DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

WEST TRIPURA :  AGARTALA

 

CASE   NO:   CC- 70 of 2018

 

Smt. Purbita Gupta,

D/O- Sri Purnendu Gupta,

Ramnagar Road No.-2(West),

P.O.-Ramnagar, Agartala,

Dist.-West Tripura, .…..…...........................Complainant.

 

         -VERSUS-

 

1). The Manager(HI),

Life Insurance Corporation of India(LICI),

Silchar Divisional Office,

Meherpur, Silchar, Assam,

Pin-788015.

 

2). The Chief Manager, LICI,

Agartala Branch No.I,

Paradise Chowmuhani, Agartala,

Dist.-West Tripura. …...............….............Opposite parties. 

 

 

      __________PRESENT__________

 

 SRI BAMDEB MAJUMDER

PRESIDENT,

  DISTRICT CONSUMER  

DISPUTES REDRESSAL FORUM,

      WEST TRIPURA, AGARTALA. 

 

SMT. Dr. G. DEBNATH

MEMBER,

  DISTRICT CONSUMER 

DISPUTES REDRESSAL FORUM, 

  WEST TRIPURA,  AGARTALA.

 

SRI U. DAS

MEMBER,

  DISTRICT CONSUMER 

DISPUTES REDRESSAL FORUM, 

  WEST TRIPURA,  AGARTALA.

 

C O U N S E L

 

For the Complainant : Sri Koushik Roy,

  Sri Udai Sankar Singha,

  Advocates. 

For the O.Ps. : Mrs. Puspita Chakraborty,

  Advocate.                                                                                                                                  

  

 

JUDGMENT  DELIVERED  ON: 28/06/2019

 

J U D G M E N T

The complainant Smt. Purbita Gupta, set the law in motion by presenting the petition U/S 12 of the Consumer Protection Act 1986 complaining deficiency of service committed by the O.Ps. 

  The complainant's case, in brief, is that the Complainant had purchased LICs Jeevan Arogya Policy bearing No.493466962(Table 903) from the O.Ps.( Life Insurance Corporation of India). She is the principal insured under the said policy. Her father Sri Purnandu Gupta and her mother Smt. Sumita Gupta are also covered under the said policy. The complainant has been paying the premium regularly. During the covered period of the policy the complainant's father Sri Purnandu Gupta under went “Ventral Hernia” surgery at the Apollo Hospitals, Chennai on 18/07/2016. Sri Gupta was admitted in the said Hospital on 17/07/2016 and was discharged on 22/07/2016. The Complainant after returning to Agartala submitted her claim of Rs.2,16,827/- being the cost of treatment of her father under her LIC policy No.493466962(Table 903) along with medical prescriptions, bills and vouchers  etc. with a forwarding letter addressed to the O.P. No.2 on 08/08/2016. After receiving the claim the O.P. No.1 had sought for some clarification from the Complainant. On 14/09/2016 the complainant replied to the quires. Subsequently on 12/01/2017 the Chief Manager, LICI, Agartala Branch-1 personally visited the house of the complainant and made physically verification of the claims raised by the complainant and also related documents. Thereafter the Complainant received one letter bearing No.SDO/HI/CL/ADMT dated 27/03/2017 from the Manager(HI), LICI, Silchar wherein she was informed that the claim raised by her was reduced by the LICI to Rs.17,100/- as of Other Surgical Benefit under the policy.  The O.Ps. did not admit the whole claim raised by the Complainant. The O.Ps. did not admit that the surgery which was performed on her father to be a major surgical one. The Complainant in her complaint has asserted that she has fulfilled the terms and conditions of the Insurance Policy but in spite of this the O.Ps. have denied her justified claim. 

Being aggrieved and dissatisfied with the conduct of the O.Ps., the complainant has filed the complaint against the O.Ps. claiming Rs.2,16,827/- being the cost of treatment, Rs.5,00,000/- for mental agony and sufferings, Rs.50,000/- as the cost of litigation and Rs.50,000/- as incidental cost, in total Rs.8,16,827/- from the O.Ps.

Hence this case.  

2. The O.Ps. LICI on receipt of notices from this Forum appeared and filed written statement denying the claim of the Complainant. It is asserted by the O.Ps. that the Complainant had suppressed the material fact about her father being a patient of Hypertension at the time of purchasing of the policy. It is also stated that ventral hernia surgery which was performed on the body of the father of the Complainant does not come under the list of major surgery as per the terms and conditions of the policy and as such the O.Ps. are not liable to reimburse the entire cost of treatment as claimed by the Complainant. According to the O.Ps. a lenient view had been taken in the case of the Complainant and the claim raised by the Complainant has been considered to be treated to  come under the Other Surgical Benefit in spite of the fact that the father of the complainant had preexisting illness(Hypertension) which has been surfaced in the discharge summery report issued by the Apollo Hospitals, Chennai. The complainant has been accordingly paid Rs.17,100/- by way of Other Surgical Benefit as per the policy. The O.Ps. have denied having committed any deficiency of service towards the Complainant. They have thus prayed for dismissal of the Complaint. 

 

3. EVIDENCE ADDUCED BY THE PARTIES:

  The Complainant has examined herself as PW-I and her father also as PW-2. Both of them have submitted examinations-in-Chief by way of Affidavit. In this case the complainant produced 09 documents comprising 64 sheets which have been marked Exhibit-I series. Documents are: Prayer for granting of Health Insurance claim, Letters dated 14/09/2016 and 25/08/2016, Email dated 30/12/2016, Letters dated 24/05/2017 and 27/03/2017, Letter dated 14/07/2017 containing impugned letter dated 05/06/2017 whereby the O.Ps. have repudiated the claim of the Complainant partially, Letter dated 04/09/2017 sent by the Complainant to the Manager(HI), LICI, Silchar Division, Copy of the Insurance Policy of the complainant, LICs Jeevan Arogya Conditions & Privileges & Letter dated 18/09/2017 issued by the Manager(HI) to the Complainant.  

The O.Ps. LICI have adduced examination-in- chief by way of affidavit by one Sri Niranjan Bal, Manager(Admn.), Agartala Branch-I, as O.P.W-I. The said O.P.W. has produced 05 documents comprising 23 sheets which have been marked Exhibit-A series. The documents are: Calculation sheet, Copy of Policy, 03 nos. of letter, Proposal form & Discharge summary along with the conditions and privileges. 

 

4. POINTS TO BE DETERMINED:

       Based on the contentions raised by both the parties in their pleadings and having regard to the evidence adduced by the complainant side and that of the O.Ps., the following points cropped up for determination:

(I) Whether there was deficiency of service on the part of the O.Ps.?

(II) Whether the complainant is entitled to get compensation/relief as prayed for?

5. DECISION AND REASONS FOR DECISION:

  We have gone through the oral evidence and the documentary evidence adduced by both sides. We have also heard arguments of both sides. 

  We find that the Complainant has filed the complaint against the O.P. LICI alleging that the O.Ps. have without any justifiable reasons have refused to satisfy fully the cost of medical treatment of her father who had under gone Ventral Hernia Surgery at Apollo Hospitals, Chennai on 18/07/2016. She had actually claimed Rs.2,16,827/- being the cost of the treatment. The O.Ps. according to her taking an erroneous view have paid her Rs.17,800/- holding that her claims does not  come  under purview of major surgical benefit rather it comes under Other surgical benefit. According to the Complainant she has furnished her claim papers to the satisfaction of the O.Ps. believing that the O.Ps. would satisfy are genuine claim fully.  

    On the other hand, the O.Ps. have asserted that regarding the claim of the Complainant the LICI Divisional Dispute Redressal Committee has taken a lenient view and approved the claim as permissible under Other surgical benefit instead of major surgical benefit. According to the O.Ps. the surgery which was conducted for the father of the Complainant does not come under major surgical benefit and an such the claim of the Complainant could not be settled fully. 

We have carefully gone through the LIC Jeevan Arogya Policy which was purchased by the Complainant in the year 2011. The Complainant till filing of the case has been paid premium regularly. The said policy also having Insurance coverage of the parents of the Complainant apart from the Complainant herself. 

We find that the O.Ps. did not deny  the fact that the father of the Complainant Sri Purnendu Gupta had under gone “Ventral Hernia Surgery” on 18/07/2016 at Apollo Hospitals, Chennai during covered period of the Policy. Sri Gupta had to remain as indoor patient at the Hospital from 17/06/2016 till he was discharged on 22/07/2016. The O.Ps. have partly allowed the claim of the Complainant and paid her Rs.17,100/- treating her father's case to have fallen under “other surgical benefit” denying the claim of the Complainant that the surgery is of major surgery one. Admittedly, the Hernia Surgery of the father of the Complainant was performed in the year 2017 which is five years after the date of purchase of the policy. As per the policy, the specific waiting period for getting benefit out of the policy for treatment of Hernia is two years. Moreover, it is on record that the father of the Complainant remained as an indoor patient for 05 days in the Apollo Hospitals for under going the surgery. This is a significant aspect to make us understand about the health condition of the father of the Complainant at the Pre-and post operation stages who is also a senior citizen. Having regard to this position we are of the opinion that the Complainant should not be deprived  of getting Insurance benefit for the “Ventral Hernia Surgery” which was under taken by her father at the Apollo Hospitals simply on the ground that such a surgery does not find place in the list of major surgical benefit. We find that the O.Ps. have only paid Rs.17,100/- to the Complainant for the surgery whereas the claim of the Complainant was Rs.2,16,827/- being the total actual cost of treatment and that too has been supported by cogent evidence produced by the Complainant from the Apollo Hospitals under Exhibit-I series.

After giving thoughtful consideration over the issue and on thorough scrutiny of the in patient bill vide No.CMH-ICS-99734 dated 22/07/2016 (Exhibit-I series) issued by the Apollo Hospitals in the name of Sri Purnendu Gupta we are of the opinion that ends of justice will prevail if the O.Ps. are directed to pay Rs.1,60,812 to the Complainant for providing services under the Heads as per the in patient bill, namely Nursing and Hospitals utilities amounting to Rs.3,500/-, O.T. Charges for Rs.31,810/-, O.T. Consumables for Rs.69,088.75/-, O.T. Pharmacy for Rs.6,914/-  & Professional charges for Rs.49,500/-. It is made clear that the amount Rs.17,100/- which has already been paid to the Complainant by the O.Ps. prior to the filing of the complaint should be deducted from the amount which we have assessed above. So the O.Ps. are to pay Rs.1,43,712/- to the Complainant. Apart from this we direct that the O.Ps. are to pay Rs.4,000/- to the Complainant as cost of litigation.   

  We are not inclined to give any other amount to the Complainant.

In the result, the Complaint U/S 12 of the Consumer Protection Act ,1986 filed by the Complainant is partly allowed on contest. It is here by directed that the O.Ps. will pay Rs.1,43,712/- being the cost of treatment together  with Rs.4,000/- being the cost of litigation. Thus the O.Ps. are to pay in total Rs.1,47,712/- i.e. (Rs.1,43,712 + Rs.4,000/-) to the Complainant within a period of 2 months from the date of judgment failing which the amount of compensation shall carry interest @9% P.A. till the payment is made in full. 

 

ANNOUNCED

 

 SRI BAMDEB MAJUMDER

PRESIDENT,

DISTRICT CONSUMER  DISPUTES 

REDRESSAL FORUM,

WEST TRIPURA,  AGARTALA

 

 

 

 

 SMT. DR. G. DEBNATH,

 MEMBER, 

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, 

WEST TRIPURA, AGARTALA SRI U. DAS

MEMBER,

DISTRICT CONSUMER 

DISPUTES REDRESSAL FORUM, 

 WEST TRIPURA,  AGARTALA.