Karnataka

Gadag

CC/15/2015

Smt. Parveen W/o Mohammadshafi Kagadagar Age: 47 years Occu: House hold work R/o Gadag - Complainant(s)

Versus

The Manager, (CRM) LIC of India Divisional Office, Dharwad - Opp.Party(s)

S.V. Grampurohit

04 Jun 2016

ORDER

JUDGEMENT DELIVERED BY

SMT.C.H.SAMIUNNISA ABRAR, PRESIDENT:

             The complainant has filed a complaint under section 12 of Consumer Protection Act, 1986 against the OPs alleging the deficiency of service for non-payment of medi-claim amount and for mental agony and pain, litigation charges along with interest and other reliefs as this Forum deems fit.  

          The brief facts of the Complaint

           2.    The Complainant had obtained a Health Insurance by the Ops namely Jeevan Arogya bearing Policy No.638368918 by paying premium of Rs.1,220/- the policy is inforce from 08.02.2013 to 08.02.2048, the Complainant was hale and healthy while obtaining the policy. After some days, the Complainant was suffering from nosal and throat problem the Complainant visited the Dr.P.L.Suresh of Shripath Nursing Home for consultation at Hospet. The doctor advised the Complainant to undergo an operation (Nosal Septm).

 

       3.   On the advice of the Doctor the Complainant had got admitted as an indoor patient on 11.05.2014 and operated at the above said hospital and discharge on 25.04.2014. The Complainant spent of Rs.18,037/- towards the treatment and operation. The Complainant furnished all the records of a treatment and bills along with the doctor certificate to the Ops to claim the medical benefits, but the OP was postponing the same one or other pretext of the some days i.e. on 15.09.2014 that the OP transferred an amount of Rs.5,250/- to the Complainant Account at Corporation Bank, Gadag as daily care benefit. But the operation charges and other expenses had been refused by OP. The OP had not mentioned any reason for the refusal of the same. The act of the OP is not justifiable, the OP had clearly over-ride the Terms and Conditions of the policy by which the OP is practicing unfair trade practice and shows negligency in discharging its parts of contract. On 11.11.2014 the Complainant got issued a legal notice to the OP through his counsel demanding to settle the claim of Rs.18,037/-. The notice had been served to the Ops, the OP has given a vague answer instead of making payment. Hence, the Complainant had prayed to order the OP to pay Rs.18,037/- towards Operation and Medical Expenses and a compensations of Rs.25,000/- towards mental agony and litigation charges of Rs.5,000/-.

 

        4.     The Complaint was registered and notice was ordered to the OP, OP appeared before this Forum through his counsel filed Vakalath and Written Version.  

        The brief fact of the Written Version of OPs as under:

           The Ops have admitted the contents of the Complaint in Para No.2 of the Complaint that the Complainant is a policy holder and obtaining a Health Insurance Policy i.e. Jeevan Arogya obtained from the OP. The date of maturity is on 08.02.2048. The OP had contended that the averments made in Para No.3 and 4 that the Complainant had admitted for surgery Septoplasty on 17.05.2014 at 6.00 PM and discharge on 20.04.2014 at 2.00 PM and got surgery on 18.05.2014, but the Complainant had stated that she had admitted on 11.05.2014 which had been contended by the OP and stated that the Complainant had deliberately suppressed the real and material fact of admission to the hospital.

 

     5.    OP further stated that the claim papers submitted to the OP were in-complete, the OP wrote a letter to the Complainant to furnish the further required documents the OP has admitted that the Complainant had submitted the claim Indemnation Form with a bill No.280, dated: 20.05.2014 for Rs.18,037/- of Sripathi Hospital on 02.06.2014.

 

      6.    The OP asked the Complainant to produce treating Doctor Certificate regarding the duration and deviation of nosal septm. The Complainant produced the certificate of the treating doctor on 04.09.2014 after the reminder letter from OP the Complainant produced the document, and suppressed the fact of admission to the said hospital  inspite of that the OP had paid of Rs.5,250/- on 15.09.2014 under day care benefit as per terms of the policy.

 

         7.    Further, OP had contended that the averments made in Para No.6 and 7 i.e. as per Terms and Conditions of the policy. The said operation comes under day care procedure benefit an amount equal to five times the application daily benefit had been paid to the Complainant on 15.09.2014. Hence, the OP had stated that there is no question of refusing the payment for operation charges and other expenses as alleged by the Complainant. Hence, the OP had not practiced any unfair trade practice or committed deficiency in service as alleged by the Complainant.

 

          8.     The OP had prayed that the Complainant is not entitled to claim the alleged amount. Hence, Complaint may be dismissed with costs.

          9.   On perusal of the Complaint allegation and detailed version, the documents on records the Complainant himself has been examined before this Forum as CW1 and got marked the documents as EX C1 to EX C7 are as follows:

1)  EX C1 L.I.C. Jeevan Arogya Policy Bond.

2)  EX C2 Reminder Letter,

3)  EX C3 Claim Pending for Requirement.

4)  EX C4 L.I.C. Divisional Office Letter,

5)  EX C5 Claim Admission Letter,

6)  EX C6 Legal Notice,

7)  EX C7 Reply to the Legal notice,

     On the other hand, OPs filed a written version and examined as RW1 and got marked documents as EX OP1 to OP30.

1. EX OP1 Original Proposal Form,
2. EX OP2 Copy of the Bond,
3. EX OP3 Proposal for Insurance Policy,
4. EX OP4 Claim Form,
5. EX OP5 Claim Intimation Form,
6. EX OP6 Brochure of Condition of the Policy,
7. EX OP7 to OP9 Hospital Bill,
8. EX OP10 to 12 Prescription,
9. EX OP13 to OP15 Tax Invoice,

10)EX OP16 Medical Certificate

11) EX OP17 Discharge Card,

12) EX OP18 Bills,

13) EX OP19 Tax Invoice,

14) EX OP20 Prescription,

15) EX OP21 Letter written by the Complainant

16) EX OP22 Doctor Certificate,

17) EX OP23 First Reminder,

18) EX OP24 Final Reminder,

19) EX OP25 Claim Admission Letter,

20) EX OP26 Summary of the Claim Process,

21) EX OP27 Ops Letter to the Complainant

22) EX OP28 Legal Notice,

23) EX OP29 Answer to the Legal notice,

24) EX OP30 Letter to Complainant   

          10.  On the pursuance of the above documents and arguments heard on both sides, the points arises before us for adjudication are as follows:          

1. Weather the OP had practicing the unfair trade?

2. Weather the complainant is entitled for relief as sort?

3. What order?

Our findings to the above points are as under:

Point No.1: Affirmative,

Point No.2 : Partially Affirmative,

Point No.3 : as per the final Order

 

R E A S O N S

       11.  POINT NO.1 and 2:  Since Point No.1 and 2 are identical, to avoid the repetition of fact, we take two points together for consideration. On careful scanning of documents produced by both the parties. The Complainant had obtained the Health Insurance from OP while the policy was in-force the insurer (Complainant) had undergone the nosal surgery at Sripati Hospital, Hospet. This is an undisputed fact.

 

      12.    The Complainant had stated in the document that she got admitted for surgery on 11.05.2014 at the above said hospital and discharge on 20.05.2014. This is controversial point by the OP. On pursuance of documents produced by the Complainant as well as the OP i.e. Medical Certificate issued by treating doctor clearly discloses that the Complainant is treated as in-patient in hospital from 18.05.2014 to 20.05.2014 i.e. Complainant was in-patient at the above said hospital is for three days. The Complainant had produced the insurance policy bond marked as EX C1 in which the Complainant is principle insured, the initial daily benefit obtained is Rs.1,000/- each. The Complainant submitted the claim form along with medical bills and required documents to the OP, the OP wrote a letter to the Complainant to furnish further documents as required. The Complainant had fulfilled the Ops request and furnished the Certificate from the doctor treated, after the acceptance of document by OP, the OP transferred an amount of Rs.5,250/- to the Complainant Account treating the said surgery had been classified in day care procedure, the OP had calculated the claim of the Complainant in the basis of day care procedure as per the Terms and Conditions of the policy which amount to Rs.5,250/- per day. The main point of the controversy here is that the amount calculated by the OP on the basis of day care procedure is for one day where the Complainant had treated as in-patient at Sripathi Hospital, Hospet from 18.05.2014 to 20.05.2014. The document marked as EX OP16 and 17 (Medical Certificate & Discharge Card) clearly discloses it. Blindly the OPs have calculated the claim for one day whereas the Complainant had undergone treatment for three days as in-patient as per the Terms and Conditions of the policy. The day care process should also to be paid for a pre and post-operative treatment, wherein the Complainant had prayed claim of Rs.18,037/-. After collecting the premium amount from insured person towards the insurance policy. The insurance company assures the party that they get cash less treatment in the hospital, but we are sorry to say that the insurance company rejects the claim or not settling the claim properly to the satisfaction of their customers.

     13.   The parties obtain insurance so that it may be helpful at the time of need. Here the Complainant had admitted in the hospital for three days and got treated as per the terms and condition of the policy and also accepted by the OP this treatment lies under day care procedure by paying the amount calculated for one day, amount to unfair trade practice hence the Ops is liable to pay the amount of RS.15,750/- by deducting Rs.5,250/- which had been already paid by the OP to the Complainant. The OP is liable to pay Rs.10,500/-. Hence, we answer the Point No.1 affirmative and Point No.2 is partially affirmative.    

         14. POINT NO.3: In view of our findings on the above points, the complaint filed by the complainant has to be allowed in part. In the result, we proceed to pass the following:

//O R D E R//

1.   The Complaint is partially allowed.

2.  The Ops are directed to pay Rs.10,500-00 (Rupees ten  thousand five hundred) to the Complainant.

3. The Ops are directed to pay a compensation of Rs.2,000/- (Rupees two thousand) towards mental agony and Rs.1,000/- (Rupees one thousand) towards litigation charges.

4.  The Ops are directed to comply this Order within 30 days from the date of the order, fails to pay the said amount within 30 days, the complainant is entitled to get 06% interest p.a. from the date of filing, till realization.

5.    Send the copies of this order to the parties free of cost.

 (Dictated to the Stenographer, transcribed by him, corrected and then pronounced by me in the Open Court on this 04^th day of June, 2016)

 

                          Member                                                      Member                                       President