Sri A.K.Patra,President

1. The captioned consumer complaint is filed by the complainant named above inter alia alleging that, the Ops falsely represent and spread a misleading message regarding benefit under “Jeevan Arogya” plan but in practice unscrupulously exploited the consumer/complainant and deficient in respect of settlement of genuine medi-claim of the complainant at peril and arbitrarily repudiated the claim of the complainant causing financial loss and mental agony to the complainant/insured.
2. Peruse the material on record. We have our thoughtful consideration on the submission of learned counsel both the  parties.
3.  The complainant seek for the following relief:-

(i)The Ops shall be held guilty in account of adopting unfair trade practice and unscrupulously exploit the complainant as well as the service of the Ops are deficient in respect of sale of insurance policy and settlement of claim.

(iv) The Ops shall be directed to pay Rs.35, 000/- to the complainant for mental agony and physical pain and litigation cost of Rs.10,000/- in this case.

(v) Hon’ble Forum may pass any other relief(s)/order(s) according to the circumstances.

4. Brief fact of the complaint is that, the complainant took a mediclaim policy known as “Jeevan Arogya” of LIC of India being influenced on the message circulated by the LIC of India that, “Jeevan Arogya” is a comprehensive health insurance policy covers self, spouse, children,  parents and parent-in-laws also cover hospitalization, surgery cost and more. He has been paying the yearly premium of Rs.7, 839/- to the Ops. Accordingly insurance policy vide No.574163129 commenced from 28.08.2015 & will be expired on 28.08.2041 is issued to him, copy of which is annexed with the complaint petition as annexure -1. During November 2015 complainant suffered health problem and on the advice of the doctor he undergone for dialysis in a periodical intervals since 20.08.2016. He was admitted in Apollo Hospital, Bhubaneswar on 13.01.2018 for kidney (Renal) Transplant Surgery and discharged from the ICU on 22.01.2018. The complainant intimated the same in writing to the OP 1 vide letter dt.11.1.2018 as annexed with the complaint petition vide annexure-2. The Apollo Hospital, Bhubaneswar authority raised a bill for an amount of Rs.3,08,894/- for the treatment of the complainant and Rs.1,41,743/- for the donor against which a certificate is issued by the Dr. Nishikant Kumar Mohanty of Apollo Hospital which is annexed  as annexure-5 of the complaint petition. Accordingly the complainant submitted his claim before the OP 1 on 7.4.2018 in prescribed form along with relevant documents which was forwarded to the OP- 2 and it was received on 25.4.2018 by the OP 2 /Sr. Divisional Manager, LIC of India, Berhampur  who then pleased to repudiate the claim on 9.7.2018 arbitrarily. Copy of letter of repudiation dt.9.7.2018 is annexed with the complaint petition as annexure-6. Hence this complaint.
5. On being notice the Ops appeared through their Learned Counsel Shri S.K.Panda and filed their written version denying the petition allegation on all its material particulars. However, the insurance policy is not disputed. It is also not disputed that, the complainant has submitted a claim on 7.4.2018 .It is contended that, as per the claim paper received from the complainant it is found that, the complainant was admitted on 13.1.2018 at Apollo Hospital, Bhubaneswar for diagnosis of T2DM, Renal Transplant etc.  The Renal Transplantation and Uretic Re-implantation Boari Flap were done on 16.1.2018. He was discharged on 22.1.2018 from the hospital. A total bill of Rs.3,08,994/-  has been raised  by the hospital for said transplantation and others medical expenses. It is further contended that, the policy was discontinued since 28.8.2016 due to nonpayment of premium dues for 28.08.2016 and 28.08.2017. The policy was revived on 23.12.2017 for the above period. The first unpaid premium was due on 28.8.2016, the policy was revived on 23.12.2017 i.e. after 90 days of first unpaid premium. It is further submitted that, as per Clause-6(2)( b) of the Policy, a general waiting period of 90 days from the date of revival is applicable. The Ops have quoted the said policy clauses-6 which contents the term and condition of the plan as follows:-“As per Clause 6 of policy terms and conditions of this plan” there shall be no general waiting period in case Hospitalization or surgery is due to accidental bodily injury. There shall be a general waiting period during which no benefits shall be payable in the event of hospitalization or survey, if the said hospitalization or surgery occurred due to sickness.

1. The general waiting period shall be 90 days from the date of cover commencement in respect of each insured.

2.If the policy is revived after discontinuance of the cover then the following shall apply in respect of each insured:

(a). If the request for revival is received by the corporation within 90 days from the due date of the first unpaid premium, then there shall be a general waiting period of 45 days from the date of revival in respect of each insured.

(b).If the request for revival is received by the corporation beyond 90 days from the date of the first unpaid premium then there shall be a general waiting period of 90 days from the date of revival in respect of each insured.”

It is further submitted that, the complainant was admitted in the Apollo Hospital on 13.1.2018, undergone Renal Transplantation and Uretic Reimplantation Boari Flap were done on 16.1.2018. He was discharged from the Hospital on 22.1.2018, so it is crystal clear that, the complainant got Renal Transplantation and other treatment well within the waiting period of 90 days from the date of revival of the policy and as such not entitle to get the benefit as per the above stated terms and conditions of the said insurance policy. Hence, claim of the complainant is rightly repudiated and intimated to the complainant on 9.7.2018. There has not been any unfair trade practice and the complainant has not been exploited unscrupulously, moreover, there is no any deficiencyin service on the part of the Ops towards the complainant as such the complaint is liable to be dismissed with cost.

To substantiate their claim the Ops have filed the following documents:-

1. Copy of policy bond “LIC Jeevan Arogya”-contends 16 pages.
2. Xerox copy of proposal form signed by Durbadal Meher.
3. Xerox copy of revival of policy dt.21.12.2017.

6. During hearing of this case, the Learned Counsel for the complainant submitted that, all medical papers in original with other required documents has been sent to the insurer/Ops for which the photocopies of those documents have been filed for kind perusal of this Commission. In this regard the Ops have not disputed. The hospitalization and treatment details of the insured are not disputed by the Ops as such we have no hesitation for consideration of the documents submitted by the complainant for perusal and settlement of the dispute on merits.
7. The Learned Counsel for the Ops placed reliance on the judgment of the Hon’ble National Commission in Rakesh Kumar Sharma vrs.  LIC of India & Anr.(Revision Petition 1633 of 2019) reported in 2020 NCJ 173 (NC) and submitted that, claim under medi claim policy can only be allowed within terms and conditions of the concerned policy. He also draw our attention on the Condition-6 of Annexure-1 (i.e.Policy Condition) of the written version :- Waiting period :-“general waiting period which admittedly contends : As per Clause 6 of policy terms  and conditions of this plan” there shall be no general waiting period in case Hospitalization or surgery is due to accidental bodily injury. There shall be a general waiting period during which no benefits shall be payable in the event of hospitalization or survey, if the said hospitalization or surgery occurred due to sickness.

1. The general waiting period shall be 90 days from the date of cover commencement in respect of each insured.

2. If the policy is revived after discontinuance of the cover then the following shall apply in respect of each insured:

(a). If the request for revival is received by the corporation within 90 days from the due date of the first unpaid premium, then there shall be a general waiting period of 45 days from the date of revival in respect of each insured.

(b). If the request for revival is received by the corporation beyond 90 days from the date of the first unpaid premium then there shall be a general waiting period of 90 days from the date of revival in respect of each insured.

8.   The Learned Counsel for the Ops also draw our attention over the Annexure-3 of the written version which is a photo copy of  standard form meant for revival of the left policy. It is submitted that, the policy was discontinued since 28.8.2016 due to nonpayment of premium due 8/2016 and 8/2017 and the first unpaid premium was due on 28.8.2016.The policy was revised  on 23.12.2017 which is after 90 days of first unpaid premium hence,  as per above clauses 6(2) (b) of the policy, a general waiting period of 90 days from the date of revival is applicable for which the Ops have rightly repudiated the claim of the complainant.
9.   The Learned Counsel for the complainant submitted that, the insurance paper issued by the Ops is of single paper, copy of which is filed along with the complaint as Annexure-1 for perusal. It is further submitted that, no paper containing any terms and condition of the insurance policy is provided by the insurer to the complainant either during commencement of the policy or subsequently at any point of time as such the condition stipulated in any form is not applicable to the complainant. The Learned Counsel for the complainant also draw our attention to the documents vide Annexure-1 of the written version filed by the Ops as per list of document dt.12.07.2022 which is nothing but a standard form of “LIC-Jeevan Arogya(without profit)” remaining blanks , without filling of the required information in the place specified . It also does not contained any endorsement to hold that it is the office copy of the policy details, copy of which, is earlier supplied to the complainant/insured at any point of time. Rather a single paper of policy bond supplied to the complainant is filed as Annexure-1 of the complaint is not disputed which contains no term and condition of the policy. We found force on the submission of Learned Counsel for the complainant.
10.  Admittedly, we are unable to accept the policy term and condition as contended vide Annexure-1 of the written version  is ever supplied to the complainant at any point of time for his reference in absence of cogent evidence in this regards rather a perusal of the policy bond of single page vide Annexure-1 of the complaint petition is not disputed that, there  contains no such term & conditions as claimed by the Ops.

11. The Learned Counsel for the complainant further submitted that, nothing contended in the complaint petition that, the alleged policy was discontinued at any point of time for nonpayment of premium and it was revived on 23.12.23017 i.e. after 90 days of first unpaid premium so as to comes under the Clauses 6(2)(b), a general waiting period of 90 days from the date of revival became  a ground for repudiation of the genuine claim   of the complainant. It is argued that, the Ops have failed to adduce any cogent evidence to prove the these facts contended in their written version that:- the policy was ever discontinued at any point of time for nonpayment of premium and revived later on 23.12.2017. With this submission he urged to discard the said contention of the Ops in want of cogent evidence. We found force on the submission of the Learned Counsel for the complainant as there is no endorsement found under undisputed document i.e. Policy bond vide Annexure-1 of the complaint petition or on the Annexure-1 of the written version of the Ops that, policy was ever discontinued at any point of time for nonpayment of premium and it was revived later on 23.12.2017.

12. Law is well settled that, insurance company cannot escape under the umbrella of so called term & conditions to thwart legitimate & justified claim of insured, if the said term and condition were not supplied to the insured. In the present case there is no iota of evidence as regards to supply of term & condition of the settlement of insurance claim to the complainant. Admittedly the contract of insurance claim is based on utmost bonafied intention of the parties. Both the parties are expected to disclose each other relevant fact at the time of commencement of policy or at the time of revival including the term & condition but not at the peril.
13.  Here in this case the Ops have not placed on record any documents whatsoever that, to establish that the term and condition of the policy  is provided to the complainant either at the time of execution of the policy or any time subsequently .The Opposite Parties have failed to adduce any evidence cogent to prove that, they have supplied the term and condition of the alleged insurance policy at any point of time to the insured/complainant and further failed to prove that, policy was ever discontinued at any point of time & subsequently revived on 23.12.2017. The LIC of India /OPs therefore, cannot escape the liability to indemnify the complainant under the said insurance policy. Repudiation of claim of the complainant vide letter No.9.7.2018 is not proper and found it to be unfair & arbitral certainly caused frustration, financial loss & mental agony to the complainant.
14.  On perusal of the medical papers it is found that, the complainant has spent not less than Rs.3.08.894/- towards his treatment when the alleged insurance policy was in force is not  disputed. It is also not disputed that, required documents for settlement of the claim has already been submitted to the insurer and copies thereof are available in the case record but not settled the claim of the complainant so called term & conditions on the part of insurer/OPs which caused financial loss & mental agony cannot be ruled out as such O.Ps are jointly & severely liable to compensate the complainant.

15.  Based on the above discussion we are of the opinion that, the O.Ps have falsely represents that, they will provide insurance benefit by way of reimbursement of the cost of hospitalization of the complainant but Ops are trying to escape from its liability taking plea of so called term & conditions is certainly an Unfair Trade Practice & deficient in service of the Ops as such the interest of the consumer is to be protected in the sprite of C.P Act 2019.

16. The claim of the insurance benefit as repudiated is found to be arbitrary and illegal certainly caused financial hardship and mental agony to the complainant which cannot be assesses as such, there is sufficient cause of action against the Ops to present this complaint.

17. On being aggrieved upon the  letter of repudiation dt 09.07.2018, this complaint is presented on 30.11.2018 before this Commission i.e  within the jurisdiction where the complainant is reside, as such the complaint is found to be in time, well maintainable under C.P.Act,2019. 

18.  In view of the above discussion we are of the opinion that, repudiation of the claim of the complainant by the Ops is unwarranted and unjustified certainly caused financial loss & mental agony. We hold that, the OPs are deficient in providing service to the complainant. The complainant is entitle for reimbursement of Rs.3.08.894/- spent towards his treatment as the alleged insurance policy was in force is not  disputed so also he is entitled for compensation for sufferings & cost of this litigation. Hence, it is ordered.

                                       ORDER

The consumer complaint is partly allowed against the Ops on contest with the following direction:-

 The Ops are directed to release the insurance benefit of    Rs.3,08,994/-(one lakh eight thousand nine hundred ninety four ) with interest @ 9% per annum, from the date of filing of this case i.e. 30.11.2018 till its realization and further directed to pay Rs.10,000/- as litigation expenses within 45 days of receiving of this order, failing which interest @18% per annum shall be attracted on the aforesaid awarded amount till its realization.

Dictated and corrected by me.

I   agree.

Pronounce in open Commission today on this 12^th day of April 2023, under the seal and signature of this Commission. The pending application if any is also disposed off accordingly.

This complaint could not be decided within the prescribed period of time due to Covid-19 situation and in want of quorum of this Commission

Free copy of this order be supplied to the parties for their perusal or party may download the same from the Confonet be treated as copy served to the parties. Complaint is disposed of accordingly.