Gopal Chandra Saha,

son of late Banimadhab Saha,

residing at 44/4, Kumar Para Lane, P.O. Liluah,

P.S. Bally, District – Howrah,

PIN – 711204.-------------------------------------------------------------------- COMPLAINANT.

-          Versus   -

1.      The Divisional Manager,

Life Insurance Corporation of India,

Howrah City Branch,

506, G.T. Road ( S ), Fazirbazar,

District – Howrah,

PIN – 711101.

2.      The Regional Manager,

 Life Insurance Corporation of India,

Rallis Building,

16, Hare Street,

Kolkata – 700001.

3.      Medicare TPA Services ( I ) Pvt. Ltd.,

6, Bishop Lefrey Road,

Kolkata – 700020.

4.      Subhas Chandra  Bera,

residing at 100,  Rabindra Sarani,

Liluah Co-operatrive Housing, P.O. Bhattanagar,

District- Howrah,

PIN  – 711203.-----------------------------------------------------OPPOSITE PARTIES.

                                                P    R    E     S    E    N     T

President     :     Shri T.K. Bhattacharya, M.A. LL.B. WBHJS.

Member      :      Shri P.K. Chatterjee.

Member       :     Smt. Jhumki Saha.

                                                 F  I   N   A    L       O   R   D    E     R

1.                  The instant case was filed by complainant   U/S 12 of the  C.P.  Act, 1986,

as amended against the O.Ps.  alleging deficiency in service U/S 2( 1 )( g ),  2( 1 )( o ) of

the C.P. Act, 1986 wherein the complainant has prayed for passing necessary direction

upon the O.Ps.  1 & 2 Life Insurance Corporation of India, to pay the claim amount of Rs. 86,800/- and for further  sum of Rs. 2,50,000/- as compensation for harassment, mental agony as the O.Ps. insurance company repudiated his medi claim on the ground that the surgery operation is not listed in the allowed surgeries.

2.                  The o.p. nos. 3 & 4 in spite of service of notice did not appear. So the case

was heard ex parte against the O.P. nos. 3 & 4.   

3.                  The O.P. nos. 1 & 2 in their written version contented interalia that the

complainant owes a Health Plus Policy being no. 4389944653 with L.I.C. Howrah under Plan No. 901 together with his wife on and from 24-03-2008 ad paid a yearly installment premium of Rs. 7,500/- and the same covered as per policy term i) daily hospital cash benefit for the principal insured as well as to the insured’s spouse and that to assure for major surgical benefit of  Rs. 1,00,000/- to be given to principal insured as well as to the insured’s spouse. The complainant incurred huge expenses for his treatment amounting to Rs. 1,50,000/- for which a sum of Rs. 13,200/- was paid on account of daily hospital cash benefit.  The O.P. nos. 1 & 2 repudiated the major portion of the claim amount of the complainant as the surgery that was undertaken is not listed in the allowed surgeries of the policy containing the list of disease and such the complaint should be dismissed.

4.                  Upon pleadings of both parties two points arose for determination :

i)          Is there any deficiency in service on the part of the O.Ps. 1 & 2  ?

ii)                  Whether the complainant is  entitled to get any relief as prayed for ? 

DECISION  WITH   REASONS      :

5.         Both the points are  taken up together for consideration. Admittedly the complainant procured a Health Plan Policy being no. 438994653 for i) daily hospital cash benefit for Rs. 500/- to the principal insured as well as to the insured’s spouse and ii) major surgical benefit of sum assured of Rs. 1,00,000/- to be given to the principal insured as well as to the insured’s spouse. When the complainant fell ill  due to sudden cardiac problem, blockage of heart was detected in the N.R.S. Medical College & Hospital, Kolkata, and accordingly on 14-08-2012 where the CABG ( off pump ) 1 graft RSVG Lad Surgery was done for clear of the heart blockage later as per advice of Dr.P. Bondoapadhyay on 25-08-2013 of NRS Medical College & Hospita, Kolata, that the patient / complainant has been suffering from Ischemic Heart Diseases, complainant needs to coronary artillery bypass crafting   under C.P. Bypass for which the complainant undergone on 29-08-2012 the CABG ( off pump ) one graft RSBG Lad Surgery at the said hospital. The enclosures reveal that the complainant observed all the necessary formalities and submitted the claim before the O.P. no. 1 & i.e., LICI but unfortunately the major portion of claim i.e.,  Rs. 86,800/- ( Rs. 1,00,000 – Rs. 13,200 ) was repudiated on the ground that the major surgical benefit as undertaken by the complainant / insured was not within the list of 49 diseases maintained in the policy terms and conditions.

6      Now the pertinent question arises how the complainant can be made deprived by

repudiating the claim of the complainant when he initiated his mediclaim, the O.P. nos. 1 & 2, LICI has sufficient opportunity to consider the claim because of the fact that the complainant is a layman and that to they will not be knowing the conditions of the policy as they are from rural areas. Therefore, we are of the view that such innocent person shall not be made to suffer only because he has taken treatment in the hospital in view of the facts that the complainant underwent a surgery is not disputed.

7.   We have heard ld. Counsel for the petitioner and have gone through the evidence on record submitted by the complainant also the corresponding prescription and discharge certificate issued time to time by the concerned medical practitioner makes it clear that the medical benefit shall mean in patient hospital including the related surgery which can be availed by the member/s subject the maximum eligibility as per policy. However, considering complication his medical condition was ignorance of the terms and conditions for which the LICI was found cannot be a justification for him not adhearing to those and yet insisting on claiming the benefit of medical treatment under the scheme/ policy.

8.   We have therefore, of the view that the O.Ps. LICI committed gross deficiency in service in repudiating the bonafide claim of the complainant. They have no way escape from the rigours of law. We have examined the enclosures meticulously. The O.P. nos. 1 & 2  LICI was  thoroughly unjustified in turning a deaf ear to the claim of the complainant.  This is a fit case where prayer of the complainant shall be allowed.  

      The points are accordingly disposed of.

      Hence,

O     R     D      E      R      E        D

      That the C. C. Case No. 134  of 2013 ( HDF 134  of 2013 )  be  allowed on contest with  costs  against  the O.P.  no. 1  and ex parte without cost against O.P. nos. 3 & 4.

      The O.P. no. 1, Divisional Manager, L.I.C.I. Ltd., Howrah City Branch,   be directed to  release the mediclaim to the tune of Rs. 86,800/- to the complainant within 30 days from the date of this order failing the claim shall carry interest @ 9% p.a. since the date of submission of  further claim on 02-04-2013 till  satisfaction.

      The O.P. no. 1, Divisional Manager, L.I.C.I. Ltd., Howrah City Branch, do also pay a sum of Rs.  30,000/- as compensation for causing mental pain and prolonged harassment to the complainant.

      The complainant is  also entitled to a litigation cost of Rs. 5,000/-.

      The complainant is at liberty to put the decree into execution after expiry of the appeal period.

      Supply the copies of the order to the parties, as per rule.

DICTATED  &    CORRECTED

BY   ME.  

         ( P. K. Chatterjee.)                                               (    P. K. Chatterjee)

  Member,  C.D.R.F.,Howrah.                                    Member, C.D.R.F.,Howrah.

 (  Jhumki Saha  )                                                              (  T. K. Bhattacharya  )

 Member, C.D.R.F.,Howrah.                                       President,  C.D.R.F.,Howrah.