Haryana

Yamunanagar

CC/78/2014

Ranjana Verma W/o Rajbir - Complainant(s)

Versus

lIfe Insurance Corporation Of India - Opp.Party(s)

Harvinder Aneja

10 Oct 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, YAMUNA   NAGAR.

 

                                                     Complaint No.78 of 2014.

                                                     Date of institution: 03.02.2014.

                                                     Date of decision: 10.10.2017.

Ranjana Verma, age 48 years, wife of Rajbir, resident of H.No.33, Vishal Nagar, Yamuna Nagar, Tehsil Jagadhri, District Yamuna Nagar.

                                                                     

                                                                                                …Complainant.

                        Versus

Life Insurance Corporation of India, Opposite Madhu Palace Jagadhri Road, Yamuna Nagar, through its Branch Manager.

 

….Respondent.

BEFORE     SH. SATPAL, PRESIDENT

                    SH. S.C.SHARMA, MEMBER.

                    SMT.VEENA RANI SHEOKAND, MEMBER.

 

Present:     Sh. Harvinder Aneja, Advocate, for complainant.   

                 Sh. Rajiv Gupta, Advocate for the OP.

               

                ORDER

         

(SATPAL, PRESIDENT)

                The complainant-Ranjana Verma has filed this complaint under section 12 of the Consumer Protection Act 1986, as amended up to date (hereinafter respondents will be referred as OPs). 

2.             Brief facts of the complaint, as alleged by the complainant, are that she purchased an insurance policy bearing No.178018524 from the Op.  It is alleged that on 03.07.2012, the complainant met with an accident, due to which, she suffered injuries as knee fracture on left leg and she got plaster on the said leg’s knee.  The complainant was admitted in Civil Hospital, Yamuna Nagar from 12.07.2013 to 15.07.2013.  As per the policy, in case of accident of the insured, the Op is liable to pay the double of sum assured to the complainant.  It is further alleged that the complainant lodged the claim with the Op and submitted all the required documents but the Op did not settle the claim of complainant.  So, it is a clear cut case of deficiency in service on the part of Op and prayed for acceptance of complaint with the direction to Op to pay all the amount of medical bills alongwith interest @ 24% p.a. and to pay all the accidental benefits alongwith compensation of Rs.50,000/- on account of harassment and mental agony or any other relief which this Forum deems fit.  Hence, this complaint.

3.            Upon notice, the OP appeared and filed their written statement raising preliminary objections with regard to locus-standi; maintainability; cause of action; that on receipt of the claim paper, the claim was processed as per the terms of the policy.  The policy covers two types of benefit one for hospitalization and other for surgery.  As the surgery performed on the policy-holder is covered under day care procedure benefit, a claim of Rs.5,000/- i.e. five time of IDB (Initial Daily Benefit) chosen by the policy-holder at the time of inception of policy is payable.  The policy-holder had opted for IDB of Rs.1,000/-, therefore, a sum of Rs.5,000/- has been paid to the policy-holder as per surgery No.71 under DCPB list.  There is no deficiency in service on the part of Op.  On merits, the pleas taken in the preliminary objections are reiterated and so, prayed for dismissal of complaint.

4.             Ld. Counsel for the complainant tendered in evidence affidavit of complainant as Annexure-CX and documents Annexure-C1 to Annexure-C9 and closed evidence on behalf of complainant. 

5.             On the other hand, ld. Counsel for the Op tendered in evidence affidavit of Sh. Ajay Gupta, Manager as Annexure-RW/A alongwith documents Annexure-R1 to Annexure-R6 and closed evidence on behalf of Op.    

6.             We have heard the ld. Counsel for both the parties and perused the record carefully and minutely.                                      

7.             After hearing the ld. Counsel for both the parties and on perusal of record available on the file, the foremost question which arises before us for consideration is that whether the Op-insurance company is liable to pay the entire amount of medical bills which was incurred by the complainant on her treatment as-well-as accidental benefits?

                The version of the complainant is that she met with an accident and suffered injuries as knee fracture on left leg and she was admitted as indoor patient and spent huge amount on her treatment.  Due to said accident, the complainant became permanently disabled and the Op-insurance company is liable to pay the accidental benefit but the Op-insurance company paid only Rs.5,000/- which is illegal and the complainant is entitled for refund of entire amount incurred on her treatment as-well-as accidental benefits. 

                On the other hand, the version of the Op is that the complainant was treated surgically by applying POP Cast for fracture fibula.  The liability of Op-insurance company is subject to terms and conditions of the insurance policy and the surgery performed upon the complainant is covered under day care procedure benefit under which a claim of Rs.5,000/- i.e. five time of IDB (Initial Daily Benefit) chosen by the policy-holder at the time of inception of policy is payable.  The policy-holder had opted for IDB (Initial Daily Benefit) of Rs.1,000/-, therefore, a sum of Rs.5,000/- has been paid to the policy-holder as per surgery No.71 under DCPB list.  The complainant is also not entitled to any accidental benefits as per terms and conditions of the policy.

                We have perused the document Annexure-R2 which is a proposal form for health insurance policy of Op-insurance company wherein it is clearly mentioned that the Op company is only liable to pay Rs.1,000/- per day in all daily cash benefit availed.  We have also perused the document Annexure-R1 which is terms and conditions of the policy, the clause-III Day Care Procedure Benefit is reproduced as under:-

                “In the event of an insured under the policy undergoing any specified Day Care Procedure (as mentioned in the Day Care Procedure Benefit Annexure) within the cover period in a hospital due to accidental bodily injury or sickness first occurring or manifesting itself after the date of cover commencement and during the cover period, then, subject to the terms and conditions, waiting period and exclusions of this policy, an amount equal to 5 (five) times the Applicable Daily Benefit, shall be payable by the Corporation, regardless of the actual costs incurred.”

                After perusal of aforesaid clause of terms and conditions, it is clear that the Op-insurance company is only liable to pay an amount equal to 5 (five) times of the applicable daily benefit and the insurance company is not liable to pay the actual cost of treatment.  We have also perused the Day Care Procedure Benefit Annexure from which it is crystal clear that the complainant had undergone surgery/plaster of his knee which falls at Sr.No.71 of the said Annexure.  From the perusal of the document Annexure-R7, it is clear that the complainant was diagnosed for fracture and the procedure for treatment is ‘Close reduction of fracture’.  Meaning thereby the Op-insurance company is only liable to pay an amount of 5 (five) times in the event of treatment which was taken by the complainant.  As per proposal form, Annexure-R2, the complainant herself opted for Daily Cash Benefit availed (sum assured) Rs.1,000/- only.  Hence, the Op-insurance company rightly disbursed the amount of Rs.5,000/- to the complainant as per terms and conditions of the policy.  The complainant has failed to submit any document to prove that the complainant became permanently disabled and she is entitled for the accidental benefits.  So, there is no deficiency on the part of Op.   

8.     Thus, as a sequel of above discussion, we find no merit in the present complaint and accordingly, the same is hereby dismissed with no order as to costs.  A copy of said order be supplied to the parties free of cost.  File be consigned to record-room after due compliance.      

Announced in open court:

Dated: 10.10.2017.

                                                           (SATPAL)

                                                           PRESIDENT.

 

 

(VEENA RANI SHEOKAND)         (S.C.SHARMA)

MEMBER                                          MEMBER