Lastly prayed to dismiss the complaint.
9. The authorized representative of OP No.2 made prayer that status of OP No.2 Sunita Rani is simply an agent of OP No.1. When the complainant approached the OP No.2 she filled up the proposal form as per the information supplied by Sushma. Everything is on file and her status is as an agent, if any claim is filed by the complainant with the OP No.1 then OP No.1 is at liberty to dispose if off as it deems proper. Further more, in case forum has come to the conclusion that OP No.1 has wrongly declined the claim then the forum is at liberty to grant relief as per law. However, no claim can be enforced against OP No.2.  
10.  Complainant is resident of District Rupnagar and OP No.1 is having office in this District. Sunita Rani authorized agent is also of this District. The purchase of policy bearing No. 164997102 dated 01.06.2011was purchased by the complainant and then deposits Rs.226/- per month w.e.f. June 2011 and its validity / expiry date is July 2048 are the admitted facts. The relation between the parties as consumer exists, it is held that this forum has territorial jurisdiction and complaint is maintainable.  
11.  Coming to the real controversy, whether the complainant has been able to prove deficiency in service on the part of O.Ps. or not?. Complainant beside her affidavit Ex.C1 placed on file Ex.C3 (Insurance Policy) which proves its commencement June 2011 and expiry July 2048. Ex.C4 is detail of medical expenses. The total comes Rs.3,80,217/-. Ex.OP2/B is proposal form which was filled up by the complainant through OP No.2. Ex.OP3/B is again document relating to the proposal. Ex.OP4/B is signed by the agent. Ex.OP5 is copy of policy. Ex.OP7/B is the repudiation letter dated 6.7.2019 with the recital pre existing illness. Ex.OP8/B is the photocopy of prescription/treatment of the doctor and its top the doctor has written " C/o B/L Hip Pain X 10 years. the forum has also gone through the other documents produced by both the parties. Ex.OP9/B Jeevan Arogya Policy and its column 2 category (ii) (iii) relates to Major Surgery benefits.
12.   This forum after appreciating the entire evidence relied upon by both the parties has come to the conclucsion that issuance of the policy is the admitted facts, then admitted the monthly depositing Rs.226/-, commencement w.e.f. June 2011 to July 2048. If the period 37 years X 12 months (444 months) X Rs.226/- is counted then its come to near about 1,00,000/- till the maturity. In the policy as well as in the documentary evidence Subhash Chand husband of the complainant and counsel for the OPs remaining unable in proving how much the sum was assured against the treatment of complainant but orally admitted the policy was of Rs.1,00,000/- during the time of arguments, it was also pointed out that policy Ex.OP5/B states that its column 2 there is recital if agent admitted then to pay Rs.1000/- per day against the period indoor patient.
13.  Complainant pointed out her treatment/hip replacement the amount spent near about Rs.3,80,000/- but after going through the EMI Rs.226/- per month w.e.f. June 2011 till July 2048 and then appreciating the relief portion of the policy of Rs.1000/- per day, the forum has come to the conclusion that complainant remain successful in proving the deficiency in service on the part of O.P. No.1. Because of the reason that commencement policy relates to June 2011 and when the complainant complained her illness/hip replacement in the month of August 2018 then OP No.1 without relying upon any of the expert opinion only relied upon the observations of the doctor made in Ex.OP8 in which the doctor has simply written hip pain of ten years i.e. has not the adequate medical information to discard the claim of the complainant. Doctor has only given the history relating to the pain, OP1 has erroneously come to the conclusion by dismissing the claim. OP1 has not placed on file any of the expert opinion of the complainant for the long period of hip problem from 2011 to August 2018. OP1 has been receiving regularly month premium but when the complainant's liability accrued for the payment of the medical treatment then repudiated the claim on the flimsy ground. So the complainant is entitled to the claim according to the policy.     
14.  In the light of discussions made above, the complaint stands allowed partly with the directions to the O.P. No.1 to pay Rs.1,00,000/- towards medical replacement along with Rs.1000/- per day for 28 days along with interest @ 7% per annum w.e.f date of admission in the hospital of the complainant till the date of claim is honoured along with cost of Rs.5000/-.           
15.           The O.P. No.1 is further directed to comply the said order within a period of 30 days from the date of receiving the certified copy of this order

16. The certified copies of this order be supplied to the parties forthwith, free of costs, as permissible under the rules and the file be indexed and consigned to Record Room.          

 

                     ANNOUNCED                                    (KARNAIL SINGH AHHI)

                     Dated.04.12.2019                           PRESIDENT
 

 

 

 

                                               (CAPT. YUVINDER SINGH MATTA)

                                                                   MEMBER