DATE OF FILING                    :     10.03.2014.

DATE OF S/R                            :      21.04.2014.

DATE OF FINAL ORDER      :     06.07.2015.

Sri Shekhar Srimani,

son of late Lakshmi Kanta Srimani,

residing at village & P.O. Makardaha, P.S. Domjur,

District Howrah,

PIN 711409.  ………………………………………………………… COMPLAINANT.

• Versus -

   

  1. The Branch Manager,

     L.I.C.I., Domjur Branch,

     Village & P.O. South Jhapardaha, P.S. Domjur,

     District  Howrah,

     PIN   711405.

2. The Sr. Divisional Manager,

L.I.C.I., Howrah Division,

Office at Rallis Building,

16, Hare Street,

Kolkata 1.  …………………………………………….……OPPOSITE PARTIES.

                                                P    R    E     S    E    N     T

             Hon’ble President  :   Shri  B. D.  Nanda,  M.A. ( double ), L.L.M., WBHJS.

                               Hon’ble Member      :      Smt. Jhumki Saha.

                                Hon’ble Member       : Shri A.K. Pathak.      

                                                 F  I   N   A    L       O    R   D    E     R

1. This is an application U/S 12 of the C.P. Act, 1986 filed by the petitioner Shekhar Srimani against Branch Manager, LICI, Domjur Branch and another praying for a direction on the o.p. LICI to pay the balance amount of Rs. 47,000/- as medical assistance to the petitioner and to pay interest @ 12% till realization.   

2. The case of the complainant is that he is a policy holder of LICI Health Plus Plan being a policy no. 497803909 dated 20.6.2009 covering three members of his family namely himself and his wife and one child for a sum of  Rs. 1 lakh and deposited premium of Rs. 10,000/- since 2009 to 2013 per year i.e., for five years. His wife  Smt. Moumita Srimani  became seriously ill and admitted at  Aragya Niketan Nursing Home, Howrah, on 03.7.2013 and she underwent a surgical operation on 11.7.2013 and cost of such operation was Rs. 50,000/-. The petitioner applied before LICI but the o.p. by their letter dated 20.8.2013 told that he is entitled to only Rs. 3,600/- and being dissatisfied with the same he filed an appeal before Senior Divisional Manager, LICI, Howrah, claiming rest amount of  Rs. 47,000/- but  o.ps. did not pay any heed. Being frustrated and finding no other alternative complainant filed this complaint with the aforesaid prayer.  Hence the case.    

3. The o.ps., LICI, contested the case denying the material allegations made in the claim petition and submitted that as per terms and conditions of the policy the petitioner for a policy of 1 lac is entitled to initially daily hospital cash benefit of Rs. 500/- and thus they paid Rs. 3,600/-. They could not pay any thing for the surgery because such surgery was not part of the list ofsurgeries. The o.ps. have further submitted that they paid the money as per terms and conditions of the policy and thus the claim against them be dismissed.

4.         On the above  pleadings of  parties the following  points arose for determination :

1. Is the case maintainable in its present form ?

2. Whether the petitioner has any cause of action to file the case ?

3. Whether there is any deficiency in service on the part of the O.P. ?

4. Whether the complainant is entitled to get any relief as prayed for ?

   DECISION  WITH   REASONS      :

5. All the issues are taken up together for the sake of convenience and brevity for discussion and to skip of reiteration.  The petitioner filed this case praying for a direction on the o.ps.,  LICI, to pay a sum of Rs. 47,000/- as medical assistance as per the LICI Health Plus Plan to which he is a policy holder for himself, his  wife and child and his wife underwent a surgical operation wherein he incurred an expenses of Rs. 50,000/- and the LICI simply paid him Rs. 3,600/- and so he prayed for the rest sum.

6. The O.ps, LICI,denied the claimed of the petitioner stating that in the said claim he was entitled to Rs. 3,600/- only as is mentioned in the policy condition itself. As per the policy the benefit payable is  mainly consisted on two parts namely hospital cash benefit @ Rs. 500/- per day initially and major surgical benefit to the tune of Rs. 1 lac and it covers three months. In the policy condition there are mentioned of the names of 49 diseases covered under the policy and the surgery involved in the present case was not part of the list of surgery for which major surgical benefit is sought for her. So there is no question of granting major surgical benefit. The petitioner here is only entitled to daily hospital cash benefit to the tune of  Rs. 500/- and also entitled to an increase of 5% benefit of the initial daily cash benefit after every policy year i.e., from 2009 to 2013. The hospital cash benefit amounted to  Rs. 600/- per day  and for six days’  hospital expenses the petitioner was entitled to Rs. 3,600/- only and major surgical benefit could not be awarded to the petitioner as per the terms and conditions of the policy.

7. This Forum scrutinizes the cases of the parties, the documents deposited and the submissions of the ld. counsels and keeping in mind the present position of law it is noticed from the LICI Health Plus Plan that the kit contents a policy bond wherein conditions and privileges under the health plus policy are mentioned.

8. In the instant case the wife of the petitioner underwent a surgical operation for removal of ovarian cyst ands uch major surgical operation was not mentioned in the list of surgical procedures which was annexed with the terms and conditions of the Health Plus Policy and thus they rightly allowed her claim to the extent of Rs. 3,600/- in his favour and denied the rest.

9. This Forum scrutinizes the list of surgical procedures mentioned along with the terms and conditions of the Health Plus Policy and there is no mention of surgical procedures of removal of ovarian cyst for which the petitioner is entitled to reimbursement of the expenses incurred by the petitioner in the form of indemnification of the expenses.

10. The medi- claim insurance scheme is also in the form of an insurance policy wherein the insurance company reimburse the medical expenses of the policy holder during the policy period as mentioned in the policy document. Contract of insurance is basically governed by the rule which formed the part of general law of contract. In the contract of insurance one already agrees to pay or indemnify the loss that would be sustained by the other party.The first party is bound to pay money to the second party in the event of occurrence of uncertain event and the other party is known as the insured and the party which indemnifies the insured is known as the insurer. Generally contract of insurance being a contract of indemnity is governed by the terms and conditions of the policy document which is signed by both the parties namely insured and the insurer and they cannot go beyond the terms and conditions mentioned in the policy.

11. On scrutiny of the policy document in the instant case this Forum finds that in the Health Plus Scheme there was no mentioned of any surgical procedure namely removal of ovarian cyst in the list of surgical procedures.Thus this Forum cannot compel the o.p. LICI, to indemnify the expenses incurred by the partie in the operation of wife of the petitioner as there is no mention in the policy document for such surgical procedure.

     In view of above discussion and findings, the claim case fails.

     Court fee paid is correct. 

      Hence,

                                    O     R     D      E      R      E        D

      That the C. C. Case No. 130 of 2014 ( HDF 130 of 2014 )  be  and the same is dismissed  on contest without  costs.  

      Supply the copies of the order to the parties, as per rule.      

DICTATED  &    CORRECTED

BY   ME.  

  (  B.D. Nanda  )                                                         

  President,  C.D.R.F.,

  Howrah.