IN THE CONSUMER DISPUTES REDRESSAL  FORUM, KOLLAM

Dated this the  12^th    Day of  November   2019

  Present: -  Sri. E.M.Muhammed Ibrahim, B.A, LL.M. President

                   Smt.S.Sandhya Rani, BSc,LL.B, Member

                   Sri.Stanly Harold, B.A,LLB, Member                       

                                                        CC No.69/18

1. Mrs.Apsara                                        :         Complainants

W/o Suseelan

Chithira Veedu

Ayiramthengu cherry

Koottikkada P.O

Kollam-691020.

2. Mr.Sooraj

S/o Susheelan & Apsara

Chithira House

Ayiramthengu cheri

Koottikkada P.O

Kollam-691020.

[By Adv.M.Muhammed Humayoon]

V/s

          The Sr.Divisional Manager                :         Opposite party

          LIC of India, Divisional Office

          Jeevan Prakash, Pattom P.O

          Thiruvananthapuram-695004.

          [By Adv.K.Jayakrishnan]

FAIR   ORDER

E.M.MUHAMMED IBRAHIM , B.A, LL.M,President

            This is a consumer  complaint filed u/s 12 of the Consumer Protection Act 1986.  The averments in the complaint in short are as follows:-

          The 1^st complainant is the mother of the minor 2^nd complainant.  1^st and 2^nd complainant have insured  with LIC by taking Jeevan  Arogya(Table 903).  The date  of commencement of the said insurance policy is 17.08.13.  On  03.02.16 the 2^nd   minor   complainant   sustained   grievous  injury of the right thigh  by slipping

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down from the staircase of  Kristhuraj  School, Kollam where he was studying.    Immediately he was  removed to Sankers  Hospital, Kollam were  he has been given first aid treatment and the hospital authorities charged Rs.11,400/- as bill amount.  Immediately the said hospital referred the minor 2^nd complainant to SP Fort Hospital and he was admitted to the said hospital.  Later a surgery was conducted at the thigh and has to met expense of Rs.1,20,350/-.  After the operations the movement of the right toe was lost and again  Nurvase Exploration operation was conducted by admitting him as I.P and also met  the expenses of Rs.73,680/-  at that hospital.  After discharging from that hospital the 2^nd complainant  was again taken to SP Fort Hospital for  regular checkup  and the complainant spent huge amount for that purpose also.  Again the 2^nd minor complainant was admitted at that hospital on 19.09.16 as I.P No.1617/003361 and undergone a surgery and for that purpose he spent altogether an amount of  Rs.47,590/- as    per   I.P Bill  No.3361 dated  08.10.2016  and the complainant has   spent   an amount of Rs.2,53,060/-  as per medical bills and  also spent amount substantial to pay bystanders expenses etc.  Though the complainant has approached the opposite party LIC through  LIC  agent Smt. Sreelekha  and submitted  X-ray, original medical bill and discharge summary,  but the LIC paid altogether  Rs.17,600/- on two occasions.  Even now the minor complainant is unable to walk with the broken leg and he has been attending  his studies by suffering much pain.  There is clear deficiency in service on the part of the opposite party.  The complainant is entitled to get the bill amount plus bystanders expenses and compensation Rs.5,00,000/- along with cost of the proceedings.  Hence the complaint.

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          The opposite party LIC resisted the complaint with tooth and nail.  However the opposite party has admitted that Policy No.785680115 dated 21.08.2013 which was issued to the 1^st complainant as the principal insured and her minor children Sooraj, Swathy and Sreenanda as beneficiaries.  The policy is called Jeevan Arogya Policy(Table-903).  The date of commencement  is 17.08.13 and date of expiry is 17.08.2063 for the Principal assured, 17.08.2027,17.08.2034 and 17.08.2037 respectively for the minor children.  It is  50 years  policy.  Half yearly  premium is Rs.2202/-.  Premium paid upto and inclusive of 17.08.2016.  However the opposite parties would content that LIC’s Jeevan Arogya Plan(Plan-903) is a non-linked  Health Insurance plan which provides fixed benefits for Hospitalisation and listed surgical procedures irrespective of actual cost incurred.  This is different from Mediclaim policies which are Indemnity based policies.  LIC’s Jeevan Arogya is a Health Insurance Plan wherein the benefit payable and it’s  quantum are pre-defined in the Policy document.  The benefits provided under this policy are:-

1. Hospital Cash Benefit(HCB)
2. Major Surgical  Benefit(MSB)
3. Day Care Procedure Benefit(DCPB) and
4. Other Surgical Benefit(OSB)

The Principal Insured chosen the Initial Daily Benefit (IDB) amount of Rs.1,000/- for each of the insured and all other benefits are dependent on this.  The Hospital Cash Benefit(HCB) increases @ 5% of the IDB every year till it reaches 1.5 times of the IDB.  Major Surgical Benefit (MSB) during a year will be 100 times of the Applicable Daily Benefit.  Policy commenced on 17.08.2013.  Hence the applicable daily benefit is Rs.1,100/-.  As per the claim papers submitted to LIC,   Mast.Sooraj  was admitted in SP Fort Hospital, Trivandrum on   03.02.2016

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where he was diagnosed with fractured left thigh bone.  He was treated there during the period  03.02.2016 to 05.02.2016 and underwent ‘Nailing # shaft of Femur (Rt) done, Rerograde TEN Nailing’.  He was again admitted in SP Fort Hospital on 18.04.2016  and on 19.04.2016 underwent ‘GA Common peroneal nerve exploration-TEN removal’.  He was discharged on 21.04.2016.  Claim was submitted for Rs.1,21,350/- for the first Hospitalisation and for Rs.73,690/- for the second.  Claims were settled as shown below.

First Claim:-

HCB payable for one day as per condition 2(1) ie Rs.1,100x1=Rs.1,100/-.

     As per the discharge summary of SP Fort Hospital, Mast.Sooraj had undergone Nailing and shaft of femur in the course of  hospitalization.  Policy  conditions under major Surgical Benefit does not cover Shaft or Femur.

MSB is not payable since the surgery underwent is not listed in the MSB Annexure.  OSB is payable for 2 days as per condition 2(IV)@ 2 times the ADB.  That is Rs.1,100 x 2 x 2 = Rs.4,400/-.   This  benefit  is payable for surgeries whichare    not    covered    under    MSB    and    is   payable   for  the number of days of hospitalization @ 2 times the Applicable Daily Benefit.  Thus the total amount payable was Rs.5,500/- which was paid on 27.10.2016.

Second Claim:-

HCB is Payable for 3 days.  That is Rs.1,100 x 3 = Rs.3,300/-

OSB Payable for 4 days.  That is Rs. 1,100 x 2 x 4 = Rs.8,800/-

     MSB  is not payable since the surgery undergone is not listed in the MSB Annexure which lists 140 surgeries.

Total amount thus payable is Rs.12,100/- which was paid on 27.12.2016.

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     Thus the eligible amount as  per the Policy terms and conditions were paid.  Major surgical benefits were not paid since the procedure underwent is not a surgery covered by the Policy terms and conditions.

Policy holder lodged a complaint before the Insurance Ombudsman on 16.12.2016.  The Ombudsman observed that, as  per the terms and conditions of the policy, Shaft of Femur does not come under MSB, and hence considered as OSB, that is Other Surgical Benefit and the  claim has been settled by the insurer accordingly.  By the Award dated 21.02.2017 the Ombudsman dismissed the  complaint, stating that the Insurer has settled the claims as per the terms and conditions of the policy.  Subsequently,  the complainant has approached  this Forum.  Demand made  by the complainant for payment of  Rs.2,53,060/- is against the terms and  conditions of the policy.  There is no deficiency in service or unfair trade practice from the side of the opposite party.  There is no cause of action for the  complaint.  The opposite party further prays to dismiss the complaint with their costs.

     In the light of the above pleadings the points that arise for consideration are:-

1. Whether there is any deficiency in service or unfair trade practice on the part of the opposite party insurance company in respect of the insurance claim put forward by the complainant?
2. Whether the complainant is entitled to get the  reliefs prayed for?
3. Reliefs and costs.

Evidence on the side of the complainant  consists of the oral evidence of PW1 and Ext.A1 to A5 documents.    Evidence on the side of the opposite party consists of oral evidence of DW1 and Ext.D1 to D9 documents. Heard both sides. The learned counsel appearing  for both sides have also filed notes of arguments.

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Point No.1&2

     For avoiding  repetition of discussion of materials these 2 points are considered together. The opposite party  has issued Jeevan Arogya Policy No.785680115 dated 21.08.13 in the name of the 1^st complainant as Principal insured and her minor children Sooraj, Swathy and Sreenanda as beneficiaries.  The policy is valid from 17.08.13 till 17.08.63 which is   50 years policy.  The complainants have been remitting half yearly premium regularly upto an inclusive of 17.08.2016.  LIC’s  Jeevan Arogya Policy(Table-903) is a non linked health insurance policy which provides fixed benefits  for hospitalization and also for listed surgical procedures irrespective of actual cost incurred.  The policy is different from medi claim policies which are Indemnity based policies.  The benefit provided under the policy are:-

1.Hospital Cash Benefit(HCB)

2.Major Surgical  Benefit(MSB)

3.Day Care Procedure Benefit(DCPB) and

4.Other Surgical Benefit(OSB)

There is also no dispute with regard to the rate of benefit applicable to each head.

The learned counsel for the opposite party has vehemently argued that policy issued by LIC is  Uberimma fidei contract based on utmost good faith.  Accordingly the policy is governed strictly by the terms and conditions stipulated.  The opposite party would further admit that the 2^nd complaint Master Sooraj was admitted in SP Fort Hospital, Trivandrum on 03.02.2016 where he was diagnosed with fractured right thigh bone.  He was treated there during the period 03.02.2016 to 05.02.2016 and underwent ‘Nailing # shaft of Femur(Rt) done, Rerograde TEN Nailing.  He    was    again    admitted    in  SP Fort Hospital on 18.04.2016 and  on

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19.04.2016 underwent ‘GA Common peroneal nerve exploration-TEN removal’.  He was discharged on 21.04.2016.  However the complainant has submitted claim papers raising claim of Rs.1,21,350/- for the first hospitalization and for Rs.73,690/- for the second hospitalization. 

It is clear from the available materials that policy condition under Major Surgical Benefit  does not cover shaft or femur.  Therefore Major Surgical Benefit is not payable since surgery underwent by the 2^nd complainant is not listed in the MSB Annexure. 

As per condition No.2(1)  HCB is payable for one day only @ Rs.1100/-.  Therefore the complainant is eligible to get Rs.1100/- under the head HCB and it  is seen from the records that the opposite party had paid the same to the complainant.  It is clear from the available materials that  though  Other Surgical Benefit is payable for 2 days as per condition 2(IV) @ 2 times the ADB which would be Rs.1100x2x2=4400/-.  The said benefit is payable for surgeries which are not covered under MSB and is payable for the number of  days  for  hospitalization at  2 times the Applicable Daily Benefit.  In the circumstance the complainant is entitled to get  together Rs.5500/- which is admittedly paid by the opposite party on 27.10.2016.  The 2^nd claim lodged by the complainant is HCB.

It is clear from the available materials that HCB is payable for 3 days @ Rs.1100.  Hence eligible HCB is Rs.3300/-  and the complainant is also entitled to get OSB payable for 4 days @ 1100x2x4=8800/-.

In view of the materials discussed above it is clear that total amount payable under the above 2 heads is  Rs.3300+8800= Rs.12,100/- which is also seen paid according to the opposite parties.

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It is brought out in evidence that the complainant is  an education lady having MSc. Degree and has been working as Conductor in K.S.R.T.C.  PW1 would further admit that she read and understood the policy conditions.  Even according to PW1 each policy is a contract.  However PW1 would assert that she has not received the terms and conditions of the policy but at the same time she would read and understood the terms and conditions of the policy  which is highly unbelievable that without receiving copy of D3 terms and conditions of the policy she cannot understand the policy conditions.  It is also clear from the available materials that  if the policy holder is not satisfied the terms and conditions of the policy he  or she can very well cancel the policy during the cooling off period within  15 days from date of receipt of policy document which is clear from  Clause 22 of the Terms and conditions of  Ext.D3.  Admittedly the complainant has received sum of Rs.17100/- towards the total claim. 

In view of the materials discussed above it is clear that demand made by the complainant for payment of Rs.2,53,060/- is against the terms and conditions of the policy.    Ext. D7  would  further  indicate  that the complainant has approached the Insurance Ombudsman at Kochi  and the complaint was dismissed by the said  Ombudsman wide order dated 21.02.2017. 

In view of the materials discussed above it is cristal clear that  there is no deficiency in service or unfair trade practice on the side of the opposite party and that there is no merit in the complaint and the same is only to be dismissed.  The point answered accordingly.

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Point No.3

In the result the complaint stands dismissed.  Parties are directed to suffer their respective costs.

Dictated to the  Confidential Assistant  Smt. Deepa.S transcribed and typed by her corrected by me and pronounced in the  Open Forum on this the 12^th   day of  November  2019.      

E.M.Muhammed Ibrahim:Sd/-

S.Sandhya Rani:Sd/-

Stanly Harold:Sd/-

Forwarded/by Order

Senior Superintendent

INDEX

Witnesses examined for the complainant:-

PW1:-Apsara

Documents marked for the complainant:-

Ext.A1:-LIC Policy

Ext.A2 Series:- Receipts and reports

Ext.A3 Series:- Bill and discharge summary

Ext.A4:-Bill dated  30.04.2016

Ext.A5:-Bill dated 08.10.2016

Witnesses examined for the opposite party:-\

DW1:- S.Geetha

Documents marked for the opposite party:-

Ext.D1:-Proposal form for health insurance policy

Ext.D2:-Policy document dated 21.08.13

Ext.D3:-Policy conditions and privileges

Ext.D4:-Attested copy of claim form

Ext.D5:-Discharge summary issued from S.P.Fort Hospital(Attested copy)

Ext.D6:-Claim settlement letter (Attested copy)

Ext.D7:-Attested copy of award passed by the Insurance Ombudsman, Kochi

Ext.D8:-Confirmation of issue of the policy bond with the terms and conditions by the concerned LIC  Agent(Original)

Ext.D9:-Attested copy of delegation of powers under Regulation No.41 of the LIC regulations 1959.

E.M.Muhammed Ibrahim:Sd/-

S.Sandhya Rani:Sd/-

Stanly Harold:Sd/-

Forwarded/by Order

                                                                                    Senior Superintendent