Orissa

Debagarh

CC/10/2019

Kailash Chandra Somani, C/O.Rajhans - Complainant(s)

Versus

The Branch Manager, Life Insurance Co.Ltd - Opp.Party(s)

18 Dec 2021

ORDER

IN THE COURT OF THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, DEOGARH

C.C. Case No- 10/2019

Present-Sri Dipak Kumar Mahapatra, President, Smt. Arati Das, Member.

Kailash Chandra Somani, aged about 35 years,

C/O-RAJHANS

At-Rajamunda, Ward No-11,

P.O/P.S/Dist-Deogarh.                                                                                              ...Complainant

Versus

1. The Branch Manager,

          Life Insurance Corporation of India,

          Satellite Office, Kuchinda

          P.O/P.s-Kuchinda, Dist-Sambalpur.

2. The Branch Manager(Claim),

           Life Insurance Corporation of India,

           Sambalpur Division Office,

      3.   The Divisional Manager,

             Life Insurance Corporation of India,

             Sambalpur Division Office,

4.   The Zonal Manager,

            Life Insurance Corporation of India,

East Central; Zonal Office,

Jeevan Deep, 6^th Floor, Exhibition Road,

Patna-800001.                                                                                             …Opposite Parties.

 

COUNSELS

For the Complainant           :-         Self

For the O.P-1, 2, 3 & 4        :-         Sri P.Guru, Advocate.

DATE OF HEARING : 17.12.2021, DATE OF ORDER : 18.12.2021

SRI DIPAK KUMAR MAHAPATRA,PRESIDENT:- Brief facts of the case is that,  the Complainant being motivated by the agent of O.P-1, has availed a Health Insurance Policy  named as LIC’s Health Protection Plus Plan (Table-902)in his name along with his wife and children vide Policy No-594400784  dtd. 12.06.2017, with a payment of Rs. 28,500/as annual premium amount. On dtd. 28.04.2017, while the Complainant along with his wife and his younger brother were proceeding towards Kuchinda from Deogarh by a Xylo Car, at about 10.00 a.m. the car was got accident and the Complainant and his wife Sarita Devi Somani were severely injured and by the help of local people they shifted to the hospital at Kuchinda for necessary treatment. Thereafter the Complainant and his wife were shifted to Gupta Nursing Home at Burla for higher medical treatment where they stayed for a short period and again shifted to Shree Narayan Hospital at Raipur. The Principal Insurer Kailash Chandra Somani have acquired “Fracture Lateral Condyle Left Tibia” and undergone surgery i.e Locking Plate Fixation Left Tibia” by the surgeon at the above noted hospital. The wife of the Complainant Sarita Devi Somani have acquired “Fracture Clavicle Left” and “Fracture Lower 3^rd Shaft Humerus Right” and undergone surgery i.e “ORIF with Locking Plate Fixation Right Humerus with Bone Grafting”. As the condition of the principal insurer was serious hence the Insurance Claim form was duly filled in and submitted by the Agent of the O.P-1. After their treatment at Shree Narayana Hospital the Complainant was discharged on dtd. 06.05.2017 with a payment of Rs.1,38,695/-( Rs.1,06,000/- for Nursing home Charges and Rs.32,695/- for medicines). His wife Sarita Devi Somani was discharged from the said Hospital on dtd. 06.05.2017 with a payment of Rs.1,42,196/-( Rs.1,10,000/- for Nursing home Charges and Rs.32,196/- for medicines). The O.P-1 asked to submit required documents which are needful to settle the Claim and the Complainant has submitted the required documents with the O.P-1 without any delay but the claim was not settled. The O.P-1 on dtd. 23.07.2017 sent a registered letter to the complainant for submission of requirements under the said policy no-594400784 where the O.P-1 has asked for the treating doctor’s certificate relating to history of Bronchial Asthma suffering by the Complainant and his wife and the Complainant complied the same on dtd. 21.08.2018. The O.P-1repudiated the claim of the Complainant and his wife on the ground as the Complainant and his wife were suffering from Bronchial Asthma for which they are not eligible to avail the claim benefits. As there is no connection of injuries sustained by the Complainant i.e “Fracture Lateral Condyle Left Tibia” and surgery i.e Locking Plate Fixation Left Tibia” and his wife sustained “Fracture Clavicle Left” and “Fracture Lower 3^rd Shaft Humerus Right” and undergone surgery  i.e “ORIF with Locking Plate Fixation Right Humerus with Bone Grafting” with Bronchial Asthma if acquired earlier as because in medical terms bone fracture and Bronchial Asthma are two different diseases and separate treatments needs to be provided for the both.

As per the O.Ps the petitioner has availed a health protection plan from LCI bearing no. 594400784 on 22 02 2012 with yearly mode of premium for Rs. 28500. That the complainant and his wife has been admitted in to Gupta Nursing Home at Burla for higher treatment after the incident as narrated by him. Later they were shifted to Narayan Hospital, Raipur. It is as per the papers received from the petitioner. That in Narayan Hospital Raipur the petitioner and his wife has been admitted on 25.04.2017 and discharged on 08.05.2017 due to development of Fracture Lateral Condyle Left Tibia (K C Samani) and K/C/D-BA. Fracture Clavicle Left" "fracture Lower 3 Shaft Humerous Right (Smt 30 Somani) and they had undergone surgery for Locking plate fixation left tibia under SAB on 29.04.2017 (K C Somani) and DRIF with locking plate right humerus bone grafting on 01.05.2017(Smt S D Saman) which does not come under Major Surgical Benefit of the said plan. Major Surgical Benefit means as specified under the terms & condition of Health Protection Plus policy. The claim was placed before DMR(Divisional Medical Referee) on 30.08.2018 for consideration of claim but after going through the papers the DMR opined that the surgery performed were not covered under MSB of plan 902. The OPs denies that they do not settle the claim on the ground of treatment of Bronchial Asthma (Although the complainant did not submit the related treatment particular as asked by the OP) Rather we are furnishing here the details of the treatment and the causes of repudiation:-

1. Diagnosis as per discharge summary Fracture Lateral Condyle Left Tibia due to accident.
2. Surgery Performed: Locking plate fixation left tibia under SAB on 29.04.2017.
3. Reason of Rejection of Claim Surgery performed is not covered under MSB under plan 902 (List of surgery as per policy condition enclosed). In this way the claim was repudiated.

 

POINTS OF DETERMINATION:-

1. Whether the Complainant is comes under the purview of Consumer Protection Act-2019?
2. Whether the O.Ps has committed any Deficiency in Service to the Complainant?

 

From the above discussion and materials available on records we inferred that the Complainant had paid the premium of Mediclaim policy of the opposite party from dtd.12.06.2017 and was existent during that year. During the purchase of this policy in the year 2017, there is no document on record showing that, the policy terms and conditions were informed to the complainant and also signed by complainant indicating acceptance of the terms and conditions, which is essential of any contract. We consider that printed terms and conditions are one sided contract terms and conditions, which IS ACTUALLY UNFAIR TRADE PRACTICE ON THE PART OF O.Ps. Another aspect is that the Insurance Company cannot suppress the terms and conditions but ought to seek clear informed approval from the contracting partner. Hence repudiating claim on the basis of the terms and conditions not accepted by the party in contract is itself breach of contract and deficiency in service.  In United India Insurance Co. Ltd vs. M.K.J. Corporation, Civil Appeal no.6075-6076 of 1995, decided on 21st August 1996, Hon'ble Supreme Court has discussed as follows, [A/17/819] "It is a fundamental principle of Insurance law that utmost good faith must be observed by the contracting parties. Good faith forbids either party from concealing (non-disclosure) what he privately knows, to draw the other into a bargain, from his ignorance of that fact and his believing the contrary. Just as the insured has a duty to disclose," similarly, it is the duty of the insurers and their agents' to disclose all material facts within their knowledge, obligation of good faith applies to them equally with the assured". We are of the opinion that, buying healthcare insurance-mediclaim is for medical risk management. When the mediclaim is purchased for payment of certain premium, it is in view of managing the expenditure that might be incurred in future risk of any disease and thus the contract of insurance between the Insurance Company and the insured is always in good faith. The repudiation of the mediclaim on the basis of one sided changed terms and conditions is unfair trade practice and hence as the complainant has proved that the opposite party followed unfair trade practice. Again it is seen from list of surgery as per policy condition amongst the other surgical procedure, the surgery of Musculoskeletal System is mentioned where total replacement of hip or knee joint following accident  and amputation of arm or hand or foot or leg due to trauma or accident is considered. Also the  surgery of fracture Lateral Condyle left Tibia, Fracture Clavicle Left, Fracture Lower 3^rd,surgery for Locking Plate Fixation left tibia SAB, all are related to or a part of Musculoskeletal System. Hence the O.Ps cannot denied that the above surgery performed by the Hospital were excluded from Musculoskeletal System and thus excluded from the list. So repudiating the claim of the Complainant the O.Ps has committed Deficiency in Service as well as Unfair Trade Practice as per the C.P Act-2019 and we order as under :-

ORDER

The Complaint petition is allowed. The O.P-1, 2, 3 & 4  are jointly and severally directed to pay the amount of Rs.2,74,891/-(Rs.1,32,695  Rs.1,42,195)  with  9% interest per annum from the date of filling of this case i.e dtd.12.03.2019 till it’s realisation, to the Complainant  which was paid to Narayan Hospital at Raipur for their treatment in cash. Further the O.Ps are jointly and severally further directed to pay Rs. 50,000/-(Rupees Fifty Thousand) as compensation and Rs. 10,000/- (Rupees Ten  Thousand) towards the cost of litigation. All the above orders are to be carried out within 30 (Thirty) days of receiving of this order, failing which, the complainant is at liberty to proceed in due process of law. 

Order pronounced in the open court today i.e, on 18^th day of December-2021 under my hand and seal of this Commission.

Office is directed to supply copies of the Order to the parties free of costs receiving acknowledgement of the delivery thereof.

I agree,

                                                                                               

MEMBER(W).                                                                                               PRESIDENT.

                                                      Dictated and Corrected

                                                                      By me.

 

                  PREIDENT