Delhi

North East

CC/320/2014

Ritu Gupta - Complainant(s)

Versus

National Ins. co. Ltd. - Opp.Party(s)

28 Aug 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

 

Complaint Case No.320/14

 

 

In the matter of:

 

	Smt. Ritu Gupta, Wo Sh. Rakesh Kumar Gupta R/o 18/69, Block 18, Kalyan Puri, Delhi 110092	Complainant
	Versus
	Life Insurance Corporation of India 11th Floor, Scope Minar, North Tower, Core-2, District Centre Laxmi Nagar, Delhi 110092   Also At: Life Insurance Corporation of India Plot-6, Jeevan Pragati Building, 3rd Floor, Dist. Centre, Laxmi Nagar, Delhi 110092	Opposite Party

 

DATE OF INSTITUTION:         JUDGMENT RESERVED ON:                         DATE OF ORDER  :

21.08.2014 12.07.2023 28.08.2023

 

 

CORAM:

Surinder Kumar Sharma, President

Anil Kumar Bamba, Member

Adarsh Nain, Member

 

ORDER

Surinder Kumar Sharma, President

The Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986.

Case of the Complainant

1. The case of the Complainant as revealed from the record is that the Complainant had taken a LIC Jeevan Arogaya Policy vide policy no. 125911107 from the Opposite Party. Complainant paid Rs. 4,569/- as first yearly premium. The commencing date of policy was from 28.07.2011 to till date subject to due receipt of the subsequent premiums as set out the schedule was issued in the name of the Complainant with benefit in hospital indemnity. The Opposite Party had also provided the cashless facility and provides cashless i-card to member. Complainant stated that she had paid yearly premium till date against the said policy. Complainant stated that under the terms of the policy the Opposite Party was obliged to reimburse the Complainant for the hospitalization expenses for medical/surgical treatment at any nursing home/hospital incurred in connection with the disease, sickness/illness or bodily injury/accident up to the amount covered under the policy. Complainant has no previous history or any sickness/illness/disease prior to the insurance of LIC’s Jeevan Arogya policy. On 12.03.2014, Complainant was admitted in Sunrise Hospital, New Delhi for fever, uncomfortable and complaints of occasional palpitation. Complainant discharged on 14.03.2014. Complainant spent Rs 1,23,677/- on her medical treatment. Complainant filed claim forms for quick cash facility on major surgical benefit under the Opposite Party but Opposite Party did not give any reply till the discharge. Complainant paid all the medical expenses from her pocket. On 14.04.2014 Complainant filed all the documents to the Opposite Party for the reimbursement of the medical bills as per the terms and condition of the policy. Opposite Party passed Rs. 11,000/- towards the day care benefit against the total hospital bill amount Rs. 1,23,677/-. Complainant stated that vide letter dated 02.07.2014 Opposite Party rejecting the remaining claim of the Complainant without mentioned any reason. Complainant visited the office of Opposite Party and Opposite Party told that the balance claim was being processed and future development would be communicated to the Complainant. Complainant stated that the reason for rejection of balance claim of the Complainant is absurd and baseless in as much as the Complainant had complained of fever, uncomfortable and complaints of occasional palpitation. Complainant also sent written representation to the Opposite Party against the rejection of partly claim, but till day no response from the Opposite Party. It is the case of the Complainant that partly rejection of the claim under the said policy of the assured is bad-in-law and has been passed in mechanical manner without any application of mind. Hence, there is a deficiency on the part of Opposite Party. Complainant has prayed to direct the Opposite Party to pass remaining claim  i.e. Rs. 1,12,677/- with interest @ 18 %, Rs. 50,000/- on account of mental harassment and Rs. 25,000/- on account of litigation expenses.  

 

Case of the Opposite Party

2. Opposite Party contested the case and filed its written statement. It is stated that the Complainant had taken the policy Jeevan Arogya (Table 903) on 28.07.2011. The said plan is non-linked Health Plan which provides fixed benefits for hospitalization and almost all types of surgical procedure irrespective of the actual cost incurred and benefit is in addition to any other health insurance cover that insured lives may have subject to certain terms and condition. It is stated that as per the guidelines a help book namely, LIC’s Jeevan Arogya Conditions & Privileges of Table 903 was handed/dispatched to concerned policy holder along with Original Policy Bond. This help book contains names of all surgeries, types of Benefits, General & Specific waiting period & exclusions. It is stated that the arithmetic addition of an amount equal to 5 % of the initial daily benefit to the applicable daily benefit of the previous policy year. It is pertinent to mention that such increase in the applicable daily benefit shall be effected on each policy anniversary during the cover period and shall continue until it attains a maximum amount of 1.5 times the initial daily benefit. Thereafter, this amount in each policy year in future shall remain at that maximum level attained. In this case policy holder had undergone treatment for TLH (Fibroid Uterus) in Sunrise Hospital, Kalindi Colony, New Delhi. This treatment is enlisted under Day Care Procedure Benefit and not under Major Surgical Benefit. Accordingly, the payment was made to the Complainant as per terms and conditions of the policy. The treatment was total Laparoscopic hysterectomy and duration of treatment was one hour. The Complainant/policyholder was admitted on 12.03.2014 at 05.08 p.m and was discharged on 14.03.2014 at 7:28 p.m. The Opposite Party has denied the averments made in the complaint and has prayed for the dismissal of the complaint.

Evidence of the Complainant

3. The Complainant in support of her case filed her affidavit wherein she has supported the assertions made in the complaint.

Evidence of the Opposite Party

4. To support its case Opposite Party has filed affidavit of Shri Ajay Tyagi, Manager, Legal, and Shri. D.K Joshi, wherein, they have supported the case of the Opposite Party as mentioned in the written statement.

Arguments & Conclusion

5. We have heard the Complainant and Ld. Counsel for the Opposite Party.  We have also perused the file and written arguments filed by the Complainant and Opposite Party. The case of the Complainant is that she has purchased LIC Jeevan Arogya (Table 903) policy from the Opposite Party. It is her case that as per the terms of the said policy she was entitled for cashless facility for treatment. It is her case that under the terms of the policy Opposite Party was required to reimburse the Complainant for hospitalization expenses for medical/surgical treatment at any nursing home/hospital. It is her case that Opposite Party has given her LIC health card for cashless treatment. On the other hand the case of the Opposite Party is that the Complainant had purchased the policy Jeevan Arogya (Table 903). It is the case of the Opposite Party that as per the terms of the said policy fixed benefits are provided for hospitalization and almost all types of surgical procedure irrespective of the actual cost incurred and benefit is in addition to any other health insurance cover.
6. The Complainant has not led any cogent evidence that under which terms or condition of the policy she was entitled for the cashless facility or full reimbursement of the treatment. On the other hand, the case of the Opposite Party is that the Complainant was only entitled for fixed benefits for hospitalization irrespective of the actual cost incurred by her. The Complainant has not rebutted this evidence. Further the Complainant also relies upon the photocopy of the LIC health card issued by the Opposite Party. As per the case of the Complainant the said LIC health card provides cashless facility. The perusal of the said card shows that it does not provide cashless facility. On the card it is mention as follows:

“The card does NOT entail any benefits such as ‘Cashless Hospitalisation’ etc.”

7. Therefore, under these circumstances we are of the opinion that the Complainant has failed to prove her case. Hence, the complaint is dismissed.

 

8. Order announced on 28.08.2023.

Copy of this order be given to the parties free of cost

File be consigned to Record Room.

(Anil Kumar Bamba)	(Adarsh Nain)	(Surinder Kumar Sharma)
(Member)	(Member)	(President)