Date of Filing: 25-08-2015 Date of Final Order: 21-04-2017
Sri Gurupada Mondal, President.
This is an application U/S 12 of the C.P. Act, 1986 filed by one Kalyan Kumar Saha against the Branch Manager, L.I.C, Divisional Manager, Jalpaiguri and the Officer-in-charge, Medicare T.P.A Services Pvt. Ltd., praying for direction to the O.Ps to pay the claim amount of Rs.2,87,040/-, compensation of Rs.1,00,000/- for mental pain & agony and harassment, Rs.1,00,000/- for deficiency in service and Rs.10,000/- as litigation cost.
The case of the Complainant in short is that the Complainant took one LIC Health Plus Plan Policy from LIC, Cooch Behar and the O.Ps assured the Complainant to render proper service towards him and his spouse. The Complainant obtained policy being No.454732276 on 31/03/2008 Plan & Term 901. The major surgical benefit for the principal and spouse was of Rs.2,40,000/- each and the Complainant paid the premium of Rs.15,000/-. The policy was valid till 31/03/2024.
As per the terms of the policy that during the tenure of the policy, if treatment of the policy holder or his spouse required then the O.Ps shall indemnity or reimburse the actual expenditure as per the Plan No.901.
Further the case of the Complainant is that during the subsistence of the policy, the Complainant suffered abdominal pain and as such he consulted with the local doctor at Cooch Behar and detected jaundice and advised to consult higher centre. Then the Complainant consulted with his family members and decided for better treatment and went to Asian Institute of Gastroenterology at Hyderabad and consulted Dr. D. Nageshwar Reddy, who diagnosis after several tests “Liver failure, HBV related and Liver Transplantation”.
It is the case of the Complainant that he was admitted at Asian Institute of Gastroenterology at Hyderabad on 14/01/2014 under the care of Dr. D. Nageshwar Reddy for Liver Transplantation and the date of transplantation was on 19/02/2014. The Complainant had to remain in the Nursing Home for a period from 14/01/2014 to 31/01/2014, 17/02/2014 to 17/03/2014, out of which he was in ICU from 18/02/2014 to 28/02/2014, 14/04/2014 to 18/04/2014 and 25/04/2014 to 28/04/2014, total 54 days including ICU. It is also alleged in the complaint of the Complainant that he had to incur expenses of Rs.15,22,593/- at Asian Institute of Gastroenterology at Hyderabad in four occasions and to that effect the hospital authority issued a certificate. Thereafter the Complainant preferred claim of HCB and MSB according to 901 plan from the O.P. No.1 together with supportive documents on 28/06/2014 with a request to reimburse the claim. Subsequently, the O.P. No.3 issued a letter intimating the Complainant to submit documents “Commencement of Prostatic Hypertrophy” has to be certified by attending Physician, otherwise unable to proceed with the claim and asked the Complainant to submit all the documents before the O.P. No.3.
Further the case of the Complainant is that the claim of the Complainant was denied by LIC an account of 1.99 showing the reasons “it was not possible to keep the case open for indefinite period for certificate awaited and the claim can be re-opened on submission of required certificate”. Thereafter the Complainant filed required certificate before the O.P. No.3 with a request to condone the delay in proceeding the certificate and in the month of July, 2015 (01/07/2015) the Complainant received a letter from the O.P. No.2, Jalpaiguri Division that a payment of Rs.1,560/- was made against the said policy but the Complainant was entitled to get Rs.2,87,040/- as per Plan 901. The Complainant made several attempts to get the actual claim but all efforts went in vain. The O.Ps with an ill motive did not grant the claim of the Complainant causing irreparable loss, injury and negligence to the Complainant by the O.Ps. Accordingly, the Complainant has brought this case against the O.Ps for proper reliefs in accordance with law and the L.I.C Health Plus Policy.
The O.P. No.1 & 2 in order to contest this case have jointly filed W/V denying all material allegations contending inter-alia that the instant complaint is not maintainable either in law or in fact, the Complainant has no cause of action to file this case and the case is barred by the law of limitation.
The O.P. No.1 & 2 have admitted that the Complainant had obtained L.I.C Health Plus Policy from the office of the O.P. No.1 on 31/03/2008 for a period of 16 years under certain terms and conditions. But the O.Ps were not aware of the alleged treatment and transplantation of Liver of the Complainant and came to know about the fact of treatment, when the Complainant preferred the claim on 26/04/2014. The O.P. No.1 & 2 referred the case to Medicare TPA Service India Pvt. Ltd. for entitlement of the claim of the Complainant. During the process of the claim, they found insufficient documents supplied by the Complainant and the O.P. No.3 informed to the Complainant that he could not furnish the documents till 12/01/2015 and then the O.P. No.3 rejected the claim and the same was informed to the Complainant. It is also alleged that the Complainant by his letter dated 15/02/2015 prayed for re-opening the claim and on the basis of such application, the claim was re-opened and the papers were forwarded to the TPA for settlement. The O.P. No.3, TPA assessed and a cash of Rs.1,560/- was credited in the account of the Complainant and the Complainant is not entitled to get further amount from the O.Ps. Moreover, the claim of the Complainant was exorbitant and baseless and not entitled to get further amount from the O.Ps. During the pendency of this case, the O.Ps paid Rs.82,740/- to the Complainant. On the basis of the aforesaid facts, the O.P. No.1 & 2 prayed for dismissal of the case with cost.
Notice upon the O.P. No.3 was duly served but the O.P. No.3 did not turn up to contest this case. Hence the case was heard in Ex-parte against them.
On the basis of the Complaint and W/V, the following points are taken into consideration to arrive at a conclusion.
POINTS FOR CONSIDERATION
- Is the Complainant a Consumer as per Section 2(1)(d)(ii) of the C.P. Act, 1986?
- Has this Forum jurisdiction to entertain the instant complaint?
- Have the Opposite Parties any deficiency in service and are they liable in any way?
- Whether the Complainant is entitled to get relief/reliefs as prayed for?
DECISION WITH REASONS
We have gone through the record very carefully. Perused the entire documents in the record and also heard the argument as advanced by the parties at length.
Point No.1.
Admitted fact that the Complainant took LIC’s Health Plus Plan from the O.P No.1 & 2 is the Divisional Manager, LIC, Jalpaiguri, the higher authority of the O.P. No.1 and the O.P. No.3, the Medicare TPA Service Pvt. Ltd. engaged by the O.P. No.2 to look after the LIC’s Health Plus Plan. The O.P. No.1 sold the LIC’s Health Plus Plan to the Complainant at a consideration of Rs.15,000/- and on the basis of the said Policy, O.P. No.1 assured the Health Care Services like HCB and MSB to the Complainant till 31.03.2024. The Complainant is the beneficiary and the OPs are service provider. As per definition, consumer is one, who purchases goods for private use or consumption. The meaning of consumer is broadly stated in the definition so as to include any one who consumes goods or services at the end of the chain of production. Therefore, the Complainant is a consumer as per definition of CP Act, 1986. Hence, this point is decided in favour of the Complainant.
Point No.2.
The OP No.1 is the resident of Cooch Behar and the transaction took place within Cooch Behar. The claim amount is within the pecuniary limit of this Forum. Hence, this Forum has sufficient territorial as well as pecuniary jurisdiction to try this case. Hence, this point is decided in favour of the Complainant.
Point No.3 & 4.
Both the points are taken up together for the consideration of discussion as both the points are related with each other.
Admitted fact that the Complainant took a LIC’s Health Plus Plan from the OP No.1 after paying installment premium of Rs.15,000/- commencing from 31.03.2008 and expiry date is 31.03.2004. It is also the admitted fact that the Complainant and his spouse are entitled to get H.C.B (Hospital Cash Benefit) and MCB (Major Surgical Benefit) for the above mentioned period. As per LIC Health Plus Plan, the Complainant and his spouse are entitled to get H.C.B of Rs.1,200/- per day at the initial daily expenditure and Rs.2,40,000/- as M.S.B. The OP No.1 & 2 have admitted in their written version about the treatment of the Complainant. According to the OP No.1 & 2, they paid Rs.1,560/- to the Complainant after considering his documents (Treatment Sheets and Bills). The Complainant has admitted during the pendency of this case that the OP No.1 paid Rs.82,740/-. The OPs in their additional w/v have admitted that they paid Rs.82,740/- to the Complainant during the pendency of this case.
Let us see how much claim the Complainant is entitled to get as per LIC Health Plus Plan. The LIC Health Plus Plan was valid on the date of the treatment of the Complainant. The LIC (OPs) also did not deny it.
From the documents as produced by the Complainant, it reveals to us that Complainant was admitted at Asian Institute of Gastroenterology from 14.01.14 to 31.01.14, 17.02.14 to 17.03.14, 14.04.14 to 18.04.14 and 25.04.14 to 28.04.14 i.e. 54 days including I.C.U. for Liver Transplantation. The Complainant was admitted in the I.C.U from 18.02.14 to 28.02.14 i.e. 10 days.
As per LIC Health Plus Plan, the Complainant and his spouse are entitled to get Rs.1,200/- per day plus increase @ 5% per Policy anniversary i.e. H.C.B @ Rs.1,500/- per day. The LIC Health Plus Plan was of six years at the time of Hospitalization. Therefore, the Complainant is entitled to get Rs.1,560/- per day for H.C.B.
At the time of 1st hospitalization of the Complainant, the L.I.C Health Plus Policy was five years old and the Complainant is entitled to get H.C.B of Rs.1,500/- per day.
In our earlier discussion, we hold that the Complainant was admitted at the Hospital/Nursing Home for “Liver Transplantation” under the care of Dr. D. Nageswar Reddy for a period of 54 days, out of which the Complainant was admitted for 11 days in the I.C.U and the L.I.C Health Plus Plan completed 5th anniversary and as per the L.I.C Health Plus Plan, the benefit is two times of the Daily Hospital Cash Benefit. As such the Complainant is entitled to get Rs.1,500/- (HCB) X 2 X 11 days comes to Rs.33,000/-. The Complainant was admitted in the Nursing Home/Hospital for 34 days, where the L.I.C Health Plus Plan completed 5th Anniversary and as such the Complainant is entitled to get HCB of Rs.1,200/- plus 25% of Rs.1,200/- comes to Rs.1,500/- per day i.e. Rs.1,500/- X 34 days comes to Rs.51,000/-. The Complainant was admitted at the Nursing Home/Hospital for 9 days where the L.I.C Health Plus Policy completed 6th Anniversary and as such the Complainant is entitled to get HCB of Rs.1,200/- plus 30% of Rs.1,200/- comes to Rs.1,560/- per day the Complainant is entitled to get Rs.1,560/- X 9 days comes to Rs.14,040/-. After adding the above mentioned amount, the Complainant is entitled to get HCB of Rs.98,040/- for his admission at the Nursing Home/Hospital.
As per the L.I.C Health Plus Plan, the Complainant is entitled to get Major Surgical Benefits as mentioned therein. As per the Exhibit-D/1, the Complainant underwent surgery of “Liver Transplantation” under the care of Dr. D. Nageswar Reddy. The Complainant is entitled to get MSB which is specifically mentioned in the said policy. As per the L.I.C Health Plus Plan, the Complainant is entitled to get partial resection of Liver @ 60%. So far our knowledge is concerned “Liver Transplantation” and partial resection of Liver are two different surgeries. One cannot be compared with the other.
The Ld. Adv. for the Complainant during the argument cites a case decision reported in (2015) CJ 441 (NC), where in Hon’ble National Consumer Disputes Redressal Commission held – Consumer Protection Act, 1986 – Section 15, 17, 19 & 21, Medi-claim – Health Plus Unit Linked Insurance Plan – claim repudiated on the ground that Open Reductive Internal Fixation is not covered under the list of allowed Surgical Procedure – claim allowed by Forum below – Policy Holder received injury during substance of the Policy – There is wee bit of difference between the brain and head, Leg fracture and replacement of knee joint – This is also covered under the Policy. Duty of the Petitioner is to winnow truth and false hood – Mere technical formality should not come into the way. Hon’ble National Commission further held mere technical formality should not come into the way of settlement of Insurance Claim.
We hold that “Liver Transplantation and Partial resection of Liver 60% are two different things and dictionary meaning are separate. Resection means cut out tissue or part of any organ and Transplantation of Liver means an operation in which a Liver is transplanted. Therefore, it is not a mere technical matter. The case decision cited by the Complainant is not applicable in this case. The Complainant is only entitled to get his claim which one specifically mentioned in L.I.C Health Plus Plan No.901. As per the Plan No.901 of L.I.C Health Plus Plan, the Complainant is not entitled to get the claim of “Liver Transplantation”. Partial Resection of Liver and Liver Transplantation are not the same and identical and as such the Complainant is not entitled to get any claim for “Liver Transplantation”.
But the Complainant is entitled to get Hospital Case Benefit of Rs.98,040/- for his admission at the Nursing Home/Hospital. The Complainant filed an application before the O.P. No.3 and the O.P. No.3 allowed the claim application in part and paid Rs.1,560/- to the Complainant in his Bank account. But after filing of this case, the O.P paid a substantial amount in the Bank account of the Complainant. Unless the Complainant filed this case, the Complainant did not get anything, it amounts to negligence as deficiency in service from the part of the O.Ps and as such the Complainant is entitled to get compensation in accordance with law.
Both points are disposed off accordingly.
Hence,
Ordered,
That the present Case No. CC/81/2015 be and the same is allowed in part on contest against the O.P. No.1 & 2 with cost of Rs.5,000/- and Ex-parte against the O.P. No.3.
The Complainant do get Hospital Case Benefit of Rs.98,040/- from the O.Ps along with interest @ 8% P.A. from 25/08/2015 till repayment.
The O.Ps are hereby directed to pay Rs.7,000/- as compensation for their negligence and deficiency in service for causing mental pain and agony to the Complainant.
The O.Ps are jointly and/or severally liable to pay the aforesaid amount within 45 days from this date, failing which the O.Ps shall have to pay Rs.50/- for each day’s delay and the amount so accumulated be deposited in the Legal Aid Account.
Any amount paid by the O.Ps to the Complainant during the pendency of this case be adjusted at the time of final payment.
A plain copy of the order be supplied to the parties free of costs for information and necessary action as per rule.
Dictated and corrected by me.
