Complaint filed on: 05.09.2014
Complaint Disposed on:17.12.2016
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AT CHICKMAGALUR.
COMPLAINT NO.93/2014
DATED THIS THE 17th DAY OF DECEMBER 2016
:PRESENT:
HON’BLE SRI RAVISHANKAR, B.A.L, LL.B., - PRESIDENT
HON’BLE SMT B.U.GEETHA, M. COM., LL.B., -MEMBER
HON’BLE SMT H. MANJULA, B.A.L., LL.B., - MEMBER
COMPLAINANT:
Yogish H.C. S/o Chinnappa Shetty,
Aged about 45 years, R/o Bettigere,
Mudigere Taluk, Chikmagaluru Dist.
(By Sri/Smt. L.P.Satish, Advocate)
V/s
OPPONENT:
1. The Branch Manager,
LIC of India, Opposite
Police Station, Belur Road,
Mudigere.
2. Senior Divisional Manager,
LIC of India, Divisional Office,
Jeevan Krishna, Ajjarkadu, Udupi.
(By Sri/Smt. D.K.Lakshmikanth, Advocate)
By Hon’ble President Sri. Ravishankar,
:O R D E R:
The complainant filed this complaint U/s 12 of the Consumer Protection Act 1986 against OP Nos. 1 & 2 alleging deficiency in service in not settling medical claim. Hence, prays for direction against Ops to pay the medical claim amount of Rs.2,03,250/- along with compensation of Rs.50,000/- for deficiency in service.
2. The brief facts of the complaint is that:
The complainant had obtained health insurance policy namely Jeevan Arogya vide policy No.626706022 on 22/08/2012 and he is regularly paying the premium of Rs.10,000/- every year. Such being the case, the complainant suffered health problem and approached KMC Hospital, Mangalore for treatment, where the Doctors revealed that the complainant is suffering from “bilateral epidimy morchitis with cystitis DM” and as per the advice of the Doctors, he was admitted to KMC Hospital as an inpatient on 26/08/2013 and took treatment as an inpatient and discharged on 02/09/2013. After the discharge the complainant still suffering severe pain, again he admitted to the Hospital and discharged on 10/09/2013. Further on 30/01/2014 the complainant again suffered ill-heath; again he hospitalized in the same hospital and discharged on 04/02/2014. During all these hospitalization, the complainant had nearly spent Rs.2,30,000/- towards treatment.
The complainant further submitted that being the beneficiary of the policy, the complainant claimed for reimbursement of the said medical expenses as per the policy. But the Ops have paid only Rs.15,750/- instead of paying the entire medical expenses. Immediately the complainant issued a legal notice dated:23/05/2014 and called upon the Ops to settle the entire claim, for which after service of notice, the Ops have paid another Rs.11,000/-, but have not paid the entire claim amount as per the terms and conditions of the policy. Hence, Ops rendered deficiency in service in not settling the entire claim of the complainant. Hence, the complainant prays for direction against the Ops to settle the claim to the tune of Rs.2,03,200/- along with compensation of Rs.50,000/- for deficiency in service as prayed above.
3. After service of notice the OP appeared through his counsel and filed version and contended that the complainant has filed this false complaint alleging deficiency in service and has not revealed the actual facts of the case. The complainant has taken Jeevan Arogya policy plant No.903 which is nothing but a medi claim type policy. But here as per the terms and conditions two types of payments are made Hospital case benefit (HCB) and Surgikal benefit for the premium paid by the insured payments are made in the following order. HCB is maximum amount payable in respect of hospital admission as opted by the insured. Again in surgical benefit there are two types, one is Major surgical benefit (MSB) and the other is minor surgeries or investigation procedures wherein for minor ailments Day care Procedure benefit upto 5 times the HCB is paid. MSB is for major surgeries as per the conditions of the policy wherein payment upto nearly 100 times the HCB is payable per day. Every year 5% rise will be given to HCB. There is a schedule of ailments which part and parcel of the policy wherein every ailment is categorized and reveals for which ailment or surgeries whether HCB or MSB or Day care benefit is applicable.
The OPs further contended in the instant case the insured had opted to pay premium of Rs.10,000/- per year wherein his HCB per day was maximum Rs.3,000/- for himself, Rs.1000/- each for his wife and daughter. MSB is maximum upto Rs.3,00,000/- for him and Rs.1,00,000/- each to his daughter and wife and Day care benefit is 5 times of HCB i.e. 15,000/- is payable. Admittedly the complainant was suffering from Bilaterial Epidimymorchitis with Cystisis which is nothing but infection and inflammation of the testicles and urinary tract for which he got admitted on 26/08/2013 and after diagnosis he was done Paranatical maropenam Cystiscopy and Trocar SPC which is nothing but investigation of the ailment by inserting necessary tubes with lenses to see the urinary bladder and urethra and removing the unwanted fluids through needles. The above said ailment comes under day care procedures at clause given in the schedule of the policy and as such as per the terms and conditions of the policy he was eligible for Rs.3,000/- X 5 times i.e. 15,000/- and since he taken treatment in the 2nd year of the policy 5% of Rs.3,000/- i.e. 150X5 times so in total Rs.15,750/- was paid to him as per condition No.2(111) of the policy. Again the complainant got admitted from 30.01.2014 for 4 days and since he was just hospitalized and no surgeries were conducted as per the terms of the policy HCB is allowed and he was entitled for Rs.3,000X4 days and since he taken treatment in the 2nd year of the policy 5% of Rs.3,000/- i.e. 150X4 days so in total Rs.12,600/- was paid to him as per condition No.2(1) of the policy.
Hence, as per the policy terms and conditions they have paid eligible amount to the complainant and there is no any deficiency in service on the part of this OP. The question of payment of policy amount does not arise and even they are not liable to pay any compensation for deficiency in service. Hence, prays for dismissal of the complaint.
4. The complainant filed affidavit and marked the documents as Ex.P1 to P7. The OP also filed affidavit and marked the documents as Ex.R1 to R3.
5. Heard the arguments:
6. In the proceedings, the following points do arise for our consideration and decision:
- Whether there is deficiency in service on the part of OPs.
2. Whether complainant entitled for any relief & what Order?
7. Our findings on the above points are as follows:-
- Point No.1: Negative.
- Point No.2: As per Order below.
: R E A S O N S :
POINT NOs. 1 & 2:
8. There is no dispute that the complainant had obtained Jeevan Arogya police vide policy No.626706022 from OP No.1 on 22/08/2012 which is renewed subsequently. There is also no dispute that the complainant was hospitalized at KMC Hospital, Mangalore with a problem of bilateral epidimymorchitis with cystitis DM.
9. The only dispute raised by the complainant is during his hospitalization he spent nearly Rs.2,03,250/- towards his treatment and claimed for the entire reimbursement from OP/Company, for which the Ops had only paid Rs.15,750/- towards settlement of the claim. Immediately he issued a legal notice and after service of the said notice, the OP again had paid only Rs.11,000/- instead of paying the entire amount spent towards medical treatment. Hence, alleges deficiency in service and prays for payment of the entire claim amount along with compensation.
10. On contrary, the OP had taken a contention that the complainant had obtained daily cash benefit for Rs.3,000/- and paid Rs.10,000/- towards annual premium. As such the complainant has underwent treatment for bilateral epidimymorchitis with cystitis DM. The said ailment comes within the day care procedure benefits annexure. Any operations and surgeries towards the urinary track or testicles comes within the day care surgeries and accordingly they have counted the days of hospitalization and paid an amount of Rs.3,000/- per day to the complainant. Hence, submits no deficiency in service.
11. On going through the proposal form produced by OP which marked as Ex.R2, we noticed that the complainant definitely had obtained for payment of initial daily cash benefits for Rs.3,000/- and admittedly he paid a premium of Rs.10,000/- per year towards policy. As per the policy terms and conditions, we noticed that any benefits under Clause-I if any person undergoes a specified day care procedures as mentioned in the item No.112, 113, 114, 121, 122, 123, the complainant has underwent the said surgery at KMC Hospital, Mangalore. The said surgery was revealed in the discharge summary as per Ex.P5. Accordingly after verifying the said policy terms and conditions, the OP No.1 paid Rs.15,000/- for the first year benefit towards inpatient from 28/03/2013 to 02/09/2013. Further, again the complainant admitted to the hospital on 02/09/2013 to 10/09/2013 and thereafter again he admitted to the hospital on 30/01/2014 to 04/02/2014. Accordingly, the complainant was paid in the first year Rs.15,000/-, in the second year Rs.15,750/- and again for four days he was paid Rs.12,600/-. Hence, we found there is no any deficiency in service on the part of Ops in paying the daily cash benefits as per the policy.
12. The OP in his version has stated that they have already paid the said amounts to the complainant. If not paid, they are liable to pay the said amount to the complainant. Anyhow the complainant failed to establish a deficiency in service on the part of OP. Apart from that he failed to establish that he is entitled to get the entire medical expenses from OP. As such for the above said reasons, we answer the above points accordingly and proceed to pass the following:-
: O R D E R :
- The complaint filed by the complainant is hereby dismissed. No order as to costs.
- Send free copies of this order to both the parties.
(Dictated to the Stenographer transcribed typed by him, transcript corrected by me and then pronounced in Open Court on this the 17th day of December 2016).
(B.U.GEETHA) (H. MANJULA) (RAVISHANKAR)
Member Member President
ANNEXURES
Documents produced on behalf of the complainant:
Ex. P1 - Jeevan Arogya LIC policy
Ex.P2 - Office copy of the legal notice issued by OP2
Ex.P3&4 - Two postal due
Ex.P5 - Discharge summary issued by KMC Hospital, Mangalore
Ex.P6 - Hospital bills
Ex.P7 - Letter issued by Family Health Plan(TPA Ltd) Dt:15.01.13.
Documents produced on behalf of the OPs:
Ex. R1 - Authorization letter
Ex. R2 - Copy of the proposal submitted by complainant
Ex. R3 - Copy of the dis-charge summary
Dated:17.12.2016 President
District Consumer Forum,
Chikmagalur.
Tss
