Karnataka

Bijapur

CC/80/2014

Firoz S/oi Abdulgafoor Rozindar - Complainant(s)

Versus

The Manager health Insurance Dept LIC Of india - Opp.Party(s)

Sri L.M.HANCHALI

28 Oct 2016

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, VIJAYAPUR

 

DATE OF FILING 19^th  DAY OF MARCH, 2014

CONSUMER COMPLAINT NO. 80/2014

 

DATED THIS THE 28^th  DAY OF OCTOBER 2016   

 

 

 

01) Sri S.H. Hosalli                            -          President.     

                  B.Com.LLB. (Spl),

 

 

02) Smt.G.S. Kalyani                         -        Lady Member.

                 B.Com.LLB. (Spl),

 

 

COMPLAINANT   -

Firoz S/o Abdulgafoor Rozidar, Age: 36 Years, Occ: Principal Correspondent The Hindu English Daily News Paper, R/o:H.No.27, Pulkeshi Nagar, Managuli Road, Bijapur.                   (Rep. by Sri.L.M.Hanchali, Adv.)

- V/S –

 

OPPOSITE PARTIES  -

1.           2.             3.

The Manager (C.R.M), Health Insurance Dept. LIC of India, Divisional Office, 100 Feet Road, Gopala Gowda Extension, Shimoga-577204.   The Branch Manager, LIC of India, Branch Office, Near KSRTC  Bus Depot, B.D.Road, Chitradurga.   The Branch Manger, LIC of India, Mukund Nagar, Station Road, Bijapur.                (Rep. by Sri.S.P.Dikshit,  Adv.                                  for Op.No.1 to 3)

 

O R D E R

 

Speaking through Smt. G.S. Kalyani, Lady Member

 

 

1. This is a Complaint filed by the complainant under Section

12 of the Consumer Protection Act, 1986 (herein after referred to as Act) against the Opposite Parties (in short the “Ops”) directing them to pay Rs.3,00,000/- with 18% interest p.a. towards deficiency of service by repudiating medical claim and refund the premium paid amount of Rs.30,000/- with 18% interest p.a. and Rs.5,000/- towards cost of this complaint etc.

2.      The facts of the case in brief are that;

          It is contended that, the complainant is a policy holder of the opponents under the LIC Health Protection Plus Plan (Table-902) on 27.01.2010, under policy No.629217258 commenced w.e.f 27.01.2010 and complainant would be expired on 27.01.2014.
The branch code of said policy No.790 under proposal No. 16088. Further the complainant of Shri Abdulgafoor S/o Gousemohddin Rozindar is the nominee of the said policy.

          The Complainant further contended that in pursuance of the said policy the complainant deposited the premium amount of Rs.7,500/- p.a. and particulars of  premiums and opponents issued the reports are here below.

Sl.No.          Premium Date                Reciept No.           Amount

1                 27.01.2010                    6731061               7,500.00

2.                01.01.2011                    1044983               7500.00

3.                05.01.2012                    2422426               7500.00

4.                01.01.2013                    1742917               7500.00

                                                                          Total 30,000.00

         

Further the complainant contended that the said policies covers the health insurance coupled with ULIP beneficiary by investing savings in the form of units and the complainant and his family members are the ultimate beneficiaries.

 

          The complainant’s wife by name of Smt.Taherabanu W/o Firozrozindar admitted in the month of November 2012, in the Dr.Hussain’s  Multi Speciality Hospital in the Maternity Department for her delivery. The wife of complainant under event CESAREAN and post delivery hospitalization for 7days and she delivered a child by name Mariya. The complainant spent the delivery expenses more than Rs.40,000/-. Again the complainant has approached the Ops office made enquiry, local branch office repudiated claim of the complainant stating that any diagnosis or treatment arising from or traceable to pregnancy, child birth including caesarian section is excluded. The Ops are bound to settle the claim but they not settled the claim and they negligent and deficiency of service and complainant surrender the policy and asked for refund of premium paid amount. But the ops said that there is no provisions under policy to surrender the policy amount. The opponents intentionally hided the material facts with regard to surrendering the policies.  So the act of opponents are deficiency of service, due to act of Ops. The complainant sustained heavy loss and mental agony. Again the complainant has got issued legal notice to the opponents through his Counsel. The ops have received the said notices and not settle the claim but Op.No.1 not gave evasive reply, here the complainant filed the complaint for necessary reliefs.

 

3.      After receipt of the notice the ops have appeared through their counsel and contest the case by filing objections the ops in their objections denies all averments except those that are expressly admitted. It is submitted that the said policy offers HCB (Hospitalization Cash Benefits) and MSB (Major Surgical Benefits) for 49 listed surgeries only ( in which caesarean section is not covered) and a list of the same is given in the policy conditions and privileges booklet so also as per condition no.6 (xv) and HCB claim payment arising from or traceable to pregnancy, child birth including caesarean section is excluded. Also as per the condition 6ii (XIV) any MSB payment owing to any diagnosis or treatment or surgery arising from or traceable to pregnancy is excluded.

          The Opponents contended that, the complainant has not approached local branches and not repudiated the claim of the complainant as per the records of opponents, stated that no claim is registered under the above policies and further submitted that no claim is submitted by in the name of complainant and hence no question of any resection of the same, and complaint filed by the complainant is premature and deserved to be dismissed. On this count also and the contents of para.No.8 of the complaint are cleared. It is submitted by the Ops that, there is no deficiency of service as no claim is registered under the above said policy and after reply in the reply notice it was informed to him that surrender value payment is not allowed as per the condition No.1(ii) and opportunity was given to the complainant/policy holder at the time of making policy 15 days from the date of receiving the policy bond for rejection/accept the policy, handing of policy conditions does not arise and hence there is no deficiency of service.

          The ops contended that treatment arising form or traceable to pregnancy child birth including caesarean section is excluded from terms of the policy conditions. Here the Ops are not liable to make any payment, the Ops contended that ops informed the complainant that for caesarean will not be come under policy conditions given of the receiving claim forms sent claim intimation form, it does not amount to admission of any liability and ops contended that they are under no obligation to pay any amount. Therefore, the complaint is premature and deserves to be dismissed with compensatory costs of Rs.10,000/-.

4.      Both side counsels fled their affidavit in lieu of evidence in support of his case 1 to10 documents are produced they are marked as Ex.Co.No.1 to 10. On behalf of Ops produced 1 to 8 documents same are marked as Ex.Op.1 to 8.

          Both side advocates have filed their written arguments. Heard the arguments on both side. Now the following points do arise for our consideration in deciding the case are;

1. Whether the ops have rendered the deficiency in service to the complainant?

 

2. Whether the complainant is entitled to relief as is sought for?

 

3. What order.

Answer to the above points;

 

1. Negative
2. Negative
3. As per final order.

 

R E A S O N S :-

 

5.      Point No.1: Complainant covered his life under the HCB policy, the said policy offers “Hospitalization Cash Benefits) and MSB (Major Surgery Benefits) the fact is not disputed the complainant and family members are beneficiaries. The opponents entered into a contract of said plan with the complainant undertaking to reimburse the medical expenses, if any in the event of family members of complainant admitted in the hospital of curing their disease. The wife of complainant in the month of November 2012 had admitted in the hospital for delivery. She under event caesarean and post delivery hospital section of a week and delivered for male baby. On account of undergoing caesarean complainant incurred the hospital medical expenses, this fact is also not disputed only question is that this surgical operation come under the said policy. The complainant has not produced any documentary evidence to show that this caesarean come under the said policy on the contrary. The Ops produced the document Ex.Op.No.8, wherein exclusion clause at sl.no.6(I)(XV) and 6(II)(XV) it clearly mentioned that any diagnosis or treatment or surgery arisen from or traceable to pregnancy (whether uterine or Uterine) any diagnosis or treatment as surgeons arisen from or traceable to pregnancy (whether uterine or extra uterine) child birth including caesarean section medical treatment of pregnancy or any treatment related to pre and post natal care of the mother or the new born, is come under exceptional clause, here Ops are not liable to pay the medical expenses. Moreover, the complainant has not made any claim to Ops except sending legal notice and after receipt of notice Ops reply the same, and hence there is question of deficiency of service on the part of the Ops. Here we going through Ex.Op.No.8, it is clearly shows that complainant is not entitled to got relief under exceptional clause. Hence we answer to the point No.1 In the Negative.

 

6.      Point No.2: Once the point No.1 is held Negative the second point does not arise. Hence, we answer to the point No.2 is also Negative.

 

 

7.      Point No.3: In the result the complaint of the complainant is fit to be dismissed. Hence, we proceed to pass the following;

 

O R D E R

1. Complaint of the complainant is dismissed.
2. No order as to costs.
3. Free copy of this order shall be sent to the parties    

  immediately.

 

 

            (This order is dictated to the Stenographer, transcript edited, corrected and then pronounced in the open forum on this 28^th day of October 2016).

 

 

 

 

Sri. S. H. Hosalli,       President.

Smt. G. S. Kalyani,     Lady Member.