Tripura

StateCommission

A/39/2016

Life Insurance Corporation Of India, Agartala Branch-1 - Complainant(s)

Versus

Sri. Kajal Das Roy - Opp.Party(s)

Mr. Nepal Majumdar

22 Mar 2017

ORDER

State Consumer Disputes Redressal Commission, Tripura.

 

 

 

Case No.A.39.2016

 

 

 

1. Life Insurance Corporation of India Ltd.,

Agartala Branch No.1,

Paradise Chowmuhani, Hospital Road Extension,

P.S. West Agartala,

West Tripura, Agartala.

… … … … Appellant/Opposite Party

 

•  

 

1. Sri Kajal Das Roy,

S/o Lt. Samarendra Das Roy,

West Pratapgarh, P.S. A.D. Nagar,

West Tripura, Agartala.

 

… … … … 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 Appellant: Mr. Nepal Majumder, Adv.

For the Respondent: Mr. Amrit Lal Saha, Adv. & Mr. Kajal Nandi, Adv.

Date of Hearing: 11.01.2017 & 22.03.2017.  

Date of Delivery of Judgment: 22.03.2017.

 

 

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

 

 

U.B. Saha,J,

This appeal filed by the appellant Life Insurance Corporation of India Ltd. under Section 15 of the Consumers Protection Act, 1986 is directed against the judgment dated 09.08.2016 passed by the Ld. District Consumers Disputes Redressal Forum, West Tripura, Agartala (hereinafter referred to as District Forum), in Case No.CC-31 of 2016 whereby and whereunder the Ld. District Forum allowed the benefits of treatment cost amounting to Rs.50,000/- to the respondent-complainant and also an amount of Rs.10,000/- as compensation and Rs.5,000/- towards cost of litigation. The aforesaid amount is to be paid within two months from the date of judgment, if not paid, it will carry interest @9% per annum.

2. Heard Mr. Nepal Majumder, Ld. Advocate appearing for the appellant Life Insurance Corporation of India Ltd. as well as Mr. Kajal Nandi, Ld. Advocate appearing for the respondent-complainant.
3. The facts are not in dispute that the respondent-complainant (hereinafter referred to as complainant) purchased one Health Policy, ‘Jeevan Arogya’ from the appellant-opposite party, the Life Insurance Corporation of India Ltd. (hereinafter referred to as LIC/Insurance Company/opposite party) having its Branch at Agartala. Policy was valid from 16.05.2013 to 16.05.2044. Annual premium of Rs.3,578.97 was paid. After purchasing the policy, the complainant suffered pain in his abdomen and went to ILS Hospital at Agartala. In the said hospital, while he was treated, gallbladder stone was detected and by way of surgery, stone found in the gallbladder was removed. Total charge for his treatment was Rs.50,000/-. Then the complainant claimed the said amount from the opposite party, but the opposite party, LIC refused to accept the claim of the complainant and informed him that, to get the benefit of the ‘Jeevan Arogya Policy’, he will have to wait for two years as per conditions and privileges of the LIC for ‘Jeevan Arogya Policy’. The condition of the LIC 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 party LIC, the complainant has submitted a complaint petition under section 12 of the Consumers Protection Act, 1986 before the Ld. District Forum claiming the benefits of the policy, the treatment costs as well as compensation for deficiency in service.
4. The opposite party LIC filed their written statement denying the claim of the complainant on the ground that as per terms of the treatment, 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 the two years from the date of commencement of the policy. It is also contended in the written statement that even if a policyholder went for surgery of his gallbladder after two years of purchasing the policy, then also he will be entitled 40% of the cost of the treatment, not the entire amount as ‘Jeevan Arogya Policy’ is not a policy for medical reimbursement, but for major surgical treatment, benefits categorized in the policy itself and surgery of gallbladder stones falls under Category-3 and 40% of Medical Surgical Benefit (MSB). The sum assured is payable fulfilling the terms and conditions as mentioned.
5. On the basis of the pleadings and evidence adduced by the parties, the Ld. District Forum decided the complaint petition on the following points:-

1. Whether the terms and conditions of the policy put a bar to claim the treatment cost and compensation.
2. Whether the petitioner is entitled to get treatment cost and compensation.

6. In the instant case, it is the admitted fact that the complainant was admitted in the ILS hospital, Agartala and had gone for surgery on 07.09.2014 and he was discharged from the said hospital on 09.09.2014. It is also admitted position that the cost of treatment was Rs.50,000/- in total. Furthermore, that a person obtained ‘Jeevan Arogya Policy’ is entitled to get Hospital Cash Benefit and the cost of the treatment as mentioned in the Category-3 of the Conditions and Privileges in respect of ‘Jeevan Arogya Policy’.
7. The Ld. District Forum in its findings has specifically stated that the terms and conditions is to be strictly followed and no benefit can be extended beyond the terms and conditions, but the question is whether the terms and conditions were projected before the policyholder while he purchased the policy and held that such terms and conditions were not projected to the policyholder before the policy was purchased and finally, allowed the claim of the complainant as stated (supra). Hence the appeal.
8. The instant appeal was partly heard on 11.01.2017 and the matter was fixed for further hearing on 28.01.2017. On 28.01.2017, none appears for the complainant and again the matter was adjourned and fixed for hearing on 25.02.2017, but on that date also, none appears for the complainant. Today the matter is taken up for hearing in presence of the Ld. Counsel of the parties.
9. Mr. Majumder, Ld. Advocate relying upon the conditions and privileges of ‘Jeevan Arogya Policy’ would contend that the complainant is not entitled to any benefits under the policy within the period of two years i.e. the waiting period for treatment of gallbladder stones. He further submits that even if a person went for surgery of cholecystectomy of gallbladder, he will be entitled to 40% of the Major Surgical Benefit under Category-3 of the ‘Jeevan Arogya Policy’. He has finally contended that the complainant could have withdrawn his proposal within the cooling period i.e. 15 days from the date of receipt of the Policy and Conditions & Privileges of the Health Insurance Policy, but in the instant case, he did not withdraw himself within the ‘Cooling Period’ of 15 days.
10. On the other hand, Mr. Nandi, Ld. Advocate while supporting the judgment of the District Forum has submitted that in the proposal form there is nothing about such terms and conditions. He has also submitted that in the said policy there is nothing that the benefits will be available in case of treatment after two years of commencement of the policy. He has finally contended that the Ld. District Forum rightly mentioned in its findings that the terms and conditions were not projected to the complainant while purchasing the policy. He has also relied upon the Paragraph-10 and 11 of the impugned judgment which are as under:-

“10: In this case, the only point is in respect of fulfillment of terms and conditions in respect of waiting period. The date of sending of ‘welcome kit’ to the petitioner, date of receipt by him and opportunity to exit from the policy not clearly comes out from the evidence of the O.P. There is nothing before us to support that sufficient time and opportunity was given to the petitioner to exit from the policy if not satisfied with the terms and conditions. The terms and conditions were not projected to him while purchasing the policy. Such proposal also not given. Generally, the waiting period is written 90 days from the date of commencement in respect of each policy. Again, specific waiting period given for specific disease which is contradictory with the general waiting period. This terms and conditions is not statute. It is one sided and not signed by the petitioner after understanding the same.

11:  Waiting period as written not satisfactorily explained to the petitioner. The process of exit from the policy not disclosed while giving proposal. In the ‘welcome kit’, the condition and privileges were written in a microscopic alphabet illegible and cannot be read over by naked eyes. Learned Advocate for the petitioner argued that the petitioner was not aware about such terms and conditions at any point of time. He paid the premium 2 times and was under the impression that he was covered by the policy. The matter of waiting period was disclosed to him only when he placed the claim before the LIC. This was shocking and it was deficiency of service by the LIC.”

11. We have gone through the submission of Ld. Advocates appearing for the parties as well as the evidence on record and the findings in the impugned judgment. In our considered view, the only questions arise for decision are (i) whether any assured has to be waited for two years for getting the benefits of the policy as per the waiting period mentioned in Condition No.6 in the LIC’s Jeevan Arogya Conditions & Privileges, wherein, it is stated that for treatment of gallstones, the specific period shall be two years from the date cover commencement in respect of each insured and (ii) whether an assured is entitled to get the entire treatment costs as allowed by the Ld. District Forum.
12. In the Affidavit-in-Chief of the complainant, he has specifically stated that the opposite party never informed him about any such conditions at the time of taking the policy. He has also stated that in the Proposal Form also, there is no mention about the waiting period. In his cross-examination, he has stated that he did not make his claim within the specified time, but prayed for extension of time, which was allowed by the Insurance Company. In the Affidavit-in-Chief, the O.P.W.1 Manager (Administration), LIC of India, Agartala has stated that the complainant accepted the terms and conditions of the policy issued to him on receipt of the policy bond with enclosed booklet of “Conditions & Privileges” under “Jeevan Arogya” (T-903) which was sent to the policyholder along with the policy document as “Welcome Kit”, but in his cross-examination, the Manager (Administration), LIC the O.P.W.1 has specifically stated that he does not know about ‘welcome kit’. It is also stated that in the Proposal Form it is not written that the benefits of the policy will take effect after two years. There was no evidence before the District Forum that the ‘welcome kit’ was sent along with Policy Certificate wherein the ‘Conditions & Privileges’ regarding the ‘Jeevan Arogya Policy’ were mentioned.
13. Mr. Majumder, Ld. Counsel for the appellant Insurance Company has placed the photocopy of the relevant page of one Receipt and Dispatch Register before us to show that the complainant had received the ‘Conditions & Privileges’ along with Insurance Policy Certificate. Though the said Receipt and Dispatch Register is not the part of the evidence, but we have gone through the same, from which it appears that the health policy of claim for insurance and the booklet was received by the complainant Kajal Das Roy on 19.07.2013. In case, the terms and conditions of the policy were not acceptable to the complainant then he could have asked for cancellation of the same during the cooling period of 15 days from the date of receipt of the policy document, but in the instant case, he did not exercise his option during the said ‘cooling period’, meaning thereby, he had accepted the terms and conditions. It is very difficult for us to accept the observation of the Ld. District Forum that the terms and conditions were not projected to the complainant and that regarding waiting period also, he was not informed. It is not the case of the complainant that he did not receive the Policy Certificate, rather the said Policy Certificate was submitted by him before the District Forum. On the overleaf of the said Policy Certificate, it is specifically mentioned that “This ‘welcome kit’ contains your Policy Bond, Conditions & Privileges under your Jeevan Arogya 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).” The petitioner in his letter dated 06.09.2014 addressed to the Branch Manager, Health Insurance Plans, Agartala attached his Health Card.
14. In Ekjot Singh Vs E-Meditek Solution Limited and Life Insurance Corporation of India, the National Consumer Disputes Redressal Commission (hereinafter referred to as National Commission) has decided almost a similar issue. In that case, the complainant-petitioner purchased LIC Health Plus Plan for which half-yearly premium of Rs.14,250/- was to be paid by him and the complainant paid premiums regularly for three years from the date of commencement of the Policy in question. After receiving the policy bond, Third Party Administrator booklet and Health Card on 28.04.2011, the complainant suffered severe pain in his chest and was admitted to Inscol Hospital, Sector 34-A, Chandigarh, where the doctor diagnosed that he had suffered from heart attack and advised for angiography. The results of angiography revealed that one of the arteries of the complainant was blocked and required to be stented. The complainant was operated upon by a team of Doctors and PTCA + Stent to RCA was done. After his discharge, he lodged claim with the E-Meditek Solution Limited for reimbursement of an amount of Rs.2,14,470/- spent by him on his treatment along with all the requisite documents. The E-Meditek Solution Limited repudiated the claim and thereafter the complainant filed the complaint before the District Forum. E-Meditek Solution Limited the Opposite Party No.1 therein did not appear and thus the claim case proceeded ex parte against the said Opposite Party No.1. The Opposite Party No.2 Life Insurance Corporation of India resisted the complaint and submitted that the complaint was not maintainable, as complainant concealed the material facts while filing complaint. It was also contended that the complainant was supplied the Welcome Kit containing the Policy document and the terms and conditions thereof. It was further contended that in case, the terms and conditions of the Policy were not acceptable to the complainant, he could have asked for cancellation of the same, during the “Cooling-off Period” of 15 days from the date of receipt of the Policy document like the case in hand. It was further stated that the parties were bound by the terms and conditions of the Policy and since claim of the complainant did not fall within the definition of terms and conditions of the policy, the same was legally and validly repudiated. The Ld. District Forum allowed the claim of the complainant in that case. The judgment of the District Forum was challenged by the Opposite Party no.2. It has filed an appeal before the State Commission, Chandigarh and the State Commission of Chandigarh after hearing the parties allowed the appeal and dismissed the complaint petition. Against the said judgment of the State Commission, Chandigarh, the complainant has preferred a Revision Petition before the National Commission. Before the National Commission, Ld. Counsel for the petitioner submitted that as the terms and conditions of the policy were not supplied to him, District Forum rightly allowed the complaint and the Ld. State Commission has committed error in allowing the appeal. On the other hand, Ld. Counsel for the Opposite Party No.2 Insurance Company has contended that the order passed by the Ld. State Commission is in accordance with law, hence, Revision Petition be dismissed. The National Commission dismissed the Revision Petition stating that Ld. State Commission rightly observed that as admitted by the complainant, the complainant was supplied policy bond, TPA booklet and health card. It is also noted by the National Commission that as per exclusion clauses embodied in conditions and privileges of policy, complainant was required to be hospitalized for more than 48 hrs. and complainant was entitled to 40% of the expenses incurred in treatment only after two or more coronary arteries were stented. Admittedly, in that case, complainant’s hospitalization was for less than 48 hrs. as per discharge summary and two or more coronary arteries were not stented so, complainant was not entitled to even 40% of the expenditure incurred in the treatment.
15. In the instant case also, admittedly, the complainant was admitted in the ILS Hospital and his surgery of gallbladder was done before completion of the waiting period. According to the terms and conditions, if a policyholder went for surgery of his gallbladder after two years i.e. the completion of waiting period, then only he will be entitled not the whole amount of expenditure for his medical treatment, but 40% only of the expenditure. As we are satisfied from the evidence of the Insurance Company, from the O.P.W.1 particularly, his Affidavit-in-Chief wherein it is specifically mentioned that the petitioner accepted the terms and conditions of the policy issued to him on receipt of the policy bond with enclosed booklet of “the Conditions & Privileges” under “Jeevan Arogya” (T-903) (Annexure-R/1) which was sent to him along with the policy document as “Welcome Kit”.
16. In support of the aforesaid contention, Mr. Majumder, Ld. Counsel has placed the Receipt and Dispatch Register maintained by the appellant-Insurance Company regarding receipt and dispatch of the Policy Certificate along with the Booklet which was also received by the complainant, the respondent herein.  
17. It also appears from the Proposal Form that the complainant-policyholder is a Sub-Inspector of Police by profession and it cannot be said that he was not aware regarding the terms and conditions of the Policy received by him along with Policy Certificate on 19.07.2013.
18. We are unable to accept the findings of the District Forum, inter alia, that terms and conditions of Policy were not explained to the complainant by the opposite party Insurance Company. Complainant is not an ordinary person, but a Sub-Inspector who can easily go through the policy certificate wherein it is specifically mentioned regarding “Welcome Kit”.
19. It would not be proper on our part to disbelieve the said official Receipt and Dispatch Register maintained by the appellant-Insurance Company as in the said Register, the signature of the complainant is also available.

In view of the judgment passed by the National Commission in Ekjot Singh (supra), we are unable to accept the impugned judgment passed by the Ld. District Forum whereby and whereunder the Ld. District Forum allowed the claim of the respondent-complainant. Accordingly, the same is set aside. In the result, the appeal is allowed and the complaint is dismissed.

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

 

 

MEMBER State Commission Tripura MEMBER State Commission Tripura PRESIDENT State Commission Tripura