Orissa

Rayagada

CC/154/2015

Dr. Abani Kumar Mohapatro - Complainant(s)

Versus

The Branch Manager, LIC of India - Opp.Party(s)

Self

11 Jul 2016

ORDER

DISTRICT   CONSUMER  DISPUTES REDRESSAL    FORUM, RAYAGADA

                                           C.C. Case  No.154/ 2015.

P R E S E N T .

Sri Pradeep Kumar Dash, LL.B,                             President.

Sri Gadadhara Sahu,B.Sc.                                     Member

            Dr.AbaniKumar Mohapatro, S/o late Dr.Seetaram Mohapatro,aged  57years,          Lecturer, Gunupur College, At/Po Gunupur, Dist. Rayagada.                                                                                                                   ………….Complainant

                                                            Vrs.

1. The Branch Manager, LIC of India, Rayagada Branch Office,At/Po/Dist.Rayagada.
2. Senior Divisional Manager, Health Insurance, L.I.C Division Office, Khodasingi, At/Po Berhampur, Dist. Gangam.

 

                                                                                          …….…..Opp.Party

Counsel for the parties:

For the complainant: Sri N.K.Das,Advocate,Rayagada.

For the O.P : Sri S.Chowdhury & Associate Advocate, Rayagada.

 

                                                                JUDGMENT

The  facts of the complainant is that  the  complainant with his wife and son have taken  a Health Protection Plus Plan from the Ops vide Policy No.572993883 commenced from 31.3.2010  and the sum assured is Rs.2,00,000/-  and the yearly installment is Rs.20,000/-  and the first installment of  the premium was paid on 31.10.2010  and regularly paying the premium from the date of commencement of the policy and till now he has paid six installments.  All of a sudden in the month of May,2014 the complainant developed small ulceration on the left side  of his tongue  and he went to Tata Memorial Hospital,  Mumbai and got checked up who detected that it is cancer and advised the complainant for surgery   and the complainant  went to Tata Cancer Hospital  and got admitted and was operated  and discharged on  and the complainant spent  aboutRs.1,21,956/- for treatment at Mumbai and after return he intimated his fact to the OP 1 and requested to  send necessary papers for submitting his claim and thereafter as per the advice of the  doctor the complainant  joined  at Bangalore hospital for chemo therapy treatment and spent Rs.1,57,150/-  and the complainant submitted all the necessary documents  along with the treatment papers. Thereafter the OP 2 asked  to submit the certificate  from treatment doctor and the complainant immediately submitted the said papers to the OP 2  through Regd. Post . There after  the complainant received a letter from the Op 2  intimating that the Ops has repudiated the claim of the complainant on the ground that the complainant is a chronic tobacco chewer since 25 years  and gutuka  since two users  and the same was not disclosed during the policy inception.  The Op 2 has summarily rejected the claim of the complainant  in a mechanical and arbitrary manner. Hence prayed to  direct the Ops  pay the claim amount of Rs.2,00,000/-  along with interest and compensation for mental agony and cost of litigation .Hence, this complaint.

The O.Ps appeared through their learned counsel and file counter inter alia denying the petition allegations on all its material particulars.  It is submitted by the Ops that the  Policy No.572993883 was commenced on31.3.2010   with sum assured Rs.2,00,000/- . On receipt of intimation along with duly filled  forms the OPO forwarded all the papers to the Third Party Administrator, Health Plan, Hyderabad and the TPA  called for treating doctor  certificate  and the OP received the requirements on 16.02.15 and forwarded the same to the TPA.  Basing on the various records and documents submitted by the complainant  he was a chronic tobacco chewer since 31 years and guttka since two years  and the same was not disclosed in the proposal form and the complainant himself has mentioned  in the history details  of the prescription. The objected the claim on the grounds of pre existing disease  and for non disclosure of material facts at the time of submission of proposal form. The OP also informed in the  same repudiation letter that in case the complainant is not satisfied with the decision of the OP he can represent the Zonal Manager, LIC of India, Patna for reconsideration but he fails to do so.  The complainant has not availed our other Grievance Redressal Mechanisms  and directly filed the case to mislead the honorable forum. Hence, prayed to drop the complaint petition in the interest of justice.

                                          F I N D I N G S

                         We have gone through the averments made by the respective parties and come to  the conclusion as such. Now the issue to be decided by this forum.

1.         Whether the present dispute can be disposed of by this forum ?

2.         Whether the Ops have committed any deficiency in service and payment of          insurance to the complainant in time ?

3.         Whether the complainant  is entitled  to get any relief , if so, to what extent ?

 

Issue No.1

It is stated by the Ops that admittedly the Ops repudiated the claim of the complainant  basing on various records and documents submitted by the complainant. They also stated that the complainant was a chronic tobacco chewer. The Ops  also informed in the repudiation letter, if the complainant is not satisfied with the decision of the OP, he can represent the zonal Manager, LIC of India, Patna for  reconside5ation. The complainant has not availed our other grievance redressal mechanism and directly filed the case to  mislead  the forum and submitted that the present complaint is not maintainable.

                        On the other hand the advocate for the complainant argued that as the consumer protection act is a benevolent legislation and as an additional remedy available to the consumers, as such as per Sec.3 of the C.P.Act,1986  the complaint is maintainable . Sec.3  of the C.P.Act provides additional remedy in addition to the remedies provided  under other Acts and it is not in derogation of any provisions of any law. The Consumer Forum  has therefore  jurisdiction to entertain this complaint. Hence, in view of the above submission of the complainant, it is concluded that the case of the complainant would fall within the scope and am bit of the service 2(o)  of the C.P.Act which provides  that service means service of any description which is made available to potential (users and includes but not limited to, the  provision of) facilities in connection with ban king and financing. Hence, the complainant is a consumer and the present dispute can be disposed of by this forum.

Issue No.2

            It is the case of the complainant that the complainant is a policy holder of Health Protection Plan from the Ops vide Policy No.572993883 commenced from 31.03.2010 and it was valid till today.  All of sudden in the month of May,2014 the     complainant developed small ulceration on the left side of his tongue and he went to Tata Memorial  Hospital, Mumbai. There after  as per the suggestion of the doctor the complainant  joined  Bangalore for chemo therapy treatment and spent Rs.1,57,150/-  and the complainant submitted all the necessary documents along with the treatment papers. Thereafter the complainant  received a letter from the OP 2 intimating that the Ops has repudiated the claim on the ground that the complainant is a chronic tobacco chewer since 25 years and ghutuka since two years  and  the same was not disclosed during the policy inception.

                        The Learned advocate for the complainant has filed the case reported in 2008(I) C.P.R (N.C) 52 –The insurance is a contract between the insured and the insurer so the parties are governed by the terms of contract i.e. terms of the policy but for the third party the liability is statutory to pay the amount to the third party with liberty to claim   refund from the insured or on establishing any breach of the terms of the policy by them.

                        Claim for reimbursement can be repudiated in case where breach of condition of the policy is fundamental on material.

                        In case breach is irregular or merely contributory there is provision for settlement as non standard according to the guidelines.

                        Further, the complainant filed the case reported in 2007 (II) OLR (CSR) 70 Where it is stated that Consumer Protection Act,1986 – Medi Claim- Repudiation of the claim on the ground that the complainant was suffering from the decease prior to the commencement of the policy which was not disclosed at the time of making the policy any of the family members had prior knowledge of the decease of  cancer for which  he was treated- ground of repudiation is untenable. It is also stated in our own State Commission decision in C.D. Appeal No.2127220 of 2000 from order dated 15.04.2000 that “ whether the husband of the claimant suppressed material facts with regard to his health condition in the  proposed form- In appeal the Commission held there was no suppression”.

                        Hence, in view of the above decision and other decisions of the apex court the Issue No.2 is answered. The Ops ;have no right to  reject the claim of the complainant in a mechanical  and arbitrary manner  that the claim on the grounds of pre existing  disease and for non disclosure of material facts at the time of submission of proposal form.

Issue No.3

                        Admittedly the OP 1 & 2 are the statutory authority and who has to settle the claim are responsible for the case. We perused the case law in the  instant case. It is held and reported in CPR 1991,Page 540 the Hon’ble Haryana State Commission held that  whenever there is any delay on dilatoriness in finalizing the insurance claim, the same would be tantamount to a deficiency in service and  this comes squarely within the provisions of Consumer Forum.  It is held that default or negligence in the settlement of an insurance claim is a deficiency in service than an arbitrary on mischievous rejection of an insurance claim would  patently be a default within its larger meaning.

                        We have gone through the complaint petition and documents available in the record. This forum by relying upon a citation passed by national Commission, New Delhi in the New India Assurance Co. Ltd. Vrs. M/s Snkhadham India Pvt. Ltd.,2011 (I) CPR 191  “ Insurance  Company must settle claim without delay”. In the light of the above  decision of law we allow the case. Hence, it is order.

                                                            ORDER

                        In the result the complaint petition is allowed on contest. We directed  the O.P to  pay the claim Insurance  amount   of policy No.572993883     with 10 % interest to the complainant  from the date of claim with    compensation of Rs.4,000/-  for mental agony and harassment.

                        The O.Ps are directed to make the aforesaid payment within 30 days from the date of receipt of this order failing which the complainant is at liberty to receive penal interest  @ 12% and to  take further proceeding U/s 25 and 27 of the C.P.Act.

            Pronounced in open forum today on this  19^th of  December,2016 under the seal and signature of this forum.

                         A copy of this order as per the statutory requirements , be forwarded to the parties    free of charge.

 

 

             Member                                                                        President