Haryana

StateCommission

A/443/2018

LIC OF INDIA AND ANOTHER - Complainant(s)

Versus

KARAM SINGH - Opp.Party(s)

PIYUSH SHARMA

08 Aug 2018

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                 

First Appeal No  :    443 of 2018

Date of Institution:    11.04.2018

Date of Decision :     08.08.2018

 

1.     Life Insurance Corporation of India, Jeevan Jyoti Building, Sector-15, Sonipat through its Branch Manager.  

2.     Life Insurance Corporation of India, Divisional Office, LIC Building, SCO 3,4,5 Sector-1, HUDA Rohtak-1234001 through its Divisional Manager.

                                      Appellants-Opposite Parties

Versus

 

Karam Singh s/o Sh. Roop Singh, Resident of House No.1545, New Colony, Railway Road, Sonipat.

                                      Respondent-Complainant

 

CORAM:             Hon’ble Mr. Justice Nawab Singh, President.

                             Mr. Balbir Singh, Judicial Member.

                                                                                                         

Argued by:          Shri Piyush Sharma, Advocate for appellants.

                             Respondent Karam Singh in person.

 

                                                   O R D E R

 

BALBIR SINGH, JUDICIAL MEMBER

 

        This appeal has been preferred against the order dated January 03^rd, 2018 passed by District Consumer Disputes Redressal Forum, Sonipat (for short ‘the District Forum’).

2.                Karam Singh-complainant (respondent herein) was provided Health Protection Plus Plan (Table 902) insurance policy bearing No.176944066 (Exhibit C-15) by Life Insurance Corporation of India (LIC) –Opposite Parties (appellants herein) mentioning the date of commencement as October 03^rd, 2009, date of payment of last premium as October 03^rd, 2019 and sum assured as Rs.2,00,000/- regarding major surgical benefits. Karam Singh (hereinafter referred to as ‘the insured’) received only the insurance policy on October 07^th, 2009. The terms and conditions of the Insurance Policy were also not received by the complainant. On January 20^th, 2017 the complainant felt pain in his chest, retrosternal region. The complainant was taken to Mittal Hospital, Model Town, Sonipat. As the heart specialist was not available in the Mittal Hospital, the complainant was taken to Frank Institute of Medical Science, Bahalgarh Road, Sonipat on the same date at about 8:04 P.M. On that date after physical and systemic examination, coronary artery angiography was done in which triple vessel disease was found.  Immediately Urgent PTCA with stent to LAD was done by Cardiologist.

3.                The complainant remained admitted in hospital for his treatment from 8:04 P.M on January 20^th, 2017 up to January 22^nd, 2017 at about 12:35 P.M. The complainant made payment of total amount of Rs.1,59,000/- in Frank Institute of Medical Science, Bahalgarh Road, Sonipat.  Apart from it, the complainant has also spent an amount of Rs.353/- on January 20^th, 2017 and an amount of Rs.1385/- on January 22^nd, 2017 and an amount of Rs.2475/- on January 23^rd, 2017 for purchase of medicines. An amount of Rs.1350/- was paid to Cygnus JK Hindu Hospital, Sonipat on January 23^rd, 2017 for Echo Cardiography. The complainant submitted insurance claim alongwith all relevant documents amounting to Rs.1,64,563/- but the insurance claim was repudiated by the opposite party No.2 vide letter dated March 08^th, 2017 mentioning that total hospitalization period was less than 52 hours. The repudiation of the insurance claim is wrong and illegal. The complainant had to face unnecessary harassment, mental agony and he is entitled to receive an amount of Rs.2,00,000/- as compensation.

4.                The complainant filed complaint under Section 12 of the Consumer Protection Act, 1986 with a prayer to direct the opposite parties to pay an amount of Rs.1,64,563/- spent by the complainant for his treatment with interest at the rate of 12% per annum from the date of discharge from the hospital; to pay an amount of Rs.2,00,000/- on account of unnecessary harassment and mental agony and an amount of Rs.2200/- as litigation expenses.

5.                The opposite parties in their written version have taken plea that the complaint is not maintainable in the present form; that the complainant has no locus standi to file the present complaint and that it is not a case of deficiency in service. It is admitted fact that the complainant was provided Health Protection Plus Plan (Table 902) insurance policy by the opposite parties mentioning the date of commencement as October 03^rd, 2009 and last payment premium date as October 03^rd, 2019 and total sum assured as Rs.2,00,000/-. It is denied that along with the insurance policy, terms and conditions of the policy were not sent to the complainant. It is denied that the complainant has paid an amount of Rs.1,59,000/- in the hospital or that he spent any more amount for purchase of medicines.

6.                The Life Insurance Corporation received the claim form of the complainant alongwith other documents for payment of hospitalization/major surgical benefits. The insurance claim after proper verification and investigation was repudiated as terms and conditions of the insurance policy have been violated. As per terms and conditions the insurance claim cannot be accepted as the stay of the complainant in the hospital for his treatment was less than 52 hours. As per Clause 2(i)(a) of Conditions and Privileges, for acceptance of the insurance claim, the period of treatment in hospital should not be less than 52 hours. The repudiation of the insurance claim is valid and justified. The complainant is not entitled to receive any amount as prayed in the complaint. It is prayed that the complaint filed by the complainant be dismissed with cost.

7.                Parties led evidence in support of their respective claims before the District Forum.

8.                After hearing arguments vide impugned order dated January 03^rd, 2018 passed by the learned District Forum, the complaint filed by the complainant was allowed directing the opposite parties (LIC) to pay an amount of Rs.1,50,000/- spent by the complainant for his treatment in lump sum within a period of 60 days from the date of passing of the order failing which the opposite parties shall be liable to pay interest at the rate of 9% per annum from the date of passing of the impugned order failing which the opposite parties shall be liable to pay interest at the rate of 9% per annum from the date of passing of the order.

9.                Aggrieved with the impugned order, the opposite parties have filed the present First Appeal No.443 of 2018 with a prayer to set aside the impugned order and to dismiss the complaint.

10.              We have heard learned counsel for the appellants, the respondent in person and perused the case file.

11.              It is admitted fact that the complainant was provided insurance policy Exhibit C-15 under Health Protection Plus Plan by the opposite party No.1 mentioning the date of commencement of the insurance as October 03^rd, 2009 and last premium payment date as October 03^rd, 2019 and total sum assured as Rs.2,00,000/-. It is also admitted fact that the complainant was taken to Frank Institute of Medical Science, Bahalgarh Road, Sonipat for his treatment when the complainant felt pain in his chest, retrosternal region. The complainant was admitted in hospital at 4:04 P.M. on January 20^th, 2017 and he was discharged from the hospital on January 22^nd, 2017 at about 12:35 P.M. After physical and systemic examination, coronary artery angiography was done in which triple vessel disease was found.  Immediately Urgent PTCA with stent to LAD was done by Cardiologist, which is evident from the Emergency Certificate Exhibit C-1, Coronary Angioplasty (PTCA) Report is Exhibit C-3 and Angiographic Findings is Exhibit C-4. The complainant adduced in evidence hospital bill Exhibit C-2 which shows payment of an amount of Rs.1,59,000/- by the complainant. 

12.              The complainant adduced in evidence hospital bill Exhibit C-2 and receipts regarding purchase of medicines and other payments Exhibit C-8 Exhibit C-12. On the basis of the above mentioned bills and receipts, it appears that the complainant spent an amount of Rs.1,64,563/- for his treatment.  Learned District Forum has given finding that the complainant is entitled to receive only an amount of Rs.1,50,000/- in lump sum  the amount spent by the complainant for his treatment and purchase of medicines. Anyhow, the complainant appears to be satisfied with the order passed by the learned District Forum as the complainant did not prefer to file appeal against the impugned order passed by the learned District Forum for modification of the order. In this way, in case the consumer complaint is allowed, findings can be safely given that the complainant is entitled to receive an amount of Rs.1,50,000/- spent for payment of hospital bills and purchase of medicines.

13.              Insurance claim submitted by the complainant was repudiated vide letter dated March 08^th, 2017 Exhibit C-7 only on the ground as the total hospitalization period of the complainant was less than 52 hours. During the course of arguments, there was no controversy of any type that for surgical benefits the insurance claim can be accepted if the hospitalization of the patient remained for a period of 52 hours. The insurance company in its written version has not mentioned the period of admission of the complainant in hospital for his treatment specifically in the Emergency Certificate Exhibit C-1. In the Discharge Summary Exhibit C-5 and the hospital bill Exhibit C-2 time of admission in the hospital is mentioned as 8:17 P.M. on January 20^th, 2017 and time and date of discharge is mentioned as 12:35 P.M. on January 22^nd, 2017. It is evident from the above mentioned documents that the complainant remained admitted in hospital for more than a period of 52 hours and there was no violation of any type of terms and conditions of the insurance policy. In this way, it cannot be considered as a case of violation of Clause 2(i)(a) of Conditions and Privileges of the insurance policy Exhibit R-3.

14.              As a result as per discussions above in detail, we find no illegality in the impugned order dated January 03^rd, 2018 passed by the learned District Forum. Hence, findings of the learned District Forum stand affirmed and the appeal stands dismissed.

15.              The statutory amount of Rs.25,000/- deposited at the time of filing the appeal be refunded to the complainant against proper receipt and identification in accordance with rules, after expiry of period of appeal/revision, if any.

 

Announced: 08.08.2018

(Balbir Singh) Judicial Member

(Nawab Singh) President

 

CL