IN THE KODAGU DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, MADIKERI

ORDER DELIVERED BY HON’BLE MEMBER

SMT. GOWRAMMANNI

1. This complaint filed under section 35 of Consumer Protection Act, 2019 The Complaint Prays the following relief against the opposite party:-

1. That the Hon’ble commission may be pleased to pass an Order directing the Opposite party to make Payments due to the complainants from the settlement of claim form out of the Policy as per law and to compensate the compensation as the case may be and pay compensation of Rs.25,000/- towards loss and damage and inconvenience and physical stress and cost and other expenses and pass any such Order as deemed to be fit in the interest of justice.

2. Brief facts of the complaint of the complainant is as under;

1. The complainants are husband and wife. The 1^st Complainant had purchased an LIC Jeevan Arogya Health Insurance Policy on 11/10/2021 from the Opposite party. The Health covers the complainants and their daughter respectfully for a total installment premium of Rs.12,946/- per annum. The complainant has been paying the premium amount without fail. The 2^nd Complainant underwent treatment for her ailment fistula from 12/04/2023 to 17/04/2023 at AJ Hospital Mangalore. After the treatment of the 2^nd Complainant the 1^st Complainant applied to the opposite party for settlement of the claim on 12/05/2023 by providing the opposite party with all the documents as sought for by the OP for the settlement of the claim of the complainants. That on 01/06/2023 the Opposite party sought for additional documents from the complainants to process their claim which was duly complied by the complainants.  Thereafter that on 03/07/2023 the Opposite party vide a letter communication to the complainants that the claim amount has been admitted as per terms and conditions of the policy and have Enumerated the amount as per the different heads that the claim amount is due eligible as per terms and conditions of the policy. On the basis of which Rs.16,500/- was credited through NEFT to the bank account of the insured on 03/07/2023.
2. Further the complainants alleged in their complaint that complainants do not understand the technicalities of the insurance policy and the benefits the policy provides. Further they submitted that the 1^st Complainant had issued an letter to the Opposite party to know the details of the policy and the break off of the amount of Rs.16,500/- But on 22/01/2024 the OP issued an unattainable reply to the complainant. The 1^st Complainant has spent a amount of Rs.1,12,359/- for her wife’s treatment. The opposite party is duty and bound and ought know provide the details of the policy to the policy holder The Act of the Opposite party not furnishing the details of policy of the complainants in spite of the complainants seeking to provide information amounts to deficiency of service Hence this case.

3. After registration of the complaint, notice was issued to opposite party.  In response to the notice, Opposite party appeared through their counsel and filed their version.  

4. Brief Facts of the Version filed by the Opposite parties:-

1. This complaint filed is not maintainable either in law or in the facts of the same is devolved of merits and hence liable to be dismissed. It is submitted that the Opposite party is not aware of the averments made in Para-1 and 2 of the complaint. The complainant may be put to strict proof of the same. It is true to admit that the policy mentioned in the complaint it is health insurance policy and issued to 1^st Complainant who is the proposal and principal insurer of policy. This insurance contract is between principal insured and LIC of India. In the health insurance policy the principal insurer has an option to add any of his family members as additional members to the policy. As such the 1^st Complainant has added his wife as additional other member of the health policy. As a additional member as she will get only the health insurance coverage as per the terms and conditions of the policy. It is true that Opposite party has received claim form from the 1^st complainant for medical treatment taken by 2^nd complainant. The benefits are calculated based on the limits daily benefits opted by the principal insured in the proposal form on the life referred in the policy and the period of hospitalization and type of surgery eligible as per the policy terms and conditions as elaborated in the condition and privileges referred to in the policy documents. The claim has been admitted as per terms and condition of the policy. Further they contented that LIC Jeevan Arogya Policy is a health insurance policy covering prescribed Benefits under prescribed surgeries and daycare benefits. The principal insured will decide the IDB cash benefit payable at the time of submitting proposal to the policy itself. All the benefits will depend in IDB and in the case the principal insured the 1^st complainant as opted 2,000/- as IDB. The additional member of the policy the 2^nd Complainant has undergone operation surgery for fistula and admitted in the hospital for 5 Days which is not listed in the surgical benefits list under this policy. But it is covered entire daycare procedure benefit as per the amount payable under the DCPB. The opposite party has paid Rs.16,500/- to the complainant. The policy is not a medical reimbursement policy. The benefit under the policy are payable as per the policy terms and conditions.
2. The opposite party further they denied contention taken by the complainants made in the Para 8 of the complaint. They further contended that after accepting the Policy accordingly LIC has issued policy bond and LIC has given an opportunity to the life assured to cancel his policy within 15 days from the date of Receipt of the policy bond. If he has not satisfied with the terms and conditions of the policy cancelling of period further they contended that Jeevan Arogya Policy is not a medical reimbursement policy the benefit under the policy are not directly relate to the actual expenses incurred by the principal insured or additional member under the policy. The benefits are calculated based on the basis daily benefit opted by the principal insured as per the proposal form.   The Opposite party denied the Para 12 of the complaint. They contended that it is to stage that the proposal as proposed the LIC Jeevan Arogya Only after getting full details of the policy features terms and conditions. Accordingly the OP has issued the policy bond to the complainant. There is no delay or deficiency in the service of this Opposite party LIC of India. Further they denied the allegation made in the Para 13 of the complaint. They submitted that LIC is a premier financial institution and the main object of LIC is to spread Life Insurance widely to the rural areas and to the society and economically backward classes with a view to reaching all insurable persons in the country and providing them adequate financial power against death at a responsible cost to the policy holder.  The amount so collected from the policy holders are held in its complexity on trustee to public money which will be returned to the family members of the insured in case of contingencies. The compensation is not expected part with money by honoring such unlawful claims as it is holding  public fund as a trustee which in fact is belonging to the policy holder at large.  Further they denied the entire facts of the complaint. The opposite party reserve the right to alter or add any additional information at a later stage.
3. Wherefore the opposite party prays that the Hon’ble commission may kindly be pleased to dismiss the complaint with cost in the ends of justice and equity.

5. In this case 1^st complainant filed his examination-in-chief by way of affidavit evidence as CW-1 with 11 documents marked as exhibits C-1 to C-11. And The Opposite party has filed their examination-in-chief by way of affidavit evidence taken as RW-1 with 02 documents marked as exhibits R-1 to R-2. Both parties filed their written arguments, Heard the oral arguments of both the parties and posted for orders.
6. The points that would arise for our consideration are as under;
   1. Whether the complainant proves the deficiency in service by the opposite party and thereby he is entitled for the reliefs sought ?
   2. What order ?

7. Our findings on the above points are as under;
   1. Point No.1 :- Partly Affirmative
   2. Point No.2:-  As per the final order for 
   13031.  

R E A S O N S

1. Point No.1:- Perused that contents of complaint, objection of the opposite party affidavit evidence and documents produced by the both parties, we noticed that the opposite party have admitted that the LIC Jeevan Arogya Bearing Policy No.725442837 issued to the 1^st Complainant on 11/10/2011. There is no dispute with regard to the said policy. The main dispute arise in this case the opposite party did not provide policy details and policy benefits information and privileges of the said policy to complainant at the time of issuing the insurance policy.
2. In this case complainant alleged in their complaint the policy was covered to his wife and his daughter. His wife underwent treatment for Fistula at AJ Hospital, Mangalore. She was admitted in the said Hospital on 12/04/2023 to 17/04/2023. Thereafter the complainant submit the claim form to OP and provide all details sought by the OP. But the opposite party have settled the claim amount of Rs.16,500/- Only. The complainant spent a sum of Rs.1,12,369/- rupees for his wife medical treatment. Without sufficient reason, opposite party has given the small amount of claim. Further complainant alleged that in their complaint he has given a letter to OP at what basis they calculated the claim amount instead of that the Opposite party gave a untenable reply and they were not produce any policy information and benefits of the policy and they made a deficiency of service.
3. In this  case opposite party took a specific contention that as per the policy terms and conditions the policy holder and the assured member are eligible for benefit as per initial daily cash benefit chosen the principal head assured. The benefits are covered at the based on the initial daily benefit opts by the principal insurer in the proposal form on the life return in the policy. The policy is not a medical reimbursement policy, the benefit under the policy are payable as per the policy terms and conditions and further they contended that complainant by selecting the proposal form after thoroughly understand the policy features, terms and conditions and as accepted the conditions then only put his signature to the proposal form. After accepting the same accordingly, LIC has issued the policy bond and also LIC has given an opportunity to the Life insured to cancel his policy within 15 Days from the days of receipt of the policy bond if he has not satisfied with the terms and conditions of the policy.   
4. The complainant counsel vehemently argued that the OP has given untenable reply they never furnish the additional sheet attached in the original policy bond also. It is the bound on duty of the OP have must provide the policy benefits details and information to the customers at the time of issuing the policy. In spite of the complainants seeking to provide information the act of the opposite party its amount to deficiency of service. In support of their argument they cited Supreme Court Case Civil Appeal No.3821/2024, Mahakali Sujatha Vs The Branch Manager, Future General India Life insurance company Limited and another.
5. In this case opposite party counsel vehemently argued that the Jeevan Arogya Policy is a daily benefit the policy covered under daily cash provisions benefit. The policy holder and his additional member are eligible for benefit as per the initial daily cash benefit chosen the principal life assured and OP has issued the policy bond along with conditions and prospectus under Jeevan Arogya Policy. The claim has been accepted as per terms and conditions of the policy and the policy is not a medical reimbursement policy. In support of their argument OP has produced the proposal form showing in the details provide by the 1^st Complainant and copy of the policy bond and conditions and privileges.
6. We gone through the materials placed before the commission which were carefully observed that the complainant himself accepted the proposal form and he choose the daily benefit. Even though the opposite party  has settled the claim amount of Rs.15,500/- on the basis of initially day care benefit. But at the time of issuing the Arogya Jeevan Policy, the OP has not provide policy bond and conditions and other information to the 1^st Complainant. They issue only policy 1^st Page copy they never disclose the policy terms and conditions details. After the treatment of his wife complainant sent a claim form to the Opposite party they settled the claim on the basis of daily benefit. Thereafter complainant wrote a letter to OP for clarification of the claim settlement.  On that time OP has disclosed the policy benefit, the act of the OP does not fair because as the early stage it is the bound on duty of the OP for provide policy details and benefits. As such the contention taken by the opposite party does not hold by the commission.
7. Opposite party reply to the complainant they stated in their letter as per initial daily cash benefit chosen by you please check the details of settlement in the additional sheet attached in Original Policy bond also. As per OP contention there is no attached sheets attached in the policy bond which was given to 1^st Complainant during the evidence time OP has produced the Exhibit R-1 and R-2 but they never gave policy details and information and benefit details to complainant at the time of early stage. Instead of that the OP has argued Arogya Policy which was accepted by the 1^st Complainant is not a medical reimbursement policy he himself accepted the daily benefit provisions if he has not satisfied with the conditions of the policy he has got every right to cancel the policy within 15 days, but complainant accepted the proposal form and he has signed and accepted confirming the policy for the aforesaid reason there is no deficiency of service on the part of the LIC. As per policy terms and conditions we acted upon and settled the claim.
8. For a better appreciation of the controversy it would be important to analysis Utmost good faith and ground. The Insurance contracts it may also be observed that insurance contracts are special contracts based on the general principals of fair disclosure in as much as person seeking insurance is bound to disclose all materials facts relating to the risk. As the insured  has a duty to disclose all material facts the insurer must also inform the insured about the terms and conditions of the policy that is going to be insured to him and must strictly confirm to the statement in the proposal form or prospectus or those made through his agents. It is claim that the principal of utmost good faith puts recipient duties of disclosure on both proposal to the contract of insurance. These reciprocal duties material that both the parties makes complete disclosure to each other so that the parties can take an informed decision and a fair contract of insurance easily between them. No material facts should be suppressed which may have a bearing on the risk being insured and the decision of the party to undertake that risk. 
9. However as per the policy terms and conditions in this policy covered only daily benefit even though the OP should have provide the policy details as much early at the time of issuing the insurance policy. The condact of the opposite party its amount on to deficiency of service hence the contention taken by the opposite party that is not sustainable in the eye of Law.
10. In the above case as per R-1 and R-2 it is clearly shows that the said policy was opted only daily benefit privileges. As such we looked into only deficiency of service. According to section 2 (11) of CP Act 2019, deficiency defined as under:
11.  

1. Any act of negligence omission or commission by such person which causes loss or injury to the consumer; and
2. Deliberate withholding of relevant information by such person to the consumer;

11. Herein the above case the OP has not provide policy details complainant continuously paid that premium amount regularly to the opposite party. Nowadays most of the insurance companies they attract the consumers to invest the money with their sector and introduce variety of policy schemes they advertised many more benefits and privileges with regard to the new policy schemes at the same time they entering into the insurance contract they never disclose the policy benefits and details and even no one cannot read the policy conditions because of they print the terms and conditions very small font it cannot be legible in reading by common man or Either educated person. Most of the peoples were buying the insurance policies, they trust with insurance company services.
12. Taken into account the aforesaid discussion we opined that opposite party committed a deficient of service to provide policy details and information to the complainant as such OP is liable to pay a compensation of Rs.20,000/- for deficiency of service and further they liable to pay cost of the proceedings of Rs.5,000/- to the complainant in the above case.  For the aforesaid facts and circumstances of the case we answer Point No.1 in Partly Affirmative.
13. Point No.2:- From the discussion made above and conclusion arrived at, we pass the following order;

O R D E R

1. The complaint of the complainant under section 35 of Consumer Protection Act 2019 is Partly Allowed.
2. The opposite party is hereby directed to pay compensation of Rs.20,000/- (Twenty Thousand Rupees) for deficiency of service to the complainants  within 45 days from the date of receipt of this order.  Failing which opposite party is directed to pay interest at 12% per annum with said amount till the realization of this order.
3. The opposite party is further liable to pay the compensation of Rs.5,000/-  (Rupees Five Thousand only) towards  the cost of the proceedings.
4. Copy of this order as per statutory requirements be forwarded to the parties at free of cost and file shall be consigned to record room.

 (Dictated to the Stenographer, transcribed, corrected and pronounced in     the Open Commission on this 07^th DAY OF OCTOBER, 2024)

 (GOWRAMMANNI)                      (RENUKAMBA.C)                                                      

                      MEMBER                              PRESIDENT(I/C)    

ANNEXURE

Witnesses examined on behalf of the complainant

CW-1- Herbert Claudis Lobo, aged 61 Years, Near Lotus Super Market, Omkareshwara Temple Road, Brahmin Valley, Madikeri-571201

Documents marked on behalf of the complainant

Ex.C-1 : Copy of the LIC Jeevan Arogya bearing Policy No.

                     725442837 Table (903) health insurance policy dated

                       11/10/2011.

Ex.C-2:  Copy of the Acknowledgment of last premium paid by

   The complainants dated 25/09/2023

Ex.C-3 : Copy of Reminder by opposite party No.2 dated 01/06/2023

Ex.C-4:- Copy of Settlement of claim by Opposite party No.2 dated

                03/07/2023.

Ex.C-5:- Certified copy of the account statement of the 1^st Complainant           along with postal acknowledgement dated 16/1/2024

Ex.C-6:-   Undated letter to the opposite party No.1 by the 1^st        complainant

Ex.C-7:-   Reply to the undated letter by the opposite party No.1

                Dated 22/01/2024

Ex.C-8:-   Postal Acknowledgement.

Ex.C-9:-   Medical Bills from 12/04/2023 to 17/04/2023 (30)

Ex.C-10:- Copy of the LIC health card of the 1^st complainant.

Ex.C-11:- Copy of the Aadhaar Card of the 2^nd Complainant.

Witnesses examined on behalf of the Opposite Party:-

RW-1:- B.R.Sreepada Rao, aged 55 Years, S/o B.Ramamurthy,  Administrative Officer, Legal Department, LIC of India,  Mysore.

Documents marked on behalf of the Opposite Party :-

Ex.R-1 : Certified copy of the Proposal Form showing the details provided

   By Sir. Herbert Claudis Lobo.

Ex.R-2:  Copy of the Policy bond and conditions and Privileges.

                                                                   (GOWRAMMANNI)

Dated: 07.10.2024                                         MEMBER