PRESIDENT DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SAMBALPUR

                                                            CONSUMER COMPLAINT NO.186/2023

Present-Dr. Ramakanta Satapathy, President,

  Sri. Sadananda Tripathy, Member,

Dr. Narendra Kumar Behera,

S/O- late Sir Jayaram Behera,

Brudaban Vihar, Behind TPWODL,

Po- Budharaja, Dist- Sambalpur, Odisha Pin- 768004.            …........Complainant

-Vrs. -

Senior Divisional Manager, LIC India

Sambalpur Division, Budharaja

Dist-Sambalpur-768004.                                                                  ……......Opp.Party

Counsels:-

1. For the Complainant         :- Sri. Anil Kumar Mishra, Adv.
2. For the O.P.                        :- Sri. A.K. Dash, Adv.

Date of Filing:27.10.2023,Date of Hearing :19.02.2024, Date of Judgement : 15.04.2024

  Presented by Dr. Ramakanta Satapathy, PRESIDENT

1. The case of the Complainant is that the Complainant is having a policy No. 595121340 and on 16.03.2023 admitted in Vikash Hospital, Sambalpur for urine infection. The Complainant filed claim No. HI-LIC-00212129964 for an amount of Rs. 25,000/- with documents. Only Rs. 2800/- was reimbursed. Being aggrieved complaint has been filed.
2. The O.P. in reply submitted that the Complainant under LIC Jeevan Veema Arogya Plan No. 904 availed the policy. The policy covers Hospital cash benefit, Major Surgical Benefit Day care procedure Benefit and other Surgical benefits. On 28.02.2016 Policy No. 595121340 was taken the initial daily Benefits(IDB) which is Rs. 1000/- and major Surgical Benefits in 100 times of the applicable Daily Benefit(ADB) and not with Initial Benefit(IDB).

The ADB covers two parts.

1. An Arithmetic additions of an amount equal to 5% if the IDB to the applicable daily benefit of the previous year.
2. Further arithmetic addition of an amount to 5%. No claim benefit will be added in 4 years and 10 years if there is no claim admitted under the policy during first 12 years from the policy commencement except in the 5^th year when a claim is admitted in respect of spouse.

No benefit will be payable for the first 24 hours of hospitalisation, however every hospitalisation that extents for a continuous period of 7 days or more the daily hospital cash benefit would also be paid for first-24 hours ( day one) of hospitalisation regardless of whether the insured was admitted in general or special ward or in ICU. The hospitalisation for 6 days 4 hours or more will be considered as 7 days.

The Complainant claimed Rs. 21,535/- to-wards treatment of Urinary Tract Infection (UTI) in Vikash Hospital on 13.03.2023 at 4.25 P.M. and discharged on 16.03.2023 at 4.53 PM. Although TPA recommended for pre-existing disease repudiation of claim but claim was admitted under recommendation of LIC’s Divisional office redressal committee to the competent authority.

The Complainant was eligible for HCB for 2 days only. Accordingly Rs. 1400/-x 2= Rs.2800/- was paid to the Complainant HCB changes. There is no  deficiency on the part of the O.P.

3. The Complainant filed:

1. Copy of Policy bond-Table No. 904.
2. Discharge Summary dated 16.03.2023 of Vikash Hospital.
3. Health India TPA Services Pvt. Ltd. request for additional documents dated 31.05.2023.
4. Final Bill of Vikash Hospital dated 16.03.2023.

The O.P. filed:

1. Comprehensive Jeevan Arogya Health Plan of LIC.
2. Jeevan Arogya Policy Bond. Table 904.

4. It is the admitted case of both the parties that policy No. 595121340 was issued by the O.P. LIC’s jeevan Arogya Policy, Table No. 904 and date of commencement 28.02.2016. The date of admission in Vikash Hospital was 13.03.2023 and date of discharge 16.03.2023 under Dr. Sovan Hota(Urology). In investigation it was found USG KUB. Grade-II prostatomegaly with median lobe bulge. Minimally complex right renal Cortical cyst.

The Complainant was treated with Broad Specimen IV antibiotics and discharged on stable and afebrile condition. From the treatment details it reveals that there is no any major treatment or Surgeries done by the treating physician.

The second point of consideration is that whether the O.P. acted as per terms and conditions of Jeevan Arogya policy Table No. 904 or not. As per terms and conditions of the Hospital cash Benefit(HCB) clause “ If any of the insured life is hospitalised due to accidental body injury or sickness then Applicable Daily Benefit(ADB) will be payable regardless or actual cost incurred subject to applicable maximum limits”

The Complainant cited N.C.D.R.C. case of Tarlok Chand Khanna Vs United India Insurance Co. Ltd. case decided on 16.08.2021 wherein the discussion is on pre-existing disease. In the present case although TPA suggested for repudiation of the claim and as per existing terms and conditions paid the claim of Rs. 2800/-. Accordingly, the citation is not applicable in this case.

The third point of consideration is whether the amount paid by the O.P. for Rs. 2800/- is proper or any other amount the Complainant is entitled to get. It is admitted buy both the parties that the total expenditure and claim amount of the Complainant is Rs. 21,535/-. This is a case of initial daily benefit(IDB) and as per terms and conditions the daily IDB is Rs. 1000/-. The Complainant was admitted on 13.03.2023 and discharged on 16.03.2023 for 3 days and 1^st day if not to be taken into account. Accordingly, the Complainant is entitled for 2 days IDB which is calculated @ Rs. 1400/- per day x for two days which is proper. The O.P. has paid the actual calculated amount as per policy terms and conditions. There is no deficiency on the part of O.P. established.

5. Taking into consideration the contention of the parties and basing on documentary evidence as no deficiency in service established the following order is passed.

ORDER

The Complainant is dismissed on contest against the O.P. No cost.

Order pronounced in the open couth on 15^th day of April 2024.

Supply free copies to the parties.