Tripura

StateCommission

A/47/2017

Divisional Manager, Life Insurance Corporation of India and Others. - Complainant(s)

Versus

Smt. Bubli Sur(Datta) - Opp.Party(s)

Mr. Prahlad Kumar Debnath

07 Dec 2017

ORDER

Tripura State Consumer Disputes Redressal Commission, Agartala.

 

Case No.A.47.2017

 

 

1. Life Insurance Corporation of India Ltd.,

Represented by its Divisional Manager, LICI,

Silchar Divisional Office,

Meherpur, Post Box No.54,

Silchar – 788015,

Cachar, Assam.

 

2. The Senior Divisional Manager,

Life Insurance Corporation of India,

Divisional Health Unit, Silchar.

 

3. The Branch Manager,

Life Insurance Corporation of India,

Paradise Chowmuhani,

            West Tripura, Agartala,

            Pin: 799001.

… … … … Appellant/Opposite Parties.

 

• VS.

 

1. Smt. Bubli Sur (Datta),

          W/o Late Somnath Datta,

          Ramnagar Road No.3 (2^nd Crossing),

          West Tripura, Agartala,

          Pin: 799002.

… … … … Respondent/Complainant.

 

Present

Mr. Justice U.B. Saha,

President,

State Commission, Tripura.

 

Mrs. Sobhana Datta,

Member,

State Commission, Tripura.

 

Mr. Narayan Sharma,

Member,

State Commission, Tripura.

 

 

For the Appellants:                                        Mr. Prahlad Kumar Debnath, Adv.

For the Respondent:                                      Mr. Sovan Mahajan, Adv.

Date of Hearing & Delivery of Judgment:    07.12.2017.

 

 

J U D G M E N T [O R A L]

 

U.B. Saha,J,

The instant appeal is filed by the appellants, Life Insurance Corporation of India Ltd. represented by its Divisional Manager, Life Insurance Corporation of India Ltd., Silchar Divisional Office against the judgment and award dated 27.06.2017 passed by the learned District Consumers Disputes Redressal Forum, West Tripura, Agartala (hereinafter referred to as District Forum), in Case No.C.C. 26 of 2017 whereby and whereunder the Ld. District Forum directed the Life Insurance Corporation of India Ltd., the appellant herein (hereinafter referred to as opposite parties/LICI) to pay to the complainant an amount of Rs.39,500/- and interest over the amount @ 9% from the date of claim till date of payment and also to pay Rs.10,000/- for deficiency of service and harassment and Rs.5,000/- as cost of litigation, in total Rs.54,500/-within two months, if not paid, it will carry interest @ 9% per annum.

4. Heard Mr. Prahlad Kumar Debnath, Ld. Advocate appearing for the opposite parties-Insurance Company as well as Mr. Sovan Mahajan, Ld. Advocate appearing for the respondent (hereinafter referred to as complainant).
5. The facts are not in dispute that the respondent-complainant purchased one Health Policy, ‘Jeevan Arogya’ being Policy No.493949329 from the opposite parties, LICI having its Branch at Agartala. Policy was valid up to 14.07.2061. It is also admitted position that the policy covered for two members i.e. the complainant and her minor son. Premium of the said Insurance Policy was Rs.2,725/-per annum and after payment of the aforesaid premium, the respondent-complainant received the Insurance Policy. After purchasing the policy, the complainant suffered pain in her abdomen and went to ILS Hospital at Agartala. In the said hospital, while she was treated, gallbladder stone was detected and by way of surgery, stone found in the gallbladder was removed. Total charge for her treatment was Rs.39,500/-. The complainant claimed the said amount from the opposite parties, but the opposite parties, LICI refused to accept the claim of the complainant and informed her that to get the benefit of the ‘Jeevan Arogya Policy’, she will have to wait for two years as per conditions and privileges of the LICI for ‘Jeevan Arogya Policy’. The condition of the LICI is that, as per terms and conditions of the policy, there is a specific waiting period for two years. Thus, the complainant has to wait for the waiting period of two years to get the benefits of the policy i.e. the respondent-complainant will be entitled to get the benefits of the policy, the treatment cost, if the illness occurred after two years of purchasing the policy. In the instant case, admittedly, the surgery of the complainant was done before completion of two years for which the claim of the complainant was repudiated. Being aggrieved by the action of the opposite parties, LICI, the complainant has submitted a complaint petition under section 12 of the Consumers Protection Act, 1986 before the learned District Forum claiming the benefits of the policy, the treatment cost as well as compensation for deficiency in service.
6. The opposite parties, LICI filed their written objection denying the claim of the complainant on the ground that as per Clause-6 of the terms and conditions of the policy, surgery of the gallbladder stones falls under specific waiting period of two years from the commencement of the policy and no benefit of hospitalization and surgery is available if the treatment is within two years from the date of commencement of the policy. It is also contended in the written objection that as per the policy, there is a Cooling-off Period in the Policy and as per Clause-23 of the Policy of the Conditions and Privileges, if a person on receipt of the policy is not satisfied with the said policy, the policy holder may return the policy document and exit from the policy, on being not satisfied with the ‘Terms and Conditions’ of the Policy. As the complainant did not object to the terms and conditions, it was implied that she had accepted the conditions of the Policy. It is also stated that the case of the complainant is fully covered by the judgment passed by this Commission in Life Insurance Corporation of India Ltd. Vs. Sri Kajal Das Roy in (Appeal Case No. A/39/2016) wherein this Commission decided the similar question involved in the instant case relying upon a decision of the Hon’ble National Commission in Ekjot Singh Vs. E-Meditek Solution Limited and Life Insurance Corporation of India (Revision Petition No.4779 of 2012).
7. On the basis of the pleadings and documents submitted as well as the evidence adduced by the parties, the Ld. District Forum decided the complaint petition on the following points:-

1. Whether terms and conditions of the policy was projected before the complainant at the time of proposal and signing the policy documents?
2. Whether petitioner had to wait for 2 years for surgery or treatment after commencement of the policy for getting any reimbursement?
3. Whether petitioner is entitled to get compensation for deficiency of service of LICI?

8. Complainant submitted the policy documents, proposal form, patient settlement voucher, print out e-mail, letter of Senior Divisional Manager, Legal Notice and also produced the statement on affidavit of the complainant.
9. On the other hand, LICI produced some documents which were accepted by the learned District Forum. Those included copy of authorization letter, claim form, copy of LICI's Jeevan Arogya, Proposal Form, copy of letter dated 05.03.2016, repudiation of the claim.
10. Both the parties after adducing the evidence submitted written arguments. 
11. The learned District Forum while deciding the case in its findings stated that admittedly complainant had signed the Policy and in the Policy, nothing has been written about the terms and conditions of the Policy or about any waiting period. It is also stated that in the letter addressed to the complainant, Bubli Sur by the Senior Divisional Manager, LICI on 05.09.2016, the Senior Divisional Manager, LICI referred to the policy document under Serial No.06 having specific waiting period of two years from the date of commencement of the policy and the treatment of gallbladder stone was done within the two years of the commencement of the policy. The learned District Forum in its findings also noted that in the original policy documents, terms and conditions of the ‘Jeevan Arogya Scheme’ was not mentioned. The opposite parties, LICI produced the photocopy of the terms and conditions of the policy, but it is not signed by the complainant or opposite parties and when these terms and conditions docket was sent to the complainant not clearly stated by the LICI in their evidence. In the written statement also, it is not clearly stated that the terms and conditions of the waiting period was clearly projected to the complainant on the date of commencement of the policy or on any particular date after commencement of the policy. Though the documents submitted by the opposite parties Insurance Company was not exhibited, the Insurance Company also did not adduce any evidence.
12. The learned District Forum discussed about the Clause-6 of the terms and conditions of the Policy which dealt with General Waiting Period and Specific Waiting Period and Clause-7 regarding Exclusions and finally held that,

“Specific waiting period is subject to general waiting period and this waiting period is given for the treatment of gall stone. Surgery definitely comes under treatment. But in the Clause 6 it is clearly written that when there is hospitalization or surgery occurred due to sickness then waiting period is 90 days not 2 years. So, in terms of clause 6 of the policy terms and condition the repudiation of the claim we consider was improper.” 

With the aforesaid observation and findings, the learned District Forum allowed the complaint petition and directed the appellant-opposite parties to pay the cost of the treatment as well as monetary benefit for deficiency of service and harassment and also litigation cost as stated (supra).

13. Mr. Debnath, Ld. Counsel for the appellant-opposite parties while urging for setting aside the judgment in view of the judgment of this Commission in Kajal Das Roy (supra) and the judgment of the Hon’ble National Commission in Ekjot Singh (supra) would contend that the complainant is not entitled to get the cost of her treatment as she went for operation of her gallbladder stone within the specific waiting period of two years and there was no deficiency of service on the part of the opposite parties-LICI.
14. Per contra, Mr. Mahajan, Ld. Counsel appearing for the respondent-complainant submits that the opposite parties-LICI did never communicate the terms and conditions to the complainant along with the Policy and more so in the Proposal Form also, there was nothing regarding the waiting period as mentioned in Clause-6 of the terms and conditions. He further submits that first time the opposite parties-LICI submitted the documents particularly the terms and conditions before the learned District Forum and even some documents were submitted after examination of the complainant. Thus he did not get opportunity even to cross-examine the opposite parties as the opposite parties did not adduce any evidence before the learned District Forum. According to him, the learned District Forum rightly passed the award of compensation in favour of the complainant, the respondent herein.  
15. We have gone through the impugned judgment and the evidence on record as well as the documents considered by the learned District Forum. Admittedly, the opposite parties, LICI did not adduce any evidence except submitting some documents and those documents were also not marked as exhibit, but the learned District Forum took note of those documents and considered the terms and conditions particularly Clause-6 and 7.
16. In Kajal Das Roy (supra), a similar question came up before this Commission and this Commission set aside the judgment of the learned District Forum whereby and whereunder the learned District Forum allowed the complaint petition and awarded compensation, and in consequent thereto dismissed the complaint petition. There is also no doubt that the case in hand is covered by the aforesaid judgment of this Commission, but only difference is this, in that case, LICI, the appellant therein has placed the photocopy of the relevant page of one Receipt and Dispatch Register before this Commission to show that the complainant received the ‘Conditions and Privileges’ along with Insurance Policy Certificate. Though the said Receipt and Dispatch Register was not part of the evidence, but we had gone through the same, from which it appeared that the health policy of claim for Insurance and the Booklet were received by the complainant Kajal Das Roy therein, but in the instant case, though the opposite parties LICI submitted its written objection with some documents before the learned District Forum, but admittedly opposite parties-Insurance Company did not adduce any oral evidence and the W.S. submitted by them on 24.04.2017 with documents and the documents submitted on the date of cross-examination of the complainant i.e. on 29.05.2017 were neither exhibited nor supported by any evidence. Therefore, according to us, the learned District Forum considered the contention of the appellant-opposite parties in their written objection as well as the documents submitted by them which were not exhibited. The learned District Forum while interpreting the Clause-6 and 7 mentioned in Paragraph-14 of the impugned judgment as follows:-

“14. There is confusion and contradiction on the terms and conditions in the policy clause no.6 & 7. Specific waiting period is subject to general waiting period. Petitioner paid the premium and waited for more than 90 days and claimed treatment cost but her genuine claim was repudiated. They assigned reason clause 7 which is subject to general clause 6. Therefore repudiation of claim is improper in our view.” 

 

17. Perused the Clause-6 and 7 of the terms and conditions of the Policy. As we stated earlier that Clause-6 is relating to waiting period i.e. General Waiting Period and Specific Waiting Period and Clause-7 is regarding Exclusion not regarding Specific Waiting Period. Therefore, we are of the view that the learned District Forum committed error while interpreting the Clause-6 and Clause-7 of the terms and conditions and more so, considered some documents which were not exhibited. It also appears from the order sheets of C.C.26 of 2017 that the learned District Forum did not provide any opportunity to the opposite parties-Insurance Company to adduce their evidence after examination of the complainant on 29.05.2017. For ready reference, the order 29.05.2017 is quoted hereunder:-

“29.05.2017- Learned advocate for Petitioner and O.P. are present. PW is cross examined. Documents submitted by the O.P. Evidence closed. To 14-06-2017 for argument.”

Not only that, the complainant was examined as O.P.W.1 instead of P.W.1. Mentioning as O.P.W.1 in case of the complainant, according to this Commission, is a typographical mistake. It is also not clear that the documents submitted by the opposite parties-Insurance Company which were accepted by the learned District Forum were admitted by the complainant or not.

18. In view of the above, it would be proper on our part to set aside the impugned judgment and remand back the case before the learned District Forum to decide afresh after giving opportunity to the opposite parties-Insurance Company for adducing their evidence, if so advised and also giving opportunity to the complainant to cross-examine the witnesses, if any produced by the opposite parties-Insurance Company. Accordingly it is ordered. The impugned judgment is set aside. Matter is remanded before the learned District Forum to decide the case afresh. As the Ld. Counsel for the parties are present before this Commission, the parties are directed to appear before the learned District Forum on 29^th of December, 2017.

In the result, the appeal is disposed of.

Send down the records to the Ld. District Forum, West Tripura, Agartala.