Punjab

Moga

CC/16/84

Narinderpal Singh Sidhu - Complainant(s)

Versus

The Manager, Life Insurance Corporation of India - Opp.Party(s)

Sh. Baljit Singh

12 Jul 2016

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MOGA.

 

                                                                                                                                                              C.C. No. 84 of 2016

                                                                                                                                                  Instituted on: 05.04.2016

                                                              Decided on: 12.07.2016

 

Narinderpal Singh Sidhu aged about 45 years, son of Harbans Singh, Resident of House No.2336, Ward No.6, Shaheed Bhagat Singh Nagar Moga, District Moga.

 

                                                                             ……….   Complainant 

Versus

 

1.       The Manager, Life Insurance Corporation of India, Model Town Road, opposite Sky Lark Hotel, Divisional Office Jallandhar.

 

2.       The Branch Manager, Life Insurance Corporation of India, opposite Bus Stand, Moga.

 

                                                                           ………. Opposite Parties

 

 

Complaint under Section 12 of the Consumer Protection Act, 1986.

 

 

 

Quorum:   Sh. Ajit Aggarwal, President

                   Smt. Bhupinder Kaur, Member

Present:       Sh. Baljit Singh, Advocate counsel for complainant.

                   Sh. Vaneet Jaidka, Advocate counsel for opposite parties.

 

ORDER :

(Per Ajit Aggarwal, President)

1.                Complainant has filed the instant complaint under Section 12 of the Consumer Protection Act, 1986  (hereinafter referred to as the 'Act') against The Manager, Life Insurance Corporation of India, Model Town Road, opposite Sky Lark Hotel, Divisional Office Jallandhar and others (hereinafter referred to as the opposite parties) for directing them to pay the amount of Rs. 3,95,999/- (Rs.1,86,904/- on account of hospitalization charges and Rs. 2,09,095/- on account of medical bills and expenses) alongwith interest regarding insurance policy no. 132913918 dated 26.08.2009 to complainant. Further opposite parties may be directed to pay Rs. 20,000/- on account of deficiency in service, Rs. 20,000/- on account of mental tension, agony and physical harassment and defamation of reputation and Rs. 22,000/- as litigation expenses to the complainant.

2.                Briefly stated the facts of the case are that in the month of July, 2009 one agent of insurance company/opposite party no.2 came to the house of complainant and introduced him regarding the insurance policy schemes of LIC of India and on the assurance of agent of the company and goodwill of company, complainant purchased insurance policy bearing no. 132913918 dated 26.08.2009. At the time of issuing the policy, officials of the opposite parties told the complainant that this policy is under a very good plan, the policy is for 26 years, policy is for annually instalments of Rs. 19,500/- and the policy is valid from 26.08.2009 to 26.08.2035 and they also assured the complainant that if any injury occurred from any type of mis-happening and accident, then this policy covered it and the complainant will be get assured 100% claim from the opposite parties. On 01.09.2014, the complainant was standing near a crane and was hit by a pillar carried by the above said crane in the street where house of complainant was situated at around 4.00 pm , due to which he developed severe pain in bilateral lower limbs and was diagnosed as a case of closed fracture left tibia and open fracture lateral malleolus right side with peroneous longus and bravis tendon injury, so the complainant was admitted at DMC, Ludhiana, where he was operated by the doctor on 02.09.2014 and complainant paid an amount of Rs. 2,09,095/- on medicines and he also deposited Rs. 1,86,904/- to DMC, Ludhiana on account of hospitalization charges (in total Rs. 3,95,999/-). On 18.09.2014, after discharging from the hospital, the complainant submitted all the relevant documents relating to his operation alongwith photocopy of policy with the office of opposite party no.2. On 09.03.2015, complainant was very astonished after seeking the rejection of claim issued by the opposite parties. In this rejection claim, the officials of the opposite parties has written that surgery performed on the complainant is not listed in the allowed surgery (1-49), but in the column no.9 of the Surgical Benefit annexure it is clear that accidents were covered in the abvoesaid insurance policy. After the rejection of claim, complainant visited the office of opposite party no.2 and requested to settle the matter, but the officials of opposite party no.2 were not ready for the same. The complainant approached the office of opposite party no.2 many a times for settlement of the claim, but they refused to pay the claim of the complainant. Complainant also served a legal notice upon the opposite parties on 3.12.2015, but all in vain. Due to the abovesaid act and behaviour of opposite parties, the complainant has to face mental tension, agony and harassment. Hence this complaint.

3.                Upon notice, opposite party nos. 1 & 2 appeared through their counsel and filed written reply taking certain preliminary objections that the present complaint is liable to be dismissed, as there is no deficiency in rendering services on the part of opposite parties. The policy opted by the complainant is purely Health Insurance Plan governed by terms and conditions as printed on the policy bond and handbook. In this policy, benefits are payable as per the terms and conditions of the policy, if the policy is kept in force. Under the policy two types of benefits are payable i.e. Hospital Cash Benefit (HCB) and Major Surgical Benefit (MSB). Whenever the claim arises, the claim form duly executed alongwith supporting documents is to be submitted to LIC of India. Thereafter, on scrutiny of documents decision is arrived at whether the claim is payable or not. The life assured Narinder Pal Singh got Health Protection Plus Policy under Plan no. 902 on 26.08.2009 and he had paid the installments from August 2009 to August 2014. As per the claim lodged, the complainant got sudden injury on 01.09.2014 and was admitted in DMC and Hospital, Ludhiana from 01.09.2014 to 19.09.2014 and surgery was performed on him on 02.09.2014. On lodging of the claim, the papers were sent to TPA on 15.10.2014 for consideration of MSB and HCB. The Major Surgical Benefit (MSB) claim has been rejected and requirements were called for Hospital Cash Benefits on 09.03.2015, as the surgery mentioned/performed is not listed in the allowed surgeries from 1 to 49 under the policy. The complainant was requested to send the requirements on 09.03.2015 to opposite parties for consideration of Hospital Cash Benefits Claim. However, the complainant has submitted the requirements for domiciliary treatment benefits (DTB) only and had been paid the claim of Rs. 53,860/- on 18.05.2015. Till date, the complainant has not complied with the requirements for consideration of Hospital Cash Benefit Claim which are still awaited and has filed the present complaint without any rhyme and reason. The present complaint is liable to be dismissed, as the complainant is guilty of suppressing the material facts from this Forum as detailed above; that the present complaint is not maintainable and is liable to be dismissed, as the same has been knowingly filed on false and frivolous facts.

          On merits, it is submitted that the Major Surgical Benefit Claim of complainant has been rejected, as the surgery mentioned/performed is not listed in the allowed surgeries from 1 to 49 under the policy and opposite parties called for requirements from the complainant for Hospital Cash Benefit on 09.03.2015. The all other allegations made in the complaint have been denied.

4.                In order to prove the case, complainant Narinderpal Singh tendered in evidence his duly sworn affidavit Ex. C-1, copy of legal notice Ex. C-2, original medical bills Ex. C-3 to Ex. C-108, copy of original OPD card Ex. C-109 and copies of other documents Ex. C-110  bto Ex. C-138 and closed the evidence. 

5.                In rebuttal, opposite parties tendered in evidence duly sworn affidavit of Sh. H.S. Gupta, Manager (L & HPF), LIC of India Ex. OP-1, 2/1 and copies of documents Ex. OP-1, 2/2 to Ex. OP-1, 2/9 and closed the evidence.

6.                We have heard the learned counsel for the parties and have carefully gone through the record placed on file.

7.                Ld Counsel for complainant vehemently argued that on assurance of agent of Ops, complainant purchased a policy. Duration of Policy was for 26 years with annual instalment of Rs.19,500/- and it was valid from 26.08.2009 to 26.08.2035 and as per assurance of OPs, said policy covered all the risks including any kind of mis-happening or accident. On 1.09.2013 at about 4.00 pm, when complainant was standing near his house in his street, he was hit by a pillar being carried by a crane, due to which he developed pain in bilateral lower limbs and was diagnosed as case of closed fracture left tibia and open fracture lateral malleolus right side with peroneus longus and bravis tendon injury and he was taken to D.M.C Ludhiana, where he was operated upon on 2.09.2014 and spent an amount of Rs2,09,095/-on medicines and deposited Rs. 1,86,904/-with D.M.C Ludhiana as hospitalization charges. It is further contended that after getting discharged from hospital, complainant submitted all the requisite documents and bill with OPs on 18.09.2014 for obtaining his insurance claim, to his great surprise, Ops rejected his claim vide letter dated 9.03.2015 on the ground that surgery performed upon his is not listed in the allowed surgeries though it is clearly written in column no. 9 of the Surgical Benefit Annexure that accidents are covered in the insurance policy purchased by him. Complainant visited OPs with request to pass his claim, but they flatly refused to do so. All this amounts to deficiency in service and caused harassment to him.  Ld counsel for complainant has prayed for accepting the present complaint alongwith compensation and litigation expenses.

8.                To controvert the allegations of complainant, ld counsel for OPs asserted that there is no deficiency in service on the part of OPs. However, it is admitted that complainant purchased the policy in question from Ops and also paid premiums from August 2009 to August 2014. It is argued that claim papers of complainant were received and sent to TPA on 15.10.2014 for consideration of Major Surgical Benefit and Hospital Cash Benefit and after thorough examination, claim of complainant was rejected on the ground that surgery performed to him is not listed in the allowed surgeries from 1 to 49 under the Policy and OPs  called for requirements for Hospital Cash Benefit from complainant on 9.03.2015, but despite repeated requests of OPs to complainant for sending the requirements for  consideration of Hospital Cash Benefit, however the complainant submit the requirements for domiciliary treatment benefit and accordingly, he was paid a claim of Rs53,680/-on 18.05.2015. It is further argued that complainant submitted papers only for DTB and did not comply with the requirements of HSB, which are still awaited by OPs. Ld counsel for OPs reiterated that there is no deficiency in service on the part of Ops, rather complainant himself did not send the documents required by them. He has prayed for dismissal of the complaint.

9.                We have carefully perused the record produced by complainant as well OPs and have gone through the evidence and documents placed on record.

10.              The case of the complainant is that in the year 2009, he purchased a Health  Insurance Policy of the OPs for 26 years, which was valid from 26.08.2009 to 26.08.2035 with annual premium of Rs.19,500/-. As per policy, he was covered from any injury occurred from any type of mis-happening and accident and then in that case, OPs will give 100% claim for the medical expenses. On 1.09.2014, complainant met with an accident and got multiple injuries. He remained admitted in D.M.C. Hospital, Ludhiana from 1.09.2014 to 18.09.2014, where he was operated by doctors. He spent Rs.3,95,999/-on his treatment. He lodged his claim with OPs and submitted all the relevant documents for the processing of his claim. On 9.03.2015, OPs rejected the claim of the complainant on the ground that the surgery performed on the complainant is not listed in the allowed surgeries, which is altogether illegal and wrong. He is entitled for reimbursement of medical expenses borne by him on his treatment. In reply, OPs admitted that the complainant purchased their Health Insurance Plan governed by the terms and conditions of the Policy. He further admitted that complainant paid regular instalments of premium and he lodged claim with them regarding his hospitalization and treatment. It is also admitted that complainant remained admitted in hospital from 1.09.2014 to 18.09.2014 and during this period surgery was performed upon him. His  claim papers were sent to TPA for consideration. The Major Surgical  Benefit Claim of the complainant has been rejected as the surgery performed on complainant is not listed in the allowed surgeries under the Policy. However, the claim of complainant is settled for domiciliary treatment benefit only and he has been paid the claim of Rs.53,860/-on 18.05.2015 and except this, complainant is not entitled for any benefit and his claim is settled as per terms and conditions of the Policy.

11.              We have thoroughly gone through the file, evidence and documents adduced by parties. It is admitted case of the parties that complainant was insured with OPs under Health Insurance Plan. It is further admitted that complainant met with an accident and remained admitted in the hospital and for reimbursement of his medical expenses, he lodged claim with OPs alongwith all the requisite documents. The only plea taken by the OPs is that the surgery performed on complainant during his hospitalization is not covered in the list of allowed surgeries as per terms of the policy. As per conditions of the policy, the definition of accident is given as Accident means a sudden unintended, fortuitous, violent, visible and external event and does not include any naturally occurring condition or degenerative process and definition of Accidental Bodily Injury means physical bodily harm or injury (but does not include any mental sickness, disease or illness) which is caused by an Accident which first occurs during the Cover Period for the Hospital Cash Benefit Cover and for the Major Surgical Benefit Cover and requires inpatient treatment or surgery in a Hospital by a Physician or surgeon as the case may be. It is not disputed that injuries suffered by the complainant is due to an accident. Further, it is not the case of OPs that these injuries are suffered by the complainant due to any mental sickness or disease or illness. Further it is not the case of the OPs that these injuries are pre existing from the inception of the Policy or these injuries are caused to complainant due to his own negligence.  Only plea of the OPs is that surgery done on complainant is not covered under the listed surgeries in Policy. It is very strange that if the treatment  of the injuries suffered in an accident is not covered under the Health Insurance Policy, then for what purpose  a person purchased a Health Insurance Policy by paying huge premiums to Insurance Companies. Now, it cannot be supposed that in case of meeting with an accident a person  should ask the Insurance Company  to check the list of the injuries in these policies that which injury or surgery  is covered under the Insurance Policy, then as per that list get injured.

12.              In our view the Insurance Companies are only interested in earning premiums and find various ways and means to decline the genuine claim of customers. Our Hon’ble Punjab & Haryana High Court has rightly observed in citation 2008 (3) RCR page 111 titled as National India Insurance Company Vs Smt Usha Yadav  & Ors, wherein Hon’ble High Court held that it seems that Insurance Companies are only interested in earning the premiums and find various ways and means to decline the claims. All conditions, which generally are hidden need to be simplified so that these can be easily understood by the persons at the time of buying any Policy. Insurance Companies in such case rely upon the Clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining Policy. So, in view of the above discussion, we are of the considered opinion that opposite parties have wrongly and illegally repudiated the claim of the complainant and he is entitled to get the full insurance claim for his treatment. The act of opposite parties in repudiating the genuine claim of complainant amounts to deficiency in service and trade mal practice on their part. Hence, the present complaint is hereby allowed. The opposite parties are directed to pay Rs.3,95,999/- to complainant as reimbursement of his medical expenses alongwith interest at the rate of 9% per annum from 9.03.2015 when they repudiated the claim of complainant till final realization less Rs.53,860/-which are already paid by opposite parties to complainant. Opposite parties are further directed to pay Rs.15,000/- (Fifteen thousand only) as compensation on account of harassment and mental agony suffered by him besides Rs.5,000/- (Five thousand only) as litigation expenses to complainant. Compliance of this order be made within one month of the receipt of the copy of the order, failing which complainant shall be entitled to proceed under Section 25 and 27 of the Consumer Protection Act 1986. Copy of the order be supplied to parties free of cost as per law. File be consigned to record room. 

Announced in Open Forum

Dated: 12.07.2016

 

 

                                (Bupinder Kaur)                                 (Ajit Aggarwal)

                                                   Member                                          President