PRESIDENT DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SAMBALPUR

                             CONSUMER COMPLAINT NO. 35 /2024

Present-Dr. Ramakanta Satapathy, President,

  Sri. SadanandaTripathy, Member,

Sri. Debakar Prasad Dhar,

S/O-Late Bhabani Sankar Dhar,

At-Modipara, Panitankigali, Po-Modipara, Ps-Town,

Dist- Sambalpur-768002, Odisha                                        ……….......Complainant.

Vrs.

The Branch Manager, Life Insurance Corporation of India,

Burla Branch, Jeevan Jyoti, Power House Road, Burla,

Dist-Sambalpur-768017.                                                          .....……….Opp. Party

Counsels:-

1. For the Complainant         :- Sri. P.K.Nath & Associates
2. For the O.P.                        :- Sri. D.K.Thakur, Adv.

Date of Filing:02.02.2024,  Date of Hearing :01.07.2024,  Date of Judgement :13.08.2024

Presented by Dr. Ramakanta Satapathy, PRESIDENT

1. The Case of the Complainant is that the Complainant opted a health insurance policy namely Jeevan Arogya(without profit) vide policy No. 831593205 from the O.P. w.e.f. 28.01.2019 to 28.07.2046 under plan 284. The Complainant paid Rs. 34,958/- to the O.P. at half yearly premium amount from 05.12.2018 to 12.01.2023. On 06.03.2023 when felt suffocated with irregular palpitation of his heart consulted Dr. N.K.Patel, Cardiologist, undergone echocardiogram and Electrocardiography tests and took medicine and bed rest for 15 days. On 07.04.2023 check up was made by Dr. N.K. Patel and advised for Angiogram test. After all tests Dr. Patel decided to install one cardio patch on the chest of the Complainant. On 23.05.2023 Complainant was admitted in Gupta Nurshing Home, Burla and cardiopatch was installed. Complainant took 3 days bed rest and on 26.05.2023 after reading the doctor decided to fit a pacemaker on the heart.

On 30.05.2023 Complainant was admitted in Samaleswari Nurshing Home, Burla but doctor could not able to install pacemaker due to some other complicacies and referred to Appollo Hospital, Bhubaneswar. In Appollo Hospital Dr. B. Dixit on 30.05.2023 detected Sick Sinus Syndrome, HTN, SSS, PPI(DDDR), St Judge, PPI Compatible, normal LV systolic function and irregular function of the heart. Complainant was admitted on 30.05.2023 as on indoor patient. Dr. B.Dikshit after tests conducted operation and dual chamber pacemaker was placed on his heart on 01.06.2023. The Appollo hospital charged Rs. 4,24,658.22P.

The Complainant for claim submitted the original bills with O.P. but instead any settlement on 24.07.2023 sent a sum of Rs. 27,500/- to the saving account of the Complainant. The Complainant total spent Rs. 4,51,604/- and entitled for the same.

2. The O.P. in reply submitted that Jeevan Arogya Policy was for 28 years with initial daily benefit of Rs. 1000/- under plan No. 904 four benefits are offered:

1. Hospital Cash Benefit(HCB)
2. Major Surgical Benefit(MSB) covering 140 surgeries.
3. Day care procedure Benefits(DCPB) covering 140 surgeries.
4. Other surgical benefits (OSB) not covered under MSB & DCPB.

In case of MCB under category (a) and (b) Ambulance cost, premium waiver benefit and quick cash facility is also available.

The Complainant has paid premium till 01/2023. The Complainant was admitted in hospital in 31.05.2023 and discharged on 07.06.2023 for his diagnosed sickness. The Complainant was paid Hospital cash Benefit (NICU) for 6 days @Rs. 1250/-, 1 days ICU Rs. 2500/- and OSB surgery amount Rs. 17,500/- as applicable under the plan. Final amount of Rs. 27,500/- has been credits to the account of the Complainant. There is no any deficiency on the part of the O.P. and complaint is liable to be dismissed.

3. Perused the documents filed by the Complainant. The O.P. has submitted a calculation as follows:-

1. Out of 7 days hospitalisation the Complainant availed 6 days in non-ICU and 1 day in ICU.
2. The Complainant is eligible for hospital cash Benefit (HCB) of Rs. 1250/- per days. The policy holder opted HCB of Rs. 1000/- and as per policy condition HCB increased by no claim benefit i.e. Applicable Daily Benefit is Rs. 1250/- per day.
3. ICU charge of Rs. 1250x2=Rs. 2500/-.

Non ICU Charges of Rs. 1250x6=Rs.7500/-.

Total Hospital Cash Benefit =Rs. 10,000/-.

4. Other Surgical Benefits Rs. 2500x7=Rs. 17,500/-.
5. Total Claim Benefit Comes to Rs. 10,000+Rs. 17,500/-=Rs. 27,500/-.

In policy No. 831593205 the initial daily benefit opted is Rs. 1000/-. The Complainant is bound by the terms and conditions of the policy. As per policy clause No.2 & 3 as the Complainant opted for HCB of Rs. 1000/- per day, the calculation made by the O.P. is proper. The Complainant admitted that Rs. 27,500/- has been deposited to his saving accounts.

Taking into consideration the circumstances of the Complaint there is no any deficiency in service established by the Complainant against the O.P.

Accordingly following order is passed:

ORDER

                   The complaint is dismissed on contest against the O.P. No cost.

Order pronounced in the open court on 13^th day of August, 2024.

Supply free copies to the parties.