Orissa

Cuttak

CC/114/2018

Subhasis Das - Complainant(s)

Versus

Senior Branch Manager,Life Insurance Corporation of India - Opp.Party(s)

A K Samal

24 Jan 2020

ORDER

IN THE COURT OF THE DIST. CONSUMER DISPUTES REDRESSAL FORUM,CUTTACK.

C.C No.114/2018

 

Mr. Subhasis Das,

S/o: Late Himansu Sekhar Das,

At:House No-77-F1,Jagannath Lane-2,

Brahmeswar Patna,Bhubaneswar,

Dist-Khurda-751018.                                                                      … Complainant.

 

                Vrs.

   

1.        Senior Branch Manager,

Life Insurance Corporation Of India,

Anugul Branch Office,

At/Po/Dist-Anugul.

 

2.        Senior Divisional Manager,

Life Insurance Corporation Of India,

Cuttack Divisional Office,Jeevan Prakash

Nuapatana,Buxibazar,Cuttack.                                               … Opp. Parties.

 

Present:               Sri Dhruba Charan Barik,LL.B. President.

Smt. Sarmistha Nath, Member(W).

 

Date of filing:      11.07.2018

Date of Order:    24.01.2020

 

For the complainant       :  Mr. A.K Samal,Adv & Assocites.

For the O.P.N.1 & 2         : Mr. R. K Pattanaik,Adv & Associates.

 

Sri Dhruba Charan Barik,President.

The complainant having attributed deficiency in service to the OPs has filed this case seeking appropriate relief against them in terms of his prayer in the consumer compliant.

1. The facts of the consumer complainant stated in brief are that the complainant while serving as an Officer in NSIC (Govt. Of India Undertaking) had obtained a health Insurance Policy named and styled as “LIC Health plus Plan” from OP No1. The said Insurance Policy bears the                        No 588468009 which is commenced from 5.10.2009 and the date of maturity is 5.9.2036. The premium payable is Rs 15000/- annually for a period of 15 years. The sum assured under the policy is Rs 5 lakhs. The wife of the complainant is the nominee in respect of the said policy. The copy of the policy bond containing term & condition has been filed and marked as Annexure-2.
2. While the policy was in force the complainant develop chest pain & he went to Apollo Hospital, Bhubaneswar for treatment. It was detected that there was blockage in the artery of the complainant & for that reason he was require to undergo angioplasty. The copy of the treatment given to the complainant by the said hospital has been filed & marked as Annexure-II.
3. The complainant got admitted in to the Apollo Hospital, Bhubaneswar on 20.03.2018 & discharge on 22.03.2018.During the period of treatment he has incurred a expenses to the tune of Rs 2,19,556.12/-.The copy of the final  bill of the said hospital has been filed & marked as Anexxure-3.The complainant there after lodged his claim together with all required documents before the OPP parties for reimbursement of the hospital expenses in 1^st week of May of2018 but no consideration of his claim was made for a long period. The complainant therefore send reminder to the OPP parties for settlement of this claim within 7 days otherwise he shall be constrained to initiate legal proceeding against them. Annexure-4 is the copy of the Email of reminder issued to the OPP parties. There was no response from the Opp. parties in the matter.   Then the complainant approach to the IRDA about the inaction by sending his complaint but the concerned authority advised the complainant to approach the Insurance Ombudsman for redressal of his grievances .Annexure -5 is the copy of the letter date 4.8.2018 sent by the IRDA to the complainant.
4. On 9.8.2019 the OPP parties intimated the complainant that the claim could not be satisfy on the ground that the complainant has undergone coronary angioplasty of one artery only with stent implantation where as the policy condition provides that two or more coronary artery must be stent in order that the claim would be admissible. That apart it is also stated in the repudiation letter vide Annexure-6 that the hospital cash benefit cannot be payable to the complainant since he has been hospitalized for less than 52 hours in this case. It is important to leave a mention here that the complainant had also obtained another health Insurance policy from United India Insurance Company Limited which has already settle the claim to the tune of Rs 162000/- in favour of the complainant on the self same documents and treatment particular.Annexure-7 is the copy of the policy bond issued by the  United India Insurance Company showing the payment of claim made by said insurer.
5. The total bill raised by the Apollo Hospital amounted to Rs 2,19,556.12/- and the TPA                    M/s Heritage Health Service PVT Ltd on behalf of United India Insurance Company Limited has released a sum of Rs 1,62,000/- to the Apollo Hospital towards hospital expenses and it has been credited to the account of the said hospital and the balance of Rs 57556.12/-                 remained to be paid .Lastly the said balance amount was paid by the complainant to the Apollo Hospital from his own pocket due to denied the claim by the OPP parties. Annexure -8 is the copy of the document for the payment of bill issued by the Apollo Hospital ,Bhubaneswar dated 20.3.2018.
6. It is further revealed that the repudiation & the claim by the OPP parties is completely vain & illegal. In this respect it is stated that the terms & condition of the policy should be interpreted in such a manner that the basic objective for taking the insurance policy should not be frustrated in the technical ground. Thus a harmonious construction should be done by the insurer in order to give effect to the total health policy.
7. The complainant has already undergone serious mental agony & harassment for repudiation his claim. It is therefore prayed that the OPP parties may be directed to pay the hospital expenses to the tune of Rs Rs 2,19,556.12/- together with interest on the above amount at the rate of 12% annually from the date of repudiation till the actual payment is made &  Compensation of Rs 2 lakh for mental agony & harassment cause to the complainant & Rs 25000/- towards litigation cost in the interest of justice.
8. Both the OPP parties entered appearance & filed written version & contested the case. It is inter alia stated that the case is not maintainable both in facts & law and there is no cause of action to file the case. There is also no deficiency in service on the part of OPP Party as attributed to them by the complainant.
9. It is further stated that the OPP parties have not repudiated the claim of the complainant, rather they asked the complainant to file certain document with regard to history & duration of diabetes mellitus & hypertension from the treating physician along with first consultation report on 16.6.2018 & 4.7.2018 but the complainant remained silent over the matter for which the claim was pending with OPP parties.
10. It is further stated that when the complainant has undergone coronary angioplasty with stent implantation of one artery and hospitalized from 20.03.2018 to 22.03.2018, his claim is does not acceptable being violative of the terms & condition of policies. At the same time it is said that the complainant can take domiciliary treatment benefit up to 50% of the fund value. Annexure- A is the is the policy condition which has contained the stipulation stated above.
11. Annexure-B, the copy of the letter issued by the OPP parties requesting the complainant to submit necessary document for processing his claim. 
12.  It is further stated that term & condition of the policy issued by the OPP parties & other insurance company are not same in substance. So acceptance of the claim of the complainant by the United India Insurance Company has got no relevance whatever to the instance case.
13. In view of the above it is said that the consumer complaint merits no consideration & it is liable to dismiss with cost.
14. We have heard the learned counsels from both the sides and gone through the pleadings of the parties and the annexures respectively filed by them.

It is an admitted fact that as per the terms and conditions of the policy, the claim under the L.I.C health plus plan is admissible if more than one coronary artery is stented and the hospital cash benefit is payable to the insured if he was admitted into the hospital for more than 52 hours.Admittedly above terms and conditions are not fulfilled by the insured. As such his claim being violative of the above terms and conditions of the policy is not admissible.

Further contention made by the learned advocate for the complainant is that too much importance should not be given to the technical aspect of the terms and conditions of the policy.Such terms and conditions of the policy should be interpreted in such a manner that the basic objective for which the insurance has been obtained should not be frustrated.According to him a harmonious construction should be made by the insurer in order to give effect to the health policy.The learned advocate for the O.P has taken serious exception to it stating that where it is admitted that there was violation of the terms and conditions of the policy, no claim should be admissible which is implicit in such terms and conditions of the policy, In absence of anything to the contrary, it is held that the submission made by the learned counsel for the O.P has force in it.Hence ordered;

                                                                                                ORDER

                                                   The case be and the same is dismissed on contest against the O.Ps.

Judgment pronounced in the open Forum on this the 24^th day of January, 2020 under the seal and signature of this Forum.

 

(Sri D.C.Barik)

President.

 

(Smt. Sarmistha Nath)

Member(W)