District Consumer Disputes Redressal Commission, Hooghly
PETITIONER
VS.
OPPOSITE PARTY
Complaint Case No.CC/24/2021
(Date of Filing:-25.01.2021)
- Shri. Somesh Sinha Roy
Village:- Dharanathpally, P.O. Khamarchandi, P.S. Haripal,
Dist. Hooghly, Pin:- 712405.…………..Complainant
- The Branch Manager,
Life Insurance Corporation of India
Tarakeshwar Branch, Post Office Road,
P.O. and P.S Tarakeshwar
District:- Hooghly, Pin:- 712410
- The Zonal Manager,
Life Insurance Corporation of India,
Howrah Division, Rallis Building,
16, Hare street, Kolkata-700001
- Anil Koley
Village and P.O. Musapur, P.S. Haripal
District:-Hooghly, Pin:- 712403
……….Opposite Parties
Before:-
Mr. Debasish Bandyopadhyay, President
Mr. Debasis Bhattachary, Member
Mrs. Babita Choudhury, Member
PRESENT:
Dtd.06.08.2024
Final Order/Judgment
Debasis Bhattacharya:- PRESIDING MEMBER
The instant case filed under section 35 of the Consumer Protection Act 2019 arises out of the grievances of the complainant with regard to repudiation of claim against a policy under the title ‘Health Plus Plan (T-901)’ of Life Insurance Corporation of India (hereinafter referred to as OP LICI in general as OP 1 i.e. Branch Manager of Tarakeshwar Branch of LICI and OP 2 i.e. Zonal Manager of LICI, Howrah Division belong to the same organization) held by him during the material period.
The brief facts of the case is that a policy under the name ‘Health Plus Plan (T-901)’ was incepted in favour of the complainant by the OP in the year 2008 and the termination date of the same was 24.03.2031. The policy reportedly covered three persons i.e. the Complainant himself, his wife and his son. The Complainant claims that he has been paying the yearly premium of Rs.12000/- regularly without any default since inception of the policy.
However, during the continuance of the policy, in the year 2019, the complainant’s son (hereinafter referred to as ‘the patient’) got sick having been suffered from acute breathing trouble. On 21.03.2019, the attending doctor detected that the patient was suffering from ‘Paroxysmal supraventicular Tachyacardia’. On 23.03.19 the said physician suggested that the patient required surgery on emergency basis as the condition of the patient was deteriorating rapidly.
Reportedly on being approached, OP1 and OP 3 assured the Complainant that there would be no problem in the matter of reimbursement of the medical expenses.
However on 01.04.2019, the Complainant took his son to Apollo Gleneagles hospital and on 01.04.19 and on 03.04.19 the complainant’s son had medical examination by the concerned doctors of that hospital. On 08.04.19 the patient was admitted to the hospital and on the same day underwent a surgery. On 10.04.2019 the patient was discharged on 17.04.2019 and on 13.05.2019 had further medical consultation and post operative follow up.
By this time, the Complainant claims to have lodged the respective claim for reimbursement of medical expenses of Rs1,26,445/- before the OP Insurance Company.
After waiting for a substantial period, the Complainant, after much persuasion came to know to his utter shock that the claim was repudiated on the ground that the ‘total hospitalization period was less than 52 hours’.
The Complainant here claims that he had no knowledge about this stipulation and it is further claimed that in the policy bond also there was no such stipulation.
When all concerned quarters shrugged off the issue, finding no other alternative the Complainant conveyed the entire issue to the Insurance Ombudsman on 04.07.2020.
On receipt of the grievance of the Complainant, a hearing was conducted by the Insurance Ombudsman on 28.09.2020 and by a communication dtd.19.10.2020 the said authority intimated the Complainant that ‘as per policy terms and conditions no claim is payable’
Considering the repudiation of the claim as deficiency in service and unfair trade practice the complainant filed the complaint petition seeking direction upon the opposite parties to pay a sum of Rs.1,26,445/- towards reimbursement of medical expenses along with interest @12% p.a, Rs.5,00,000/- as compensation for mental pain, agony and harassment and to pay , Rs.25,000/- towards cost of litigation.
The complainant along with his petition has submitted copies of the relevant documents related to the policy viz. policy bond, premium receipts, claim intimation form, claim form, hospital treatment form, relevant premium payment receipt, repudiation letter sent by the OP Insurance Company, bills raised by the hospital and discharge summary.
Evidence on affidavit filed by the Complainant is almost replica of the complaint petition. However the Complainant apart from the issues covered in the complaint petition denies to have received any welcome kit as claimed by the OP Insurance Company along with the policy bond.
It is further claimed that being ignorant of the several stipulations, he fully trusted the OP insurance Company and did not think of returning the policy within the 15 days ‘cooling off’ period.
Besides, the Complainant in his evidence on affidavit denies all the allegations raised by the OP insurance Company and OP3 agent so far as the grievances expressed by the Complainant are concerned.
The opposite parties 1 and 2, belonging to the same organization contested the case by filing elaborate rebuttals in their written version, evidence on affidavit and brief notes of argument denying therein most of the allegations leveled against them.
In view of the above discussion and on examination of available records, it transpires that OP 1 and 2 in the instant case was a service provider and hence the complainant is a consumer as far as the provisions laid down under Section 2(7)(ii) of the Consumer Protection Act 2019 are concerned.
The Complainant and OP 3 are residents within the district of Hooghly and OP 1 during the material period had their office within the district of Hooghly.
The claim preferred by the complainant does not exceed the limit of Rs.50,00,000/- Thus this Commission has territorial as well as pecuniary jurisdiction to proceed in the instant case.
Now, the issues whether there was any deficiency of service on the part of the opposite parties and whether the Complainant is entitled to any relief, will be discussed in the concluding part of the order as the issues are mutually interrelated.
Defense case
Initially in the written version the OP Insurance Company claimed without assigning any specific reason that the instant complaint petition is not maintainable in law in its present form. However no non-maintainability petition was filed by the OP Insurance Company. Hence this issue does not deserve any discussion.
However the OP Insurance company focuses on the conditions and privileges under the policy contained within the welcome kit supplied with the policy bond and puts stress on the issue that the principal insured person policyholder should have been aware of the conditions and privileges, exemptions or inadmissibility conditions attached with the policy. It is further pointed out that the policyholder had the option of returning the policy to the corporation within the stipulated ‘cooling off’ provision of 15 days.
The OP insurance company admitting the admission of the Complainant’s son in the hospital refers to the issue that the hospitalization period was 49 hours 5 minutes which was ‘much’ shorter period than the minimum admissible hospitalization period of 52 hours.
It is further mentioned that so far as the privileges and conditions of the policy as incorporated in the welcome kit are concerned, ‘No payment shall be made under this benefit for the operations performed, which are not listed in the surgical benefit annexure’. The surgery undergone by the complainant’s son as claimed by the OP Insurance Company was not appearing in the list.
The specific related terms and conditions attached with the policy, under ‘conditions and privileges’ are claimed to have been well explained and referred in clause 2(i), 2(i)(a), 2(i)(b) at page 13 of the conditions and privileges; clause 3(1)(i) and (ii); clause 3(ii)(vii) and (ix) at page 14 of the conditions and privileges and the exclusions applicable to major surgical benefit in clause 6(II) at page 16 of the booklet conditions and privileges.
In retaliation to the Complainant’s claim that OP 1 assured him of reimbursement of medical expenses, it is stated in the W/V that no branch manager can give such assurance to any one without perusal of the relevant papers related to the medical treatment.
OP Insurance Company thus claims that the claim was repudiated lawfully.
On the other hand OP 3 agent has stated in his W/V that he had no role in settling the reimbursement claim. OP 3 also denies to have extended any sort of assurance in the matter of reimbursement of medical expenses to the Complainant. He claims to have suggested the Complainant only to approach to OP 1 for lodging of the claim.
OP 3 claims also that prior to purchase of the policy, he along with some official of the OP Insurance Company visited the Complainant’s place and conveyed the rules, regulations and limitations of the policy to the Complainant.
Decision with reasons
Materials on records are perused.
The cause of repudiation as mentioned in the communication of the OP insurance Company made to the Complainant on 02.07.19 is ‘Total hospitalization period is less than 52 hours’. No other reason and this Commission repeats that no other reason was assigned for repudiation of the claim.
The other reason i.e. ‘Surgeries not listed in the surgical benefit annexure’ has been imported by the OP Insurance Company after lodging of the complaint petition by the Complainant. Besides, the OP insurance Company has not submitted the exhaustive list of surgeries not listed in the surgical benefit annexure.
In this situation the Commission is supposed to concentrate upon the sole reason assigned by the OP Insurance Company for repudiation of the claim.
Now the focus lies on the sole issue that whether the repudiation of claim on the ground that the hospitalization period was less than 52 hours was justified or not.
In the instant case the hospitalization period was 49 hours five minutes i.e. two hours 55 minutes short of 52 hours.
The policy was incepted in favour of the complainant in the year 2008 and the claim was preferred in the year 15.04.2019. The yearly premium of the policy was Rs.12000/- per annum. The OP Insurance Company gleefully enjoyed the premiums over the years. But it transpires from the way in which the claim has been repudiated that when the policyholder placed the claim for reimbursement of medical expenses, the OP insurance desperately tried to repudiate the claim by hook or by crook.
It appears that had the hospital stay of the patient been 51 hours 55 minutes, even then the OP Insurance Company might be eager to repudiate the claim on the ground that the hospital stay was five minutes short of stipulated 52 hours.
Common men in our country approach to these insurance companies to get relief from shouldering the burden of huge medical expenses. So far as the documentary evidences filed by the complainant are concerned, the genuineness of the complaint does not appear to be questionable. But the manner in which the complainant’s case has been treated by the OP is thoroughly disappointing. In a desperate attempt to get out of the burden of reimbursement, they have taken recourse to the plea that the hospital stay was less than 52 hours.
In view of the above, the District Commission is of the opinion that the OP insurance Company has refused the claim on filmsy and/or hyper-technical ground.
In the case of M/S OPG Energy Pvt. Ltd. vs The New India Assurance Company (2018) Hon’ble Madras High Court observed that ‘the insurer cannot be allowed to take shelter under a hyper-technical interpretation of the Insurance Contract’.
Arising from the fact that insurance is for protection, courts across the world, find it necessary to limit the misuse of exclusions by insurers. Hence they follow the principle that coverage clauses are to be interpreted broadly and exclusion clauses narrowly.
In light of the foregoing discussion the Commission is of the view that there was gross deficiency of service on the OP insurance Company’s part.
Hence, it is
ORDERED
that the complaint case no.24/2021 be and the same is allowed on contest but in part.
OP 1 and OP 2 who belong to the same organization are hereby directed to reimburse the medical expenses of Rs.1,26,445/- with interest @9% for the period from lodging of the claim to the date of actual payment of the principle amount.
Besides, OP Insurance Company will also be liable to pay Rs.50,000/- towards compensation and further Rs.10,000/- towards litigation cost.
OP insurance Company is hereby directed to comply with this order within 45 days from the date of this order failing which they will be liable to pay Rs.20,000/- to the Consumer Legal Aid A/C
Let a plain copy of this order be supplied free of cost to the parties/their Ld. Advocates/Agents on record by hand under proper acknowledgements/sent by ordinary post for information and necessary action.
The final order will be available in the respective website i.e. www.confonet.nic.in
