In the matter of a petition U/s 12 of the Consumer Protection Act, 1986 filed by the complainant alleging deficiency in service by the Opposite Parties.
The Factual Matrix of the Case is that :-
The complainant purchased a Health Insurance under L.I.C’s HEALTH PLUS PLAN (TABLE-901)through its Agent O.P. No. 3 bearing Policy No. 572197837 for yearly premium of Rs. 12,000/- (Rupees Twelve thousand) only and the aforesaid policy commenced from 04.9.2008 for 14 (Fourteen) years i.e. 04.9.2008 to 04.9.2022. On 20.8.2013 at about 9.30 P.M., the complainant met an accident near Gurudwara at Khariar Road and sustained a head injury and immediately he had been shifted to RAMKRISHNA CARE HOSPITAL, at RAIPUR on the same day and admitted under the supervision of Dr. S.N. Madhariya and shifted to I.C.U. on 21.8.2013 and discharged on 24.8.2013 at about 1.40 P.M. (13.40) and the complainant has paid a sum of Rs. 36,000/- (Rupees Thirty six thousand) to the said Hospital for his Hospitalization and medical expenses and as such he claimed Rs. 36,000/- (Rupees thirty six thousand) before the O.P. No. 1 for the same as he was covered under the aforesaid HEALTH PLUS PLAN of L.I.C’s and thereafter O.P. No. 1 settled the claim and partly paying a sum of Rs. 2,400/- (Rupees two thousand and four hundred) assigning the reasons in the letter dated 21.02.2015 after a lapse of about one and half year which is deficiency in service and unfair trade practice by the Opposite parties. So the complainant sustained financial loss and mental agony due to deficiency in service by the Opposite parties.The cause of action arosed to this complaint on 21.02.2015 when O.P. No. 1 settled the claim arbitrarily and illegally for which the complainant claimed for reliefs as prayed for.
The complainant has filed the documents in support of their claim as under :-
1) Policy under L.I.C’s HEALTH PLUS PLAN (Table 901) bearing No. 572197837 dated 04.9.2008 (Annexure-1).
2) Original Discharge Summary issued by Department of Neuro Surgery of RAMKRISHNA CARE HOSPITAL, RAIPUR, bearing Discharge Serial No. 130824A38494, dated 24.8.2013 (Annexure-2).
3) Medicine prescription of complainant (Annexure-3).
4) Test report of complainant (Annexure-4).
5) Medical expenses bill bearing Receipt No. RC 1300182459, dated 24.8.2013 (Annexure-5).
6) Medical expenses bill bearing No. RC 1300071711, dated 24.8.2013 (Annexure-6).
7) Medical expenses bill bearing No. RC 1300071711, dt. 24.8.2013 (Annexure-7).
8) Xerox copy of claim Intimation Form along with a letter dated10.05.2014 (Annexure-8).
9) Xerox copy of letter dated 17.01.2015 (Annexure-9).
Being noticed, O.P. No. 1 & 2 filed their written version through their Advocate and admitted the allegation of complaint petition of Paragraph No. 1 & 2. In Paragraph No. 3 of the written version, they admitted that “ However the O.P. No. 1 came to know about the accident after receiving the information of the same vide application dated 17.01.2015 of the applicant addressed to the Manager (Health Insurance), Divisional Office, Berhampur”. They have also admitted in Paragraph No. 4 of the written version that the petitioner has submitted a claim of Rs. 36,000/- (Rupees thirty six thousand) from the O.Ps which was considered. They have also stated in Paragraph No. 5 of the written version that the petitioner has been admitted to Hospital on 21.8.2013
and discharged from Hospital on 24.8.2013 and benefit has been paid on the same of Rs. 2,400/- (Rupees two thousand four hundred) to the petitioner. They have also stated in their version that as per the terms and conditions of Plan-901 no benefit would be paid for the first 48 hours (two days) of hospitalization. They have also stated in their written version in Paragraph No. 6 that “ the claim in the prescribed format was submitted by the petitioner on 10.08.2014 ”. The O.P. No. 1 & 2 have also challenged the rest of the allegations of complainant in this case and they have also filed the documents in support of their claims as under:-
1.Xerox copy of introduction of LIC’s Health Plus ( Plan No. 901) without any signature or seal of OP No.1 & 2 which is Anneure –A.
2.Xerox copy of the letter issued to the complainant by Health Insurnace Division office, Berhampur dated 21.112014 ( Annexure-B)
3.Xerox copy of letter dated 17.01.2015 issued by complainant to Manager ( Health Insurance) Divisional office ,Berhampur which is received by the Divisional Office of LIC on 21.01.2015 ( Annexxure –C).
4.Xerox copy of Claim Form submitted by complainant before LIC on 10.08.2014 ( Annexure –D).
5.Xerox copy of letter dated 22.08.2014 issued by Manager( Health) Health Insurance Division office,Berhampur, to B.M. LIC ,Nuapada Branch (Annexure-E).
The O.P. No. 3 appeared but not filed any written version in this case. In the above pleadings, the following issues are framed and considered :-
I) Whether any negligence and deficiency in service and an unfair trade practice on the part of the Opposite parties ?
II) To what relief the complainant is entitled to ?
ISSUE NO. I
On perusal of case records, as well as the documents of the complainant, it is found that the complainant purchased a Health Insurance under L.I.C’s HEALTH PLUS PLAN (Table-901) bearing Policy No. 572197837 for yearly premium of Rs. 12,000/- (Rupees twelve thousand) and commenced from 04.9.2008 for 14 (fourteen) years i.e. 04.9.2008 to 04.9.2022.
But unfortunately, the complainant met an accident near Gurudwara at Khariar Road and sustained a head injury on 20.8.2013 at about 9.30 P.M. and immediately on the very day he had been shifted to RAMKRISHNA CARE HOSPITAL, at Raipur and admitted under the supervision of Dr. S.N. Madhariya and shifted to I.C.U. on 21.8.2013 and discharged on 24.8.2013 at about 1.40 P.M. (13.40) and the complainant paid a sum of Rs. 36,000/- (Rupees thirty six thousand) to the said Hospital for his hospitalization and medical expenses and as such he claimed Rs. 36,000/- (Rupees thirty six thousand) before the O.P. No. 1 for the same as he was covered under the said Health Plus Plan of L.I.C’s but O.P. No. 1 settled the claim and partly paying a sum of Rs. 2,400/- (Rupees two thousand and four hundred) on 21.02.2015 to the complainant instead of Rs. 36,000/- (Rupees thirty six thousand) which is inadequate and squarely absurd by them.
Further it is seen that there is no any specific terms and conditions mentioned in Annexure-1 i.e. Original Policy under LIC’s Health Plus Plan (Table-901) issued by OP No.2 infavour of complainant that no benefit would be paid for the first 48 hours (two days) of hospitalization.
In another vital point is that, as per the Annexure- 1 i.e the Original Policy under L.I.C’s HEALTH PLUS PLAN (Table-901) it has clearly mentioned in the last page of the Plan stating that “ L.I.C’s Health Plus offers you health insurance coupled with ULIP benefit by investing your Savings in the form of “Units” in Health Plus Fund. We trust that this plan will be of immense help to you in managing your health care expenses as well as those of any of your family members who are covered under this policy ”.
As per the above plan, we perceived that the claim of complainant is squarely applicable.
In futher, it is seen that the advocate for OP No.1 & 2 has filed an Annexure –A i.e xerox copy of introduction of LIC’s Health Plus ( Plan-901) without any signauture or seal of OP No.1 & 2 which is clearly contradict the Annexure-1 issued by the OP No.2.
So here, it is visible that Annexure-A is not at all applicable to any corner and any help to OP No.1 & 2 and as such it is not taken in consideration and the plea of OP No.1 & 2 is an unbelivable and it is evasive.
In another factual aspect is that the complainant has already submitted the claim Intimation Form (Annexure-8) and Annexure -D before the O.P. No. 1 & 2 on 10.05.2014 and 10.08.2014 respectively.
Further it is seen that O.P. No. 1 & 2 have stated in their written version that the complainant was admitted in Hospital on 21.8.2013 and discharged on 24.8.2013. But O.P. No. 1 & 2 have settled the claim of complainant absurdly on 21.02.2015 and they violated the
terms and conditions of Annexure-1 which is gross negligence and deficiency in service by the O.P. No. 1 & 2.
In such an uncongenial situation, the complainant has knocked the door of this Forum.
In another factual aspect is that, as per the report of Neuro Surgery Department of RAMKRISHNA CARE HOSPITAL, RAIPUR (C.G.) that the complainant sustained “ HEAD INJURY WITH FRONTAL BONE WITH SAH” and C.T. SCAN HEAD DONE AND SHOWED FRACTURE FRONTAL WITH SAH”. (Anexure-2).
So, it is asserted that the head injury of the complainant is a vital part of body and the complainant was treated conservatively and discharged in a stable condition by the RAMKRISNA CARE HOSPITAL of RAIPUR.
Supporting to the above findings, we quote a decision of Hon’ble National Consumer Disputes Redressal Commission, New Delhi in R.P. No. 3842/2012 “ N. Muthuvels .. V/s .. The Senior Branch Manager, L.I.C. of India and two another decided on 03.5.2013.
Again Supporting to the above findings, we quote an another decision of the Hon’ble National Commission, New Delhi, in R.P. No. 2362 of 2014. The New India Assurance Co. Ltd., and another .. V/s .. Ishu Motwani decided on 23.02.2015.
So, from the perusal of the provision of the Consumer Protection Act, 1986, applied all type of goods and all type of services availed by the consumer against paid or promised. Section 1 (iv) of the Consumer Protection Act, 1986 is of wide connotation.
Further it is seen that there is no any negligence or any deficiency in service from the side of O.P. No. 3 and as such he is not liable in this case.
In this case, the advocate for complainant as well as the advocate for O.P. No. 1 & 2 have argued in support of their claim.
Perused the documents of complainant as well as OP No. 1 & 2 we found that the claim of complainant is justified and relevant and as such taken in consideration.
Hence, it is apparent from the above issues, that there is a deficiency of service and an unfair trade practice by the Opposite Party No. 1 & 2 as not attending properly to the grievance of complainant for which the complainant is suffering financial loss and mental agony due to negligence and deficiency of service by the Opposite Party No.1 & 2.
Thus, the Opposite Party No. 1 & 2 are liable for deficiency in service and unfair trade practice.
ISSUE No II
So, it is clear crystal that, the complainant has proved his case and he is entitled to get relief in this case. Hence, order.
O R D E R.
In the aforesaid matrix of facts and circumstances, the complaint is allowed and we direct U/s 14 (1) (d) of the Consumer Protection Act, 1986 as below :-
1. We direct the O.P. No.1 & 2 to pay Rs. 36,000/- (Rupees thirty six thousand) to the complainant towards his medical claim alongwith interest @ 9% (Nine percent) per annum from 20.08.2013 till payment within 45 (forty five) days from the date of order.
2. We further direct the O.P. No.1 & 2 to pay Rs. 8,000/- (Rupees Eight thousand) to the complainant as compensation towards financial loss and mental agony and further pay Rs. 2,000/- (Rupees two thousand) towards litigation cost within 45 (forty five) days from the date of order.
3. Failing which the above order, the complainant is at liberty to take steps as per process of law.
Judgment pronounced in the Open Court of the District Consumer Disputes Redressal Forum, Nuapada, this the 13th day of March 2018.
