Sri Kamal De, President
In short, case of the complainant is that the complainant took one mediclaim policy from O.P. under the name and style LIC’s Health Plus Plan, Vide Policy No. 439452940 vide its date of commencement being 29/02/2008 and policy expiry date being 29/02/2029 and the yearly premium installment being Rs. 7,500/-. During contention of this policy the complainant faced one medical problem for which on 10/08/2015 at 19.45 Hour he had to be admitted on an emergency basis at Narayan Hrudayalaya Institute of Cardiac Science, an unit of Narayana Health secluded at 258/A, Bommasandra Industrial area Hoser Main Road, Benglore, PIN : 560099 with diagnosis as Coronary Artery Disease Systomic M.T.N., L.V.E.F.- 55% and on the very same day an operation called “Successful P.T.C.A. + Stent to LAD” was done and he was discharged from the said Hospital on 12/08/2015 at 16.56 House.
The complainant paid the final bill amounting to Rs. 1,91,931/- to the said Hospital in cash. Thereafter, the complainant applied before the O.P. authority for reimbursement of the said amount of Rs. 1,91,931/- by submitting duly filled up from and all supporting documents, which was received by the O.P. Office on 28/08/2015. But to the utter surprise the complainant found in the Website of the O.P. Office called E- MEDITEK,(TPA) SERVICES LIMITED that his claim has been rejected by assigning reason for the same as “Total Hospitalization period less than 52 hrs.” The Complainant visited the O.P. office on many occasions and asked the O.P. to pay his genuine claim but the O.P. paid no heed to the complainant. The O.P. did not informed the terms and condition of the policy to the complainant ever before and repudiated his claim for which the complainant suffered a huge economical loss.
Hence,
This case.
Case of the O.P., on the other hand, is that the complainant purchased a Health Insurance Plus Unit linked Policy from the O.P. on 29/02/2008. It is stated by the O.P. that it is not a conventional mediclaim policy rather it is an unit Linked Health Plus Policy with certain benefit as per terms and conditions of the Policy. The complainant was admitted in Hospital on 10/08/2015 at 19.45 Hrs. and he was discharged on 12/08/2015 at 16.56 Hrs. after undergoing successful operation. The duration of complainants stay in Hospital was only 45 Hrs. which is less than the minimum stipulated period of 52 Hrs. for considering Hospital cash benefit (H.C.B.) as per terms and condition of the plan 901 [ Terms and condition, page 2, Para 2(1)]. PTCA+STENT To LAD operation of the complainant was done in which one artery was stented. But as per the scheme the reimbursement would be considered under the category Coronary Angioplasty with stent implantation ( two or more coronary arteries must be stented ). But here only one artery was stented for which it will not be considered in the said category and as such nothing is payable as per terms and condition of the Plan 901. As such TPA – E Meditek – (TPA) Services Ltd. sent a rejection letter on 12/10/2015. It is also stated by the O.P. that this Health Plus Policy (table – 901) is a unit linked policy where the premium has got two parts, one part for risk coverage and the other part is Policy Holder Fund. Units are purchased from the policy holder fund. The policy holder is entitled to 50 % of the fund value of Rs. 59,669/- through domestic treatment benefit. Apart from this the policy holder is entitled to get Rs. 500/- per day as hospital cash benefit subject to minimum period of hospitalization should be 52 Hrs. The operation of the complainant is not covered under this policy as it was involved single artery setting. But as per the terms and condition of policy the operation which was performed must be involving two or more arteries for reimbursement under this policy. As it is a Unit Linked Health Plus Policy this policy has a fund value of Rs. 59,669/- and the complainant may withdrew 50% of it through domestic treatment benefit.
Points for consideration
- Whether the complainant is entitled to relief as sought for ?
- Whether there is any deficiency in service of the O.P. to the complainant?
Both the points are taken together for brevity and convenience of discursion.
Decision with reasons
Point Nos. 1&2:
It appears from documents on records that the complainant took one mediclaim policy from O.P. under the name and style L.I.C’s Health –Plus Plan, being policy no. 439452940 with commencement on 29/02/2008 and Expiry date being 29/02/2029 at yearly premium of Rs. 7,500/- The Complainant was admitted at Narayana Hrudayalaya Institute of Cardiac Science, with diagnosis of coronary artery disease systomlic MTN,LVEF-55%. He also under went operation on the same date and was discharged from hospital on 12/08/2015 at 16.56 hrs. Final bill was charged by the hospital amounting to Rs. 1,91,931/- and the complainant paid the same by cash. The complainant thereafter put claim brfore the O.P. but the O.P. rejected the claim by assigning reason “ Total hospitalization period less than 52 hours.”
The complainant filed a Xerox copy of L.I.C.’s Health plus Plan. We find that the policy relates to amount of the one lakh in the name of the complainant and his wife Mamata Das. No terms and condition of the policy is appearing from the said L.I.C. policy O.P., however, filed a literature regarding conditions and privileges referred to in the policy documents. It appears from this Health – Plan – Policy that the premium has got two parts, one part is risk coverage and other part is policy holder fund. It also appears that the units are purchased from the policy holder fund and the policy holder is entitled to get 50% of the fund value as per N.A.V. for domicile treatment benefit from the policy holders fund account. It also appears that as per this policy the policy holder is entitled to get Rs. 500/- per day as hospital cash benefit subject to minimum hospitalization time being 52 hrs. From the medical papers it appears that the operation of the complainant involved single artery Stenting. As per terms and condition of the policy in question the operation for getting claim must involve two or more arteries for reimbursement under the policy. We find that the unit linked health plus policy of the complainant has a fund value of Rs. 59,669/- and as such we think that the complaint is entitled to 50% of it through domestic treatment benefit i.e. Rs.29,835/-. We find that no terms and condition was annexed with the complainant’s L.I.C. Health Plus Plan. It is not established that the complainant was kept abreast with the terms and condition of the policy in question. We think that the policy holder should be kept informed with terms and condition of any policy. We think that the O.P failed and neglected to do so for the reason best known to the O.P. As such we think that the complainant is also entitled to compensation and litigation cost.
Hence,
O R D E R E D
That the instant case being CC/28/2016 be and the same is allowed on contest. The complainant is entitled to get Rs. 29,835/- along with an amount of Rs. 30,000/- towards compensation, harassment and mental agony and litigation cost Rs. 5,000/-. The O.P. is directed to comply with this order within 30 days hence forth I/D the complainant will be at liberty to put the order in execution and in that case the O.P. will be liable to pay interest @ 9% per annum on the total amount till full and final payment.
