DISTRICT CONSUMER DISPUTES REDRESSSAL FORUM

WEST TRIPURA : AGARTALA

 

CASE NO:  CC – 106  of   2017

 

Sri Tarun Baran Roy,

S/O- Lt. Jogesh Ch. Bhowmik

Bankim Sarani, Akhaura Road,

Agartala, Pin- 799001. ........…...Complainant.

 

         -VERSUS-

 

      1. Branch Manager, LICI,

Udaipur Branch Office,

Hospital Road, P.O. Radhakishorepur,

Dist. (Earlier South Tripura) Now Gomati District,

Tripura. 

 

      2. Branch Manager, LICI,

Agartala Branch No. II,

Krishnanagar, Agartala.

 

      3. Divisional Manager, LICI,

Silchar Divisional Office,

Meherpur, Silchar.

 

4. Manager(H.I.), LICI,

  Silchar Divisional Office,

Meherpur, Silchar. ........... Opposite Parties.

 

 

__________PRESENT__________

 

 SRI A. PAL,

PRESIDENT,

  DISTRICT CONSUMER 

 DISPUTES REDRESSAL FORUM,

      WEST TRIPURA, AGARTALA. 

 

SMT. DR. G. DEBNATH

MEMBER,

  DISTRICT CONSUMER 

DISPUTES REDRESSAL FORUM, 

  WEST TRIPURA,  AGARTALA.

 

SRI U. DAS

MEMBER,

  DISTRICT CONSUMER 

DISPUTES REDRESSAL FORUM, 

  WEST TRIPURA,  AGARTALA.

 

 

C  O  U  N  S  E  L

 

For the Complainant : In person.   

 

For the O.P. : Sri Prahlad Kr. Debnath,

  Advocate.

  

 

JUDGMENT  DELIVERED  ON:   02.04.2018.

 

J U D G M E N T  

This case arises on the petition filed by one Tarun Baran Roy U/S 12 of the Consumer Protection Act. Petitioner's case in short is that he and his wife purchased LICI Health Plus Plan policy covering his health and health of his wife. He has been paying the premium Rs.15,000/- per year since the date of commencement of the policy during 04.03.2009. During the continuation of the policy in the year 2016 the wife of the petitioner was hospitalized at CMC, Vellore  underwent treatment there. Total cost of treatment was Rs.90,000/-. Petitioner claimed the amount. Made several correspondence. Ultimately LICI repudiated the claim on the ground that required documents not produced by petitioner. Due to such deficiency of service by O.P. petitioner suffered. He claimed the cost of treatment Rs.90,000/- and also in addition claimed compensation. In total Rs.1,80,000/-

 

2. O.P. LICI appeared, filed written statement denying the claim. It is stated that on receipt of the claim on 25.08.16 Udaipur Branch forwarded the same on 26.08.16 to the concerned Manager at Silchar Divisional Office. Silchar Divisional Office called for some requirements on 08.09.16. Claim was forwarded on 3rd Party Administrator. Some other requirements were called for. Those requirements were not produced. Since onus lies on the policy holder to comply with any requirements in the course of claim evaluation. As the Policy holder failed to comply so his claim was closed. There was no deficiency of service of O.P. and claim of the petitioner is therefore liable to be dismissed.

 

3. On the basis of contention raised by both the parties following points cropped up for determination:

(I) Whether the repudiation of claim by O.P. was justified?

(II) Whether there was any deficiency of service by O.P. and the petitioner is entitled to get compensation?

 

4. Petitioner Tarun Baran Roy produced the copy of letter of LICI in regard to submission some documents, letter written to Manager, LICI Division, another correspondence with the Manager, Silchar Divisional Office, declaration by the proposer, Policy certificate, discharge summary and paper relating to hospitalization. Petitioner also  given on oath evidence before the District Forum. 

 

5. O.P. on the other hand produced the on oath testimony of one witness, Sudip Bhattacharjee Branch Manager, LICI, Udaipur Branch. 

 

6. On the basis of all these evidence on record we shall now determine the above points.

 

Findings and decision:

7. We have gone through the discharge summary, CMC Vellore on 30th May, 2016. From that discharge summary it is found that date of admission of the wife of petitioner, Chhabi Biswas was 25th May, 2016, discharged on 30th May, 2016, diagnosis was probable Sarcoidosis in remission. 

 

8. O.P. LICI admitted that the claim of the petitioner for Rs.90,000/- along with supporting papers vouchers memos were received by them and forwarded to Silchar Division for settlement of claim. Those vouchers are not produced before us. 

 

9. We have gone through the letter issued by Manager, Divisional Office, Silchar repudiating the claim finally. By that letter dt. 02.05.17 it is informed that the policy holder did not comply with the requirements called for. So claim was closed. The requirement called for was to provide the history and duration of Sarcoidosis since 2009. This fact is disclosed from the letter issued from the Manager, Silchar Division, the letter dated 11.11.2016. In that letter it is written that patient Chhabi Biswas was hypertensive as per discharge summary. The Manager H.I called for the duration of the visit to doctor since 2009. Petitioner failed to submit it. As it was not submitted so the claim was closed. 

 

10. It is admitted position that wife of the petitioner suffered illness in the year 2009. She was treated in the CMC, Vellore in the year 2016 when the policy was alive. Treatment period was from 25th May 2016. From the discharge summary it is found that blood pressure of the wife of petitioner was 120/84. So she was not patient of hypertension. The doctor diagnosis was probable sarcoidosis. So it can not be said that she was patient of sarcoidosis since 2009 when the policy was purchased. Petitioner submitted declaration form. We have gone through the declaration form. In that declaration form, she had given clear declaration that she was not suffering from diabetics, hyper tension or any other disease in the year 2009. As in the discharge summary it was written that she had been suffering from probable sarcoidosis so O.P. Insurance company assumed that she might have been patient of sarcoidosis from 2009 when the policy was purchased. This presumption is baseless presumption after the lapse of about 7 years. 

 

11. O.P.W.1, Manager, LICI stated that patient was hypertensive so she was not entitled to get cost of treatment. Nowhere it is stated that she was hypertensive at the time of purchasing the policy in the year 2009. It is also not possible to  produce the treatment papers of 2009 after lapse of 7 years. O.P. also could not produce any evidence to support that the wife of the petitioner underwent for the treatment of hypertension or sarcoidosis in the year 2009. The presumption was raised by LICI after lapse of 7 years on the basis of observation of the doctors of CMC, Vellore. 

 

12. Petitioner stated that he purchased the health plus policy covering his health and his wife. He also stated that she was under treatment for few days in CMC, Vellore and spent about Rs.90,000/- as treatment expenditure and papers relevant to expenditure were sent to LICI. He suffered due to the deficiency of service of LICI.

 

13. From the above discussion of all these evidence it is clear that repudiation of claim by the O.P. LICI, Silchar Division  was unjust, improper. Petitioner was entitled to get the cost of treatment of his wife at CMC, Vellore. He produced all the vouchers, memos relating to expenditure. But the O.P. LICI did not consider all the vouchers and repudiated the claim on the plea that the treatment papers of 2009 not produced before them by petitioner. O.Ps are not certain whether the wife of the petitioner was treated in the year 2009 at the time of purchasing policy for hypertension or sarcoidosis. 

 

14. Learned advocate for the O.P. Insurance company referred the decision of the National Consumer Disputes Redressal Commission in Revision petition No. 2996 on 2015. In that case  claimant suppressed the material fact relating to sufferings from diabetics and hypertension.

 

15. Learned advocate also referred the decision of the State Commission of Mumbai. In that case petitioner failed to produce the death certificate of the deceased insured. 

 

16. In another petition National Commission in the Revision Petition No. 2065/2009 relates to the suppression of material fact regarding status of health. 

 

17. In this case there is no suppression of material fact regarding status of health in  the year 2009. Petitioner suffered illness in the year 2016 after 7 years of purchase of policy. And there is no evidence to show that she was treated in the year 2009 for same disease.  O.P. Insurance company repudiated the claim on presumption only  though she had not suffering from the same disease in the year 2009. Such repudiation of the claim is unjust and for that petitioner suffered a lot. He had to make correspondence and also filed the case to get redress. He is therefore, entitled to get compensation also. We direct the O.P. to pay the treatment cost Rs.90,000/- to the petitioner without any further delay. Petitioner is also entitled to get Rs.10,000/- as compensation and Rs.5,000/- as litigation cost. In total Rs.1,05,000/-. Both the points are decided accordingly.

 

18. In view of our above findings we direct the O.P. Insurance company to pay Rs.1,05,000/- to the petitioner as cost of treatment, compensation and litigation cost. Payment is to be made within one month. If not paid it will carry interest 9% P.A. Case disposed accordingly.     

 

 

Announced.

 

 

 

 

SRI A. PAL

PRESIDENT,

DISTRICT CONSUMER  DISPUTES 

REDRESSAL FORUM,

WEST TRIPURA,  AGARTALA.

 

 

 

SMT. DR. G. DEBNATH,

MEMBER,

 DISTRICT CONSUMER DISPUTES 

REDRESSAL FORUM, 

WEST TRIPURA, AGARTALA SRI  U. DAS

MEMBER,

 DISTRICT CONSUMER DISPUTES 

REDRESSAL FORUM, 

WEST TRIPURA, AGARTALA