Date of Filing :04.06.2014

Date of Disposal :31.07.2024

BEFORE THE KARNATAKA STATE CONSUMER DISPUTES REDRESSAL COMMISSION, BENGALURU (PRINCIPAL BENCH)

DATED:31.07.2024

PRESENT

Mr K B. SANGANNANAVAR: JUDICIAL MEMBER

(DIST. & SESSIONS JUDGE (R)

Mrs DIVYASHREE M: LADY MEMBER

APPEAL No.697/2014

1. Senior Divisional Manager

    (Health Insurance Division)

    LIC of India Branch

    Divisional Office

    Bannimantap Road

    Mysore-570 005

2. Branch Manager

    LIC of India

    Sakaleshpura Branch

    Sakaleshpura

    Hassan District-573 115

   Both represented by

   Life Insurance Corporation of India

   Divisional Office-1

   ‘Jeevan Prakash’ Building

   J.C Road, Bangalore-560 001

   By its Manager (L and HF)

   Mr. P.S.Markandeshwar

   (By Mr G.Nataraj, Advocate)                                        Appellant

                                                     -Versus-

Mr N.G.Kumar

S/o Gouregowda

Navilahalli Village

Tholalu Post, Belur Taluk,

Hassan District-573 115                                               Respondent

(By Mr. B.M.Mohan Kumara, Advocate)

-:ORDER:-

Mr. K B. SANGANNANAVAR: JUDICAL MEMBER:

1.       This is an Appeal filed under Section 15 of Consumer Protection Act, 1986 by OPs aggrieved by the Order dated 24.03.2014 passed in Consumer Complaint No.26/2013 on the file of District Consumer Disputes Redressal Commission, Hassan (for short, the District Forum).

2.       The Parties to this Appeal will be referred to as the rank assigned to them by the District Forum.

3.       The Commission examined the impugned order, grounds of Appeal, Appeal papers and heard the learned counsels. Now the point that arises for consideration of this Commission would be: 

          Whether impugned order dated 24.03.2024 passed in CC No.26/2013 does call any interference of this Commission for the grounds set out in the Appeal Memorandum?

4.       Learned counsel for the Appellants/OPs submits that there was several correspondences dated 21.12.2009, 26.12.2009 and 11.01.2010, being made by the Ops, through third party Administrator by claiming that the claim forms being submitted by the Complainant was not in proper form, as such required information of the documents were called from the Complainant.  He submits that the complainant has failed to submit original discharge summary, treating doctor’s certificate regarding etiology of injury and Medico legal case copy.  Further submits that the complainant has failed to submit duly filled original claim form and treatment form.  In other words, OPs/insurer informed the Complainant/insured to submit duly filled original claim form along with required documents which are to be submitted to process his claim has some considerable force. Learned Counsel further submits, consumer complaint raised is pre-mature was considered by the DF.

Let us examine the enquiry file, wherein could see copies of letters dated 21.12.2009, 26.12.2009 and 11.01.2010 respectively addressed to the complainant to furnish the details, yet he had failed to submit claim form and details of the medical records.    It has come in the enquiry as per Ex-P11 to P18, the Complainant had shown spending of Rs.75,628.22 towards medical expenditure. However, it is not known whether Ex-P11 to P18 are original or they are copies of the originals and whether they are submitted to his insurer along with the claim form, since it has also come in the enquiry, Complainant was asked to submit duly filled claim form and  details of original medical bills.

5.       It is not in dispute that the Complainant had obtained LIC Health plus plan under table No.901 by paying Rs.12,000/- premium, had obtained the policy No.724100214 which was commenced w.e.f 28.03.2008, which will be expired on 31.03.2040.  In other words, said policy would cover 32 years and the insured has to pay yearly premium of Rs.12,000/- till then to keep the policy in force.  It has come in the enquiry that the treatment which complainant had spent was Rs.75,678/-  towards injury caused to   bullet shot injury right side of neck and he is entitled to reimburse medical bills up to Rs.2 lakh. 

6.       It is not in dispute that he had paid premium up to 2011 and insurer without settling the claim of the complainant, on 06.04.2011 had returned Rs.6,341/- through cheque towards compulsory surrender which in our view could not be appreciated.  In such circumstances, in our view had Complainant claimed reimbursement towards medical expenditure on account of  Bullet Vascular injury to his neck, while the policy was in force, liability of insurer cannot be exonerated either by returning surrendering Rs.6,341/- on 06.04.2011 under compulsory surrender or by not settling the claim.  In other words, insurer is bound to settle the claim and to that effect Complainant has to submit duly filled claim along with medical records and thereafter the insurer to settle the claim within 30 days.  In such view of the matter, deciding  case without their being claim form with required documents submitted to OP, has to be held, an error committed by the District Forum,  is not sustainable under law is liable to be set-aside.   Hence, Commission proceed to allow the Appeal. Consequently, set aside the impugned order dated 24.03.2014 passed in Consumer Complaint No.26/2013 on the file of District Consumer Disputes Redressal Commission, Hassan and directed Complainant to submit duly filled claim form along with all the required documents to OP-insurer and OPs 1 and 2 are directed to settle the claim as per the terms and conditions of the policy and on their failure to settle the claim, liberty is given to the Complainant to raise Consumer Complaint within 30 days.

7.       Amount in deposit is directed to be transfer to the District Forum for the needful.

8.       Return the LCR forthwith to the District Commission.

9.       Send copy of this Order to the District Commission and the parties concerned.

                Lady Member                    Judicial Member

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