SMT. BANDANA ROY, PRESIDENT,
The synopsis of the complaint case is that the complainant is an Agent of the LICI Ltd being Agency Code No. 04461469. He availed a LIC’s Jeevan Arogya Policy from the OP No. 1,the Chief Manager of LICI Tamluk having its office at Health Insurance Department, Kharagpur. Said scheme was started on 28.03.2013. After payment of some installments, the complainant was admitted on 09.05.2014 at Vydehi Institute of Medical Science Bangalore for surgery of spine and he was discharged there from on 23.05.2014. This treatment comes under the terms and conditions of the Health Insurance scheme taken by the complainant. On 19.12.2015 the complainant applied before the OP no. 2 for claim of the medical expenses and at that time he submitted all relevant documents including medical papers. The complainant was shocked to know that in spite of repeated requests, the OP no. 2 did not pay any heed. Thereafter the complainant wrote to the Senior Branch Manager of Tamluk LICI on 07.10.2015 for having claim against his policy No. 459403086 but without any result. On 10.03.2016 the complainant got an intimation from the Administrative Officer, Tamluk LICI that the policy is pending as the Photo ID proof in HTF is required to be attested against policy No. HJ459403086. The complainant spent huge amount for his treatment and according to the terms and condsiti9ns of the said policy he is entitled to get the entire money. Ultimately the complainant sent a legal notice on 14.12.2017 to the OP no. 2 through his ld. Advocate. The OP no 2 replied to the said notice but no effective steps have been taken to liquidate the claim of the complainant.
On the aforesaid grounds the complainant has filed this complaint case before this Ld. Forum for a direction upon the OPs for the reliefs as mentioned in the complaint petition.
Both the opposite parties appeared and contested the complaint by filing written version wherein they denied all the material allegations of the complaint and claimed dismissal of the complaint petition.
The specific defense of these OPs is that the complainant being an agent of the Co. took the Health Insurance for himself under table No. 903 from 28.03.2013 with yearly premium of Rs. 4842/-. He paid his last premium on 13.03.2014 and accordingly the first unpaid premium stands on 03/2015. On 09.05.2014 i.e within 14 months the complainant was admitted in Vydehi Institute of Medical Science, Bangalore and he underwent spine surgery on 14.05.2014. As per discharge summary, he was diagnosed as having L2-3 PIVD and surgery “L.2-3 transpedicular screw and rod fixation and L2-3 discectomy and fusion by TLIF cage done under GA was done. The complainant submitted his claim at Tamluk Branch on 07.10.2015 for hospitalization from 09.05.2014 to 22.05.2014 and the said claim papers were received at the Divisional Health Unit at Kharagpur on 01.12.2015 under Inward No 212. Said claim was submitted after elapse of a period of one year five months whereas normally the claim should be submitted within 30 days from the date of discharge. The said claim was sent to the TPA after condonation of delay on 08.12.2015. Due to some discrepancy in the hospital treatment form filled up by the authority/treating doctor, the same was resubmitted and resent to TPA on 21.01.2016 . The said claim was subsequently rejected by the TPA on 27.01.2016 . There is no documentary evidence of submission of claim and/or application before 07.10.2015 and hence, the allegation against the authority is not sustainable. It is also alleged by the OPs that a welcome kit was signed by the complainant and it was provided to the principle insurer containing policy bond, the health card booklet of privileges and conditions wherein all the terms and conditions of the plan are elaborately stated. The PI was an experiences agent of the LICI since 13.07.2004 and the agent of his own policy and thus he was fully aware of the conditions and privileges laid down under the plan and hence, there was no question of deprivation or deficiency of service , compensation or advice on the part of the LICI in any manner.
The Ops further alleged that the complainant is no way eligible for any kind of payment under said plan for the said hospitalization for the specific surgery of disc disorder.
Under the aforesaid facts and circumstances the OP prays for dismissal of the complaint.
On the pleadings of the parties as above, the following issues need be considered (1) whether the case is maintainable and whether the complainant is entitled to get the reliefs as prayed for.
DECISION WITH REASONS.
Both the points are taken up together for discussion for the sake of convenience and brevity.
Perused the complaint, the written version of the OP, the affidavit in- chief of the complainant, questionnaires by the OP and reply of the complainant. Perused the documents filed by the parties. Heard the argument as advanced by the Ld. Advocate for both sides. Considered.
Admittedly the complainant took one Jiban Arogya (Table No 903), LIC’s non link Health Insurance Policy from Tamluk Branch. The complainant is an agent of his own Health Insurance Policy having Code No. 04461 – 469 of LICI Tamluk and did a only a single Health Insurance so far under his agency code. Admittedly the date of commencement of the policy was 28.03.2013 with yearly premium of Rs. 4842/-for himself only. The complainant paid his last premium on 12.03.2014 and accordingly the first unpaid premium stands as on 03/2015. The OP alleged that on 09.05.2014 within 14th month the complainant was admitted in Vydehi Institute of medical Science in Bangalore and admittedly he underwent for spine surgery on 14.05.2014. According to the discharge summary, issued by the said Institute the disease of the complainant was diagnosed of having L-2-3 PIVD and surgery “L2-3 transpidicular screw and rod fixation and L2-3 discectomy and fusion by TLIF cage done under GA was done. The OP alleged that the principal insured submitted the claim in Tamluk Branch on 07.10.2015 for said hospitalization from 09.05.2014 to 22.05.2014 and the said claim papers were received by the Divisional Health Unit at Kharagpur on 01.12.2015 under Inward No. 212. According to the OP the claim was submitted after elapse of a period of one year five months and the normal claim submission period is 30 days from the date of discharge and after condonation of delay the claim was sent to TPA on 08.12.2015. Due to some discrepancy in the hospital treatment form, the same was resubmitted and resent to TPA on 21.01.2016 but the said claim was rejected by the TPA on 27.1.2016 and the rejection letter dated 02.03.2016 was duly sent to the PI. It is the further contention of the OP that the surgery performed strictly comes under the Sl No VII of the list ( Treatment of slip disc) according to which no benefit are available and no payment will be made by the corporation for any claim under this policy on account of hospitalization or surgery directly or indirectly based on , arising out of or howsoever attributable to any of the following during the specific waiting period ie within a period of two years on the date of commencement of the policy , sickness or hospitalization and/or surgery arises which falls under the listed category, nothing will be paid. It is also alleged that the surgery performance comes under Disc disorder category which falls under the waiting period clause and hence restricts the entire payment of claim as per condition and privileges of the said plan, duly accepted by the petitioner. It is also alleged by the OP that a welcome kit was signed by the complainant and it was provided to the principle insurer containing policy bond, the health card booklet of privileges and conditions wherein all the terms and conditions of the plan are elaborately stated. The PI was an experiences agent of the LICI since 13.07.2004 and the agent of his own policy and thus he was fully aware of the conditions and privileges laid down under the poan and hence, there was no question of deprivation or deficiency of service , compensation or advice on the part of the LICI in any manner.
The complainant alleged in his affidavit-in-chief that due to deliberate negligent management, the petitioner has suffered extreme loss and economic deprivation and the OP have thus caused deficiencies in service and the OPs are responsible and as such they are liable to compensate the complainant as per prayer. He contended that in table no. 903 there was provision for treatment of Disc. Disorder slip disc. As such he sent legal notice on 14.12.2017 through his ld advocate Himangshu Nayek where the Manager of the Kharagpur Divisional Office sent reply in respect of the said legal notice which according to the complainant is completely bad in law.
We have perused the list of major surgical benefits annexure. We find from the major surgical benefits list that though there is no mention of the disease of spine disc surgery but there is mention of many other major surgical benefits. A copy of LICI’s Jivan Arogya condition and privileges is also filed. We have perused the said policy. Ld. Advocate for the OP pointed out to the clause vii of item No. 6 of the terms of the policy and argued that treatment of Disc slip surgery will not come under the scheme and so, the complainant is not entitled to get the benefits as claimed by him, hence, the repudiation too.
We find from the materials on record that the complainant took the insurance in order to get safety of his health and life and he spent huge money for his operation and though no condonation of delay application had been filed before the LICI by the complainant, it cannot be the sole ground for repudiation of the claim as because the OP did not challenge the medical treatment of the petitioner ; there may be many other causes for causing delay in submission of the claim before the OP. Admittedly he had spent huge money for his operation as it appears from the medical papers and documents on record which is not disputed in this case and so considering the above aspect alone, for interest of justice, this Forum consider that the complainant is entitled to get the medical benefit Forum but not the compensation, as prayed by him.
In this regard we find that the Consumer Protection Act confers jurisdiction on the Commission in respect of matters where either there is defect in goods or there is deficiency of service. The Act being a beneficial legislation intended to confer some speedier remedy on a consumer from being exploited by unscrupulous traders, the provisions thereof should receive a liberal construction. (Spring Meadows Hospital Vs. Harjol, (1998) 4 SCC 39.
The complainant has prayed for cost of treatment in hospital per day @Rs. 2000/- for 14 days, total Rs. 28,000/-, major surgical operation cost of Rs. 2,00,000/- and Rs. 2,00,000 for mental tension and loss suffered by him. We have already discussed that the complainant is not entitled to get any compensation for submission of the claim before the LICI without disclosing any explanation for the delay.
Both the points are answered accordingly.
Hence, it is
O R D E R E D
That CC/ 19 of 2018 be and the same is allowed on contest but in part, against the OPs. LICI.
The OPs are hereby directed to pay the complainant a sum of Rs. 2,28,000/- only towards hospitalization and treatment within one month from the date of this order, failing which the complainant will be at liberty to put this order into executionfor recovery of the said amount along with 9% interest per annum on the awarded amount.
There will be no order as to compensation. Parties do bear their respective costs.
Let copy of this judgment be supplied to the parties free of cost.
