Tripura

StateCommission

A/22/2019

The Manager (HI), Life Insurance Corporation of India(LICI) - Complainant(s)

Versus

Smti. Purbita Gupta - Opp.Party(s)

Mrs. Puspita Chakraborty

18 Jan 2020

ORDER

Tripura State Consumer Disputes Redressal Commission, Agartala.

 

 

Case No.A.22.2019

 

 

 

1. The Manager (HI),

Life Insurance Corporation of India (LICI),

Silchar Divisional Office,

Meherpur, Silchar, Assam,

Pin - 788015.

 

2. The Chief Manager, LICI,

Agartala Branch No.1,

Paradise Chowmuhani, Agartala,

District - West Tripura.

… … … … Appellants/Opposite parties.

Vs

 

1. Smt. Purbita Gupta,

D/o Sri Purnendu Gupta,

Ramnagar Road No. 2 (West),

P.O. Ramnagar, Agartala,

District - West Tripura.

                                                          … … … … Respondents/Complainant.

 

 

Present

Hon’ble Mr. Justice U.B. Saha

President,

State Commission

 

Mr. Kamalendu Bikash Das,

Member,

State Commission

 

 

 

 

For the Appellants:                                              Ms. Puspita Chakraborti, Adv.

For the Respondent:                                            Mr. Koushik Roy, Adv.

Date of Hearing:                                                  13.01.2020.

Date of Delivery of Judgment:                           18.01.2020.

J U D G M E N T

 

U.B. Saha, J,

The instant appeal is directed against the judgment dated 28.06.2019 passed by the learned District Consumer Disputes Redressal Forum (hereinafter referred to as District Forum), West Tripura, Agartala in Case No.C.C.70 of 2018 whereby and whereunder the learned District Forum partly allowed the complaint petition directing the opposite parties, Life Insurance Corporation of India, the appellants herein, to pay Rs.1,43,712/- being the cost of treatment together with Rs.4,000/- being the cost of litigation, in total Rs.1,47,712/- to the complainant within a period of two months from the date of judgment, failing which, the amount of compensation shall carry interest @9% per annum till the payment is made in full.

2. Heard Ms. Puspita Chakraborti, Ld. Counsel appearing on behalf of the appellants (hereinafter referred to as opposite parties/Insurance Company) as well as Mr. Koushik Roy, Ld. Counsel appearing for the respondent (hereinafter referred to as complainant).
3. Brief facts needed to be discussed are as follows:-

The complainant had purchased LIC’s Jeevan Arogya Policy bearing Policy No.493466962 (Table 903) from the opposite parties-Insurance Company. Complainant, Smt. Purbita Gupta is the principal insured under the said policy. Her father Sri Purnendu Gupta and her mother Smt. Sumita Gupta are also covered under the said policy. While she was paying the premium of the policy regularly, her father Sri Purnendu Gupta underwent ‘ventral hernia’ surgery at the Apollo Hospitals, Chennai on 18.07.2016 i.e. within the lifetime of the Policy. Sri Purnendu Gupta was admitted in the aforesaid Hospital on 17.07.2016 and was discharged on 22.07.2016. The complainant after completion of treatment of her father returned to Agartala and submitted her claim of Rs.2,16,827/- being the cost of treatment of her father under her aforesaid LIC Policy along with medical prescriptions, bills and vouchers etc. with a forwarding letter addressed to the opposite party no.2, the Chief Manager, LICI, Agartala Branch No.1 on 08.08.2016. Upon receipt of the claim, the opposite party no.1, The Manager (HI), LICI, Silchar Divisional Office had sought for some clarification from the complainant. On 14.09.2016, the complainant replied to the quires and thereafter, on 12.01.2017, the opposite party no.2 personally visited the house of the complainant and made physical verification of her claims and also related documents. On 27.03.2017, complainant received one letter from the Manager (HI), LICI, Silchar Divisional Office, the opposite party no.1 wherein she was informed that the claim raised by her was reduced by the LICI to Rs.17,100/- as of ‘Other Surgical Benefit’ under the Policy. The opposite parties did not admit the whole claim raised by the complainant. In her complaint petition, the complainant has asserted that she has fulfilled the terms and conditions of the Insurance Policy, but in spite of that, the opposite parties have denied her justified claim on the ground that ‘ventral hernia’ surgery is not a major surgery.

Being aggrieved by and dissatisfied with the action of the opposite parties-Insurance Company, the complainant has filed the complaint petition before the learned District Forum claiming Rs.2,16,827/- being the cost of treatment, Rs.5,00,000/- for mental agony and sufferings, Rs.50,000/- as the cost of litigation and Rs.50,000/- as incidental cost, in total Rs.8,16,827/- from the opposite parties.

4. The opposite parties, LICI on receipt of notices from the learned District Forum appeared before it and filed their written statement denying the claim of the complainant. In the written statement it is asserted that the complainant had suppressed the material fact about her father being a patient of hypertension at the time of purchasing of the policy. It is also stated that ventral hernia surgery which was performed on the body of her father does not come under the list of major surgery as per the terms and conditions of the policy and as such, the opposite parties are not liable to reimburse the entire cost of treatment as claimed by the complainant. According to the opposite parties, a lenient view had been taken in the case of the complainant and the claim raised by the complainant has been considered to be treated to come under the ‘Other Surgical Benefit’ in spite of the fact that the father of the complainant had preexisting illness (Hypertension) which has been surfaced in the discharge summery report issued by the Apollo Hospitals, Chennai and accordingly, an amount of Rs.17,100/- was paid to the complainant as ‘Other Surgical Benefit’ as per the Policy. It is also contended in the written statement that the opposite parties did not commit any deficiency of service towards the complainant. Thus the complaint petition ought to have been dismissed.
5. The complainant has examined herself as P.W.1 and her father as P.W.2. She produced nine documents which were marked as Exhibit-I series.
6. The opposite parties, Insurance Company have examined one witness, namely, Sri Niranjan Bal, Manager (Admn.), LICI, Agartala Branch-I as O.P.W.1 and they submitted five documents which were marked as Exhibit-A series.
7. The learned District Forum after considering the evidence on record framed the following points to decide the case:-
   1. Whether there was deficiency of service on the part of the OPs?
   2. Whether the complainant is entitled to get compensation/relief as prayed for?

And the learned District Forum finally passed the impugned judgment.

8.  Ms. Chakraborti, Ld. Counsel while urging for setting aside the impugned judgment submitted that the learned District Forum committed error while passing the impugned judgment particularly, observing, inter alia, that “We are of the opinion that the Complainant should not be deprived of getting Insurance benefit for the “Ventral Hernia Surgery” which was under taken by her father at the Apollo Hospitals simply on the ground that such a surgery does not find place in the list of major surgical benefit. We find that the O.Ps have only paid Rs.17,100/- to the Complainant for the surgery whereas the claim of the Complainant was Rs.2,16,827/- being the total actual cost of treatment and that too has been supported by cogent evidence produced by the Complainant from the Apollo Hospitals under Exhibit-I series.” She finally contended that when as per terms of Policy ‘ventral hernia’ surgery is not come within major surgery, rather the same is fallen under ‘Other Surgical Benefit’ therefore, the complainant is not entitled to get the actual cost of the treatment as sought for. 
9. On the other hand, Mr. Roy, Ld. Counsel while supporting the impugned judgment has contended that admittedly the father of the complainant was admitted in the Apollo Hospitals, Chennai after the completion of specific waiting period of insurance policy and went on surgery for hernia. Thus the learned District Forum rightly passed the impugned judgment awarding Rs.1,60,812/- – Rs.17,100/- which has already been paid i.e. Rs.1,43,712/-. He has further contended that when the actual cost for the surgery of the father of the complainant was Rs.2,16,827/-, but the Insurance Company paid only Rs.17,100/- mere on a technical ground. Thus, such an act of the Insurance Company is nothing but deficiency of service. He has taken us to a Press Release dated 31.05.2011 issued by the opposite parties-Insurance Company relating to ‘Jeevan Arogya Policy’ wherein it is specifically stated that other surgical benefit would also come within the ‘Jeevan Arogya Policy’.
10. We have gone through the impugned judgment as well as the evidence on record. It appears from the inpatient bill issued by the Apollo Hospitals, Chennai that the total treatment cost was Rs.2,11,826.89 which has not been denied by the opposite parties-Insurance Company. The learned District Forum in fact directed the opposite parties to pay Rs.1,60,812/- to the complainant for providing services under the Heads as per the inpatient bill namely, Nursing and Hospitals Utilities amounting to Rs.3,500/-, O.T. Charges for Rs.31,810/-, O.T. Consumables for Rs.69,088.75/-, O.T. Pharmacy for Rs.6,914/- and Professional Charges for Rs.49,500/-, but did not allow the other charges like Equipment, Medical Administration and Non Pharmacy Material etc. thus, in fact, the learned District Forum also did not allow the entire actual cost of treatment. Though according to us, the complainant is entitled to get the entire cost of treatment. We are of the opinion that, if surgery like ‘ventral hernia’ is come within the purview of Policy in question, then an insured is entitled to get the actual cost of treatment, but there is no appeal before us by the complainant. Thus, we are not in a position to provide the actual cost of treatment though the father of the complainant was admitted in the hospital from 17.07.2016 to 27.07.2016 for his surgery. For better appreciation of the impugned judgment it would be proper for us to reproduce the findings of the learned District Forum which are as follows:-

“           We find that the Complainant has filed the complaint against the O.P. LICI alleging that the O.Ps have without any justifiable reasons have refused to satisfy fully the cost of medical treatment of her father who had under gone Ventral Hernia Surgery at Apollo Hospitals, Chennai on 18/07/2016. She had actually claimed Rs.2,16,827/- being the cost of the treatment. The O.Ps according to her taking an erroneous view have paid her Rs.17,800/- holding that her claims does not  come  under purview of major surgical benefit rather it comes under Other surgical benefit. According to the Complainant she has furnished her claim papers to the satisfaction of the O.Ps believing that the O.Ps would satisfy are genuine claim fully.

On the other hand, the O.Ps have asserted that regarding the claim of the Complainant the LICI Divisional Dispute Redressal Committee has taken a lenient view and approved the claim as permissible under Other surgical benefit instead of major surgical benefit. According to the O.Ps the surgery which was conducted for the father of the Complainant does not come under major surgical benefit and an such the claim of the Complainant could not be settled fully.

We have carefully gone through the LIC Jeevan Arogya Policy which was purchased by the Complainant in the year 2011. The Complainant till filing of the case has been paid premium regularly. The said policy also having Insurance coverage of the parents of the Complainant apart from the Complainant herself.

We find that the O.Ps did not deny the fact that the father of the Complainant Sri Purnendu Gupta had under gone “Ventral Hernia Surgery” on 18/07/2016 at Apollo Hospitals, Chennai during covered period of the Policy. Sri Gupta had to remain as indoor patient at the Hospital from 17/06/2016 till he was discharged on 22/07/2016. The O.Ps have partly allowed the claim of the Complainant and paid her Rs.17,100/- treating her father's case to have fallen under “other surgical benefit” denying the claim of the Complainant that the surgery is of major surgery one. Admittedly, the Hernia Surgery of the father of the Complainant was performed in the year 2017 which is five years after the date of purchase of the policy. As per the policy, the specific waiting period for getting benefit out of the policy for treatment of Hernia is two years. Moreover, it is on record that the father of the Complainant remained as an indoor patient for 05 days in the Apollo Hospitals for undergoing the surgery. This is a significant aspect to make us understand about the health condition of the father of the Complainant at the Pre-and post operation stages who is also a senior citizen. Having regard to this position we are of the opinion that the Complainant should not be deprived of getting Insurance benefit for the “Ventral Hernia Surgery” which was under taken by her father at the Apollo Hospitals simply on the ground that such a surgery does not find place in the list of major surgical benefit. We find that the O.Ps have only paid Rs.17,100/- to the Complainant for the surgery whereas the claim of the Complainant was Rs.2,16,827/- being the total actual cost of treatment and that too has been supported by cogent evidence produced by the Complainant from the Apollo Hospitals under Exhibit-I series.

After giving thoughtful consideration over the issue and on thorough scrutiny of the inpatient bill vide No.CMH-ICS-99734 dated 22/07/2016 (Exhibit-I series) issued by the Apollo Hospitals in the name of Sri Purnendu Gupta we are of the opinion that ends of justice will prevail if the O.Ps are directed to pay Rs.1,60,812 to the Complainant for providing services under the Heads as per the inpatient bill, namely Nursing and Hospitals utilities amounting to Rs.3,500/-, O.T. Charges for Rs.31,810/-, O.T. Consumables for Rs.69,088.75/-, O.T. Pharmacy for Rs.6,914/-  & Professional charges for Rs.49,500/-. It is made clear that the amount Rs.17,100/- which has already been paid to the Complainant by the O.Ps prior to the filing of the complaint should be deducted from the amount which we have assessed above. So the O.Ps are to pay Rs.1,43,712/- to the Complainant. Apart from this we direct that the O.Ps are to pay Rs.4,000/- to the Complainant as cost of litigation.”

In view of the above, we are of the considered opinion that the learned District Forum did not commit any error thus, no interference is called for.

In the result, the appeal is dismissed being devoid of merit. No order as to costs.

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

 

 

 

 

MEMBER State Commission Tripura

PRESIDENT State Commission Tripura