Date of filing: 15.09.2015 Date of disposal: 21.12.2017.
Complainant: Dipak Kumar Karmakar, S/o. Lt. Damador Karmakar, resident of Vill. & P.O.-
Nadiha, P.S.-Durgapur Coke Oven, Dist.-Burdwan, Pin-713211.
-VERSUS-
Opposite Party: 1. The Life Insurance Corporation of India, Asansol Division, represented
through its Sr. Divisional Manager (HI Claims), having its office at Jeevan
Prakash, West End, G.T. Road, Asansol, Pin-713304
2. The Life Insurance Corporation of India, Durgapur Branch, represented
through its Branch Manager, having its office at Nehru Avenue, B-Zone,
Dist.-Burdwan, Pin-713205.
3. The Medicare TPA Services (I) Pvt. Ltd., represented through its Manager,
having its office at 6, Bishop Lefroy Road, Kolkata-700 020.
4. E-Mediek (TPA) Services Ltd., represented through its Director, having its
office 577, Udyog Vihar, Phase-IV, Gurgaon, State Harayana, Pin-122016.
Present: Hon’ble President: Smt.Jayanti Maitra(Ray).
Hon’ble Member: Miss Nivedita Ghosh.
Appeared for the Complainant : Ld. Advocate, Suvro Chakraborty.
Appeared for the Opposite Party No.1 & 2: Ld. Advocate Sourabh Dey
Appeared for the Opposite Party No.3 : Ld Advocate Amitava Chowdhury.
JUDGEMENT
This is a case U/s. 12 of the C.P. Act for an award directing the O.Ps. to pay Rs.2,19,980/- towards treatment expenses of the complainant, to pay Rs.25,000/- towards compensation for mental pain, agony and harassment, to pay litigation cost of Rs.10,000/- to the complainant and to pay an interest @ 12% from 20.8.2013 till realization to the complainant.
The complainant’s short case in hand is that the complainant got a Medi Claim Insurance Policy of the Life Insurance Corporation of India i.e. the O.P. 1 & 2 by covering the risk of the
complainant, his wife and his son for treatment and hospitalization expenditure in the year 2013. The maturity date of the policy is 15.3.2040. After getting the proposal the O.P. No.1 & 2 issued the Health Policy bearing Policy No.449686462 after taking Rs.7,206/- as premium on 15.3.2013.
During continuation of the policy the complainant had to admit in DSP Hospital at Durgapur on 4.8.2013 as he became senseless. The complainant discharged from the hospital on 5.8.2013. The treating doctor of DSP Hospital referred the complainant to Higher Centre for further evolution and management of cardiology. Thereafter the complainant went to Apollo Hospital at Chennai for better treatment and admitted there on 16.8.2013. Before admission in the Apollo Hospital some tests were done by the Department of Cardiology of said hospital. After going through the report of diagnosis the said hospital putting Pacemaker on 17.8.2013 to the complainant and discharged the complainant there from on 20.8.2013 after payment of Rs.2,19,980/- as treatment cost.
After discharged from the Apollo Hospital the complainant submitted claim form duly signed by the treating doctor on 20.8.2013 along with documents relating to his treatment. On 21.3.2014 the O.P. Insurance Company sent a letter to the complainant asking for some documents. The complainant in his reply dated 25.3.2014 stated that he already submitted all the documents as sought for by the Insurance Company. Thereafter the complainant again received another letter dated 30.4.2014 from the O.P. No.1 & 3 asked for providing documents. Though the complainant submitted documents previously, he again obtained the certificate of the treating doctor of DSP Hospital and submitted before the O.P. No.1. But very surprisingly the O.P. No.1 sent another letter for providing documents. On 10.1.2015 the O.P. No.3 sent a letter to the complainant asking for providing original ECG and Holter report. In reply the complainant submitted original ECG and Holter report on 19.1.2015 and requested to settle the claim as early as possible. On 31.3.2015 the complainant received a letter from the O.P. No.3, stating that ‘hence the claim is to be rejected instead of keeping it open indefinitely’. Through that letter the O.P. No.3 again asked for providing some documents which were duly submitted by the complainant earlier to the O.P. No.1. The complainant gave reply of that letter on 4.5.2015 stating the fact that the graph of ECG is not available from the report after a long period and as such he submitted the photo copy of the ECG done by the Apollo Hospital. Inspite of receiving the letter from the complainant the O.Ps. neither repudiated the claim nor settled the claim of the
complainant, just dragging the matter by asking one after another documents. Finding no other alternative the complainant filed the instant case before this Forum for relief as stated above.
The O.P. No.1 & 2 contested this case by filing written version stating the fact that the complainant Dipak Kumar Karmakar took a LIC Policy from the O.P. No.2, Life Insurance Corporation of India, Durgapur Branch-1, under LIC’s Jeevan Arogya Plan (Table No.903), being policy No.449686462 with the date of commencement on 15.3.2013 for availing Medical Benefit, as per terms and conditions of LIC’s Jeevan Arogya Plan having initial Daily Benefit of Rs.1000/- and Maximum Major Surgical Benefit for Sum Assured of Rs.1,00,000/- (i.e. 100 times of Initial Daily Benefit). Be it mentioned that complainant purchased the aforesaid policy for availing benefit of 140 days care surgeries and 140 major surgeries with certain percentage of sum assured of the policy. In the complaint the complainant state that he has availed medical treatment from 4.8.2013 to 5.8.2013 under DSP Hospital. But these O.Ps. had no knowledge about it and in that respect the complainant did not stated the said matter in his hospital treatment form. It is found from the hospital treatment form and discharge summary of Apollo Hospital, Chennai that the complainant availed medical treatment from 16.8.2013 to 20.8.2013. These submits that as per conditions and privileges of the LIC Policies the LICI may use the services of one or more licensed Third Party (TPA) to manage various aspect of administration including but not Limited to Claims Administration. The insured agreed to provide all necessary and accurate information to such authorized TPA and follow the process and instruction as stipulated by such TPA for smooth administration of the policy.
Be it mentioned that O.P. No.3, Medicare TPA Services(I) Pvt. Ltd. was the Third Party Administrator (TPA), who was appointed for speedy settlement and disbursement of legitimate claims raised by the holders of the said LIC’s Jeevan Arogya Plan. It appears from the document and papers that the complainant demand Rs.1000/- X 3 i.e. Rs.3000/- for daily hospital cash benefit and Rs.2,19,980/- for major surgical benefit due to medical treatment at Apollo Hospital for the period from 16.8.2013 to 20.8.2013 and procedure done on 17.8.2013 for Dual Chamber Pacemaker. On scrutiny of the document the TPA denied the claim on 31.3.2015 for non-compliance of the requirement asked by the TPA on several times. It further mentioned that in Claim Form, the complainant claimed hospital cash benefit for Rs.3000/- (i.e. Rs.1000/- X 3 days), the said rate has been mentioned in the front page of the policy bond. The complainant demanded the said amount i.e. Rs.3000/- as per conditions and privileges of the policy submitted by the complainant with the complaint petition in Page-2 of Annexure ‘S’ under Head 2, Benefits (I). The complainant also demanded major surgical benefit for Rs.2,19,980/- in his claim form for implantation of pacemaker on 17.8.2013. But as per terms and conditions of the policy in question bearing No.449686462, it is not related to the actual expenses incurred by the complainant. The actual major surgical benefits is elaborately stated in the conditions and privileges of the policy submitted by the complainant with the complaint petition in page-10 of Annexure ‘S’ serial No.7 (Initial Implementation of Permanent pacemaker in the Heart) of list of Major Surgeries and under this item 60% of Sum Assured of Rs.1,00,000/- [Sum Assured is mentioned in the conditions and privileges of the policy submitted by the complainant along with the complaint petition in Page-2 of Annexure ‘S’ under Item No.1 (XXX)] i.e. Rs.60,000/- as mentioned there.
These O.Ps. further stated that an Insurance Policy is a contract between the two parties and in terms and conditions once accepted are binding both the parties. The terms of the policy have to be construed as it is and Life Insurance Corporation of India cannot add to subtracts something and as such the insured, Dipak Kumar Karmakar cannot claim anything more than what is covered by the Insurance Policy bearing No.449686462. After receiving the denial letter issued by the TPA, Medicare TPA Services(I) Pvt. Ltd., the complainant submitted the ECG Report on 4.5.2015. Thereafter, O.Ps. No.1 & 2 referred the case i.e. the claim file to a newly appointed TPA E-Meditek, being the TPA Services Ltd. instead of earlier TPA, Medicare TPA Services(I) Pvt. Ltd. On scrutiny of the entire/total claim file, the said newly appointed TPA, E-Meditek (TPA) Services Ltd. found from the discharge summary of Apollo Hospital that the complainant was chronic smoker and he did not disclose the same in the proposal form at the time of purchasing of the aforesaid policy in question. In the proposal form for assurance dated 26.2.2013 the complainant stated that he does not use Alcohol, Cigarette, Bidis or Tobacco. These O.Ps. also stated that the complainant signed a declaration ( in page-5) of proposal form. So, any inaccurate answer will entitle the insurer to repudiate his liability because there is clear presumption that any information sought for in the proposal form is material for the purpose of entering into a Contract of Insurance. Considering the said fact the E-Meditek (TPA) Services Ltd. rejected the claim on 9.6.2015 on the ground that the complainant is not eligible for the claim as he does not fall under the purview of the policy terms and conditions and does not satisfy the same and as such the liability under the claim is rejected Following the reasos:-
- Self Afflicted Injuries or Conditions (Attempt Suicide) and/or the use or misuse of any Drug or Alcohol.
- Self Afflicted Injuries or Conditions (Attempt Suicide) and/or the use or misuse of any Drug or Alcohol.
Thereafter these O.Ps. rejected the claim of the complainant, as it does not fall under the purview of the policy terms and conditions. Hence, this case and prayed for dismissal of the instant complaint.
The O.P. No.3, Medicare TPA Services (I) Pvt. Ltd. contested the case by filing written version stating that the claim was adjudicated by the panel of Doctor of O.P. No.2 strictly following the policy conditions and the guide lines laid down by the O.P. No.1 company. The O.P. No.3 has no power to adjudicate any claim willfully without following the guideline of IRDA and referred their decision to the Insurance Company.
The O.P. No.3 also communicated the aforesaid decision of repudiation of the claim vide letter dated 31.3.2015 to the complainant. The O.P. No.2 stated that it is the complainant who did not submit all required documents after repeated request and as such he cannot ask for any relief in this instant case. The complainant cannot take advantage of his own wrong. He cannot shift his burden upon this O.P. There was no negligence on the part of this O.P.in processing the claim of the complainant.
The O.P. No.3 also submits that the dispute raised by the complainant in the present complaint is manifestly outside the purview of the said act and in any event, the act in addition to and not in derogation of the provision of the other act. Therefore, the proceeding initiated by the complainant under the act does not have any legs to stands, wholly null and void and without jurisdiction. This O.P. also stated that the present complaint is frivolous and vexatious and very much liable to be dismissed U/s. 26 of the C.P. Act.
DECISION WITH REASON
To prove the case the complainant has filed his evidence on affidavit and O.P. No.3 filed questionnaires to his evidence and the complainant files answers to the questionnaires.
O.P. No.1 & 2 prayed for considering their written version supported by affidavit to be taken as their evidence. No questionnaires on the evidence of the O.P. No.3 is filed by the complainant. Thereafter both parties advanced their arguments elaborately. After going through the materials on record and evidence of complainant, questionnaires, answers to questionnaires and evidence of O.P. No.3 and also perusal of the documents filed by the parties, it is clear to this Forum that the complainant submitted claim form along with medical documents from the treating doctors and hospital that he was first admitted in DSP Hospital at Durgapur and thereafter he was treated at Apollo Hospital at Chennai, where on 17.8.2013 he had undergone operation for implantation Pacemaker for his heart disease. He filed documents showing expenses for treatment for that purpose and he claimed Rs.2,19,980/- was incurred as expenses. In his claim form the complainant stated all the facts with documents and filled up the same following the terms and conditions of the policy. The complainant alleges that the O.P. surprisingly called for documents of treatment which he had already sent to the O.ps. However, he complied and repeatedly requested to settle the claim as early as possible. Ultimately on 31.3.2015 he received the letter of repudiation of claim. Complainant gave reply of the letter on 4.5.2015 stating the fact that ECG report after a long gap of time was not up to the mark as the graph of ECG faded away from the photocopy of ECG done by Apollo Hospital.
O.P. No.1 & 2 contested this case admitting the policy purchased by the complainant namely Jeevan Arogya Plan and the insurance paper goes to show initial Daily Benefit of Rs.1000/- but the maximum major surgical benefit for sum assured is Rs.100000/-. The terms and conditions of the policy defined 140 major surgical benefit of operation with certain percentage of the sum assured of the policy. The Ld. Lawyers of both sides agreed and concedes to this point. From the policy papers submitted by the O.P. we also find [Annexure- S (XXX)] wherein the percentage of major surgeries of 160 numbers has been defined specifically. In the item No.7 of the list which is ‘initial Implantation of Permanent Pacemaker for which major surgical benefit of sum assured as prescribed is only 60% under cagagory-2’. We have gone through the list of the policy papers and it is definitely 60% of the sum assured for surgical benefit under this policy. The sum assured is Rs.100000/-, therefore, the insurer can avail only Rs.60,000/- as benefit for his Implantation of Permanent Pacemaker.
The O.P. No.3, Medicare TPA Services also submits his argument in this regard mentioning Annexure-S and stated that the sum of Rs.3000/- demanded by the complainant does not related to the actual expenses incurred by the complainant in terms of the policy and the complainant is not entitled to receive any further sum of Rs.3000/- beyond Rs.60,000/-. TPA also submitted that the complainant illegally demanded Rs.2,19,980/- for implantation of Pacemaker which he is not actually entitled under the terms and conditions of the policy. This O.P. further argues that in the proposal form the complainant suppressed the fact that he is a chained smoker but in the treatment sheet of Apollo Hospital the complainant is identified as chronic smoker. Considering this fact the E-Meditek TPA Services argued that Insurance Company rightly rejected the claim of the complainant on 9.6.2015 that he does not fall under the purview of the policy as he suffered from Self Afflicted Injuries or Condition for use or misuse of drug or alcohol. But O.Ps. failed to prove that whether Tobacco is in the category of drug or alcohol or not. Therefore, we find that repudiation of claim on this ground is not tenable. We hold that O.P. Insurance Company isnegligent and deficient in service for not settling the claim of the complainant in terms of the policy.
After hearing Ld. Lawyers of both sides and on perusal of the materials on record as well as argument advanced by the parties this Forum finds that complainant has been able to prove that he had undergone the operation of implantation of Pacemaker on 17.8.2013 in the Apollo Hospital at Chennai and submitted all the relevant papers in this regard. Therefore, as per Terms and Conditions of the policy he is entitled to receive 60% of the sum assured as Major Surgical Benefit Annexure (Item No.7 of the list). The complainant is also entitled to get compensation for mental pain and harassment and also for litigation cost. Hence, the complaint is succeeds in part.
C.F. paid is correct. Hence, it is
Ordered
that the case be and the same is allowed on contest in part against the O.Ps. without any cost.
The O.P. No.1 & 2 are directed to pay Rs.60,000/- as Major Surgical Benefit to the complainant.
The O.P. No.1 & 2 are also directed to pay Rs.3000/- towards compensation for mental pain, agony and harassment to the complainant.
The O.P. No.1 & 2 are further directed to pay Rs.2000/- as litigation cost to the complainant.
The above all directions will be complied with within 45 days from this date of order, failing which an interest @ 8% will be carried on total awarded amount. The complainant is at liberty to execute this order in accordance with law.
Jayanti Maitra (Ray)
Dictated and corrected by me. President
D.C.D.R.F., Burdwan
Jayanti Maitra (Ray)
President,
D.C.D.R.F., Burdwan
(Nivedita Ghosh)
Member
D.C.D.R.F., Burdwan
