| Final Order / Judgement | BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM CACHAR :: SILCHAR Con. Case No. 25 of 2015 Sri Indrajit Patoa, Central Road, Silchar-1, …………………………………….. Complainants. -V/S- Life Insurance Corporation of India, Represented by its Senior Divisional Manager, Silchar Divisional Office, Meherpur, Silchar-5………….………… O.P. Present: - Sri BishnuDebnath, President, District Consumer Forum, Cachar, Silchar. Sri Kamal Kumar Sarda, Member, District Consumer Forum, Cachar, Silchar. Appeared: - Mr. A. Biswas, Advocate for the complainant. Mr. Prasenjit Deb, Advocate for the O.P. Date of evidence 02-03-2017, 14-08-2017 Date of written argument 12-10-2017, 09-03-2018 Date of oral argument 06-04-2018, 16-08-2019 02-09-2019 (None appeared for oral argument) Date of judgment 16-09-2019 Contd…P/2 P/2 C.C. No. 25/2015 JUDGMENT AND ORDER Sri BishnuDebnath - The Complainant Sri Indrajit Patoa purchased on 31/03/2008 a Health Insurance Policy No. 492231353 from Life Insurance Corporation of India (referred as LICI) for self, his wife and 2 (two) children to cover the risk of Medical expenditure for medical treatment as indoor patient in any Hospital. As per the terms & condition of the Policy, the LICI is taken risk to pay Hospital Cash Benefit (HCB) and Major surgical Benefits (MSB) in fit cases.
- On 18/02/2014 the Complainant was admitted to Apollo Gleneagles Hospital, Kolkata, for Angioplasty Surgery to implant a single stem. Accordingly, operation was done and he was discharge on 20/02/2014.
- However, the Complaint subsequently submitted him medical claim for HCB & MSB but LIC repudiated the claim on the ground that total Hospitalization period was less than 52 hours and surgeries which was done not listed in the allowed surgeries and as such further stated in the repudiation letter that claim of the Complainant was not payable under claim rejection code L-80 (stay less than 52 hours) and claim rejection code M-01 (unlisted procedure)
- On being aggrieved with the above ground of repudiation the instant complainant brought under the provision of Consumer Protection Act.1986 with prayer for award of Rs.1,91,838 together with interest and other reliefs including cost of the proceeding.
- The LICI in its W/S stated that the Complainant admitted to the Hospital on 18/02/2014 at 9:34 A.M and discharged on20/02/2014 at 10:58 A.M. So, stay in the hospital was 49 hours 24 minutes which is less than 52 hours for which the complainant is not entitled Hospital Cash Benefit as per terms & conditions.
- Moreover, the O.P. stated inter alia that the Complainant went on surgery for implant of single stent but to get MSB it is requirement to go for surgeon for implant of 2(two) or more stent as per the terms and conditions. As such the O.P. stated that claim was repudiated on the ground of mentioned rejection code No.L-08 and code No.M-01.
- During hearing the Complainant submitted his deposition supporting an affidavit and exhibited some relevant documents. Subsequently, on asking by the District Forum, submitted some bills & voucher for medical treatment at the aforementioned hospital. The O.P. side also submitted deposition of Anwar Hussain Laskar as D.W-1 and exhibited some documents including Booklet of LICI Heath Plus Plan, its Rules & Regulation. Copy of discharge summery of complainant issued from Apollo Gleneagles Hospitals, copy of claim rejection letter etc. After closing evidence both sides counsels submitted their written argument.
- I have heard both sides’ counsels and perused the evidence on record including written argument. I have also re-hear both sides’ counsels for clarification regarding rejection of claim code No.L-08 & No-M-01.
- In this case from perusal of Insurance policy vide Ext.9 & Ext.B it is understandable that the LICI has taken risk to pay HCB & MSB only in fit case to the principal policy holder, his wife and 2(two) Children. The rate of HCB & MSB benefit limits are written in the Booklet vide Ext.A.
- However, from the perusal of Hospital discharge summery vide Ext. C and on hearing both sides’ counsels and perusal of claim rejection codes it is of opinion that the Ext.C reflect a confusing fact about the exact date of coronary angiogram because in the Ext.C it is written that date of admission in the hospital was 18/02/2014 but in the relevant paragraph of the Ext.C it is written that procedure perform as coronary angiogram was done on 17/02/2014.
- Accordingly, on clarification, the Complainant submitted that Angiogram was done on 18/02/2014 and he was discharged on 20/02/2014. Not only that but also the Apollo Gleneagles Hospital by issuing letter dated 23/07/2019 confirmed that A coronary Angiogram & Percutaneous Transluminal Coronary Angioplasty was done on 18/02/2014 but due to typographical error in the Discharge summary it had been wrongly mentioned the date as 17th February 2014 instead of original date of procedure on 18 February 2014.
- However, from the evidence on record it is clear that the Complainant was hospitalized for a period less than 52 hours and on surgery 1(one) stent was implanted. But the complainant stated that his claim was within the terms and conditions of the policy Ext. 9 is the copy of Insurance Policy and original Insurance policy admittedly submitted to the O.P. with claim Form. In the Ext. 9 nothing found about the terms & condition regarding rejection code L-08 and code M-01 or any other terms & conditions except the particulars of the insured and detail of the Insurance coverage.
- As per the Ext.9, HCB is Rs.1000 and MSB is Rs.2,00,000/-. But the O.P. stated inter alia that the TPA (Third Party Administrator) after thoroughly scrutiny of all papers of complaint and after investigating the same as regards to its admissibility as per the policy terms and conditions and the details of hospitalization, nature of ailment found that the claim of the claimant is not admissible.
- To support its defense plea, exhibited the Booklet of LICI Health Plus Plan, its Rules and Regulations vide Ext.A and copy of Insurance Policy vide Ext.B. It is revealed from Ext.B that in the 3 (third) page in 3rd paragraph as below:-“This welcome kit contains your policy bond, conditions and Privilege under your Health Plus Policy. The Health cards for you and your family members covered under this policy will be sent to you by the TPA (Third party Administrator). Health card serves as an identity card and will be useful to you at the time of claiming benefits under the policy. The TAP will send you the details of his contact, name and address. This is also available at your servicing branch office”.
- The Complainant never stated in this case that he did not receive the conditions & terms as well as Health Card along with Insurance Policy. However, conditions and privilege referred to the policy above are listed in Ext.A Booklet. But in the Ext.A claim rejection codes under plan 901 are not available rather in the circular No.LIC/HI/Claims/39/2009/2010 dated 25/03/2010 the list of claim rejection codes have been given. The said list specification indicated that the list of codes are modified up to 25/03/2010 which mean the modified list of code are applicable to the plan 901 and plan 902 from the date of circular on 25/03/2010 and no retrospective effect is given.
- But on perusal of the Insurance policy of the Complainant vide Ext.9 and Ext.B, it is revealed that the Complainants Insurance policy proposal was made 31/03/2008 commenced the coverage of benefit from the above mentioned date on 31/03/2018. Thus, it is crystal clear that the circular No.LIC/HI/Claims/39/2009/2010 dated 25/03/2010 is not applicable to the complainant. It is to be mentioned here that the above circular containing the rejection codes are furnished by the O.P. when asked for clarification.
- Anyhow, in this case as per Ext.A, Booklet for conditions and previlages in reference to plan No.901 the Complainant not entitled HCB for first 48 hours of hospitalization, regardless of whether he was admitted in general or special ward or in an intensive care unit. In the instant case admittedly the complainant was hospitalized for a period of 49 hours 24 minutes.
- Thus, above evidence leads to conclude that the Complainant is entitled HCB as per clause No.3 ‘Benefit Limit’ mentioned in Ext.A.
- However, as per clause 3 (VII) of condition and privileges, vide Ext.A, no payment shall be made under the MSB which are not listed in the Surgical Benefit Annexure. The Annexure of surgical Benefit is given in page 25 to 28 of Ext.A. As per that Annexure, coronary Angioplasty with one stent implantation is not listed but 2(two) or more stent implantation is available.
- As such, as per the condition and privileges of plan 901 of LIC Health Plus. The Complainant is not entitled MSB.
- Hence, in my considered view the O.P. did not commit any disservice for rejecting the claim for MSB but materials are found for disservice from rejecting the claim for HCB.
- Hence, O.Ps are directed to make payment of HCB to the Complainant, to the extent of amount which he is entitled with interest at rate of 6% per annum from the date of submission of claims form to the O.P. till payment of full amount and also directed to pay cost of the proceeding of Rs.5,000/- and compensation for mental agony for rejection of claim of HCB of Rs.10,000/-.
- The aforesaid amount is to pay within 45 days from today. In default further amount of interest at rate of 10% per annum to be added to the total calculation awarded amount.
- With the above, this case is disposed of on contest. Supply free certified copy of judgment to the parties of this case. Given under my hand and seal of this District Forum on this the 16th day of September.
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