CONSUMER DISPUTES REDRESSAL FORUM, KOTTAYAM
Present:
Hon’ble Mr. Bose Augustine, President
Hon’ble Mr. K.N. Radhakrishnan, Member
Hon’ble Mrs. Renu P. Gopalan, Member
CC No. 380/2012
Saturday, the 6th day of December, 2014
Petitioner : Josephkutty Varghese,
Advocate,
Kallukulam House,
Thuruthy P.O.
Changanacherry.
(Adv. Sebastian James)
Vs.
Opposite party : The Divisional Manager,
LIC of India,
Divisional Office,
Kottayam.
(Adv. Annie C. Kuruvilla)
O R D E R
Hon’ble Mr. Bose Augustine, President
The case of the complainant filed on 12/10/2012 is as follows.
The complainant was a holder of a medi-claim insurance policy of the opposite party namely LIC Health plus plan, valid from 29/10/2009 to 28/10/2010. As per the terms of policy, the complainant as well as his wife was covered. According to the complainant, during policy period, the complainant was admitted at Pushpagirai Heart Institute, Thiruvalla on 11/04/2011 for Coronary Angiogram. And after that, the complainant was treated, angioplasty with stent to LADLC and RCA conducted. The complainant had incurred expenses Rs.2,00,000/- for treatment and other incidental expenses. And the complainant had submitted claim form with all relevant records and details claiming Rs.1,70,814/- with the TPA. According to the complainant as per the policy, he is entitled for Rs.1,000/- per day under HCB and Rs.2,00,000/- under MSB. And the TPA has processed the claim of the complainant and disallowed the claim under HCB and an amount of Rs.80,000/- was allowed under the major surgical benefits (MSB). Then the complainant on 03/01/2012, sent a registered letter protesting the above said decision. And on 06/01/2012, the opposite party had sent a replay notice stating untenable contentions and had cited certain policy conditions. According to the complainant, opposite party has not served any policy conditions alongwith the policy. And the said act of the opposite party amounts to deficiency in service. Hence this complaint.
The opposite party field version admitting the issuance of LIC Health Plus Plan Policy to the complainant. The complainant opted daily hospital cash benefits as Rs.1000/- for the principal insured and Rs.500/- for spouse. Major surgical benefit opted is Rs.2,00,000/- for principal insured and Rs.1,00,000/- for spouse. The complainant’s claim forms and hospital reports were forwarded to Medical Assist India, TPA, as they are authorized by IRDA. As per the IRDA Regulations, all health insurance claims should be processed by the TPA. After scrutinized the claim of the complainant with regard to the eligibility in terms of policy conditions based on the documents. They have come to the conclusion that, the surgery underwent comes under the list of allowed surgeries and 40% of sum assured is payable as surgical benefits claim as per the conditions and privileges referred in to the policy documents. Thus, Rs.80,000/- was paid as surgical benefit claim. Hospital cash benefit was not paid since the period of hospitalization was less than 52 hrs. According to the opposite party, after the receipt of notice, on 06/01/2012 they sent a replay to the complainant informing the reasons for disallowing the entire claim. According to the opposite party, the statement of the complainant that the policy conditions were not given to the complainant is baseless. And the opposite party had acted as per the terms and conditions of the policy which is attached alongwith the original policy document. And it was handed over to the complainant at the time of issuance of the policy document. There is no deficiency in service on the part of opposite party and they prayed for dismissal of the complaint with their costs.
Points for determinations are
- Whether there is any deficiency in service on the part of the opposite party?
- Relief and costs?
Evidence in this case consists of the proof affidavit of both sides. And
Ext.A1 to A3 documents from the side of complainant and B1 and B2 documents from the side of opposite party. Complainant filed argument note.
Point No.1
According to the complainant, he is entitled for the entire claim amount. Complainant issued a letter in way protest to reconsider the claim submitted by him. The copy of the letter produced is marked as Ext.A2. In Ext.A2, complainant requested for the payment of remaining amount. The opposite party issued a replay to the A2 letter. Replay issued by the opposite party dtd.06/01/2012 is produced and marked as Ext.A3. In Ext.A3, opposite party stated that, the complainant have paid the amount as per policy conditions. The opposite party quoted the conditions and privileges in page No.2. No.2 (1) (a) and page 14 list of surgical procedures. According to the opposite party, as per policy conditions, complainant is not entitled daily hospital cash benefits, which is less than 52 hours of hospitalization. Furthermore, in case of major surgery, the eligible amount is only 40% of the sum assured. So, the opposite party had paid the eligible amounts in accordance with the conditions of the policy. The learned counsel for the complainant vehemently argued that since the opposite party has not given any policy conditions to the complainant so far or else no such policy conditions were attached with Ext.A1 policy. So, the policy holder is not binding with the said conditions. In our view, the said conditions raised by the learned counsel for the complainant is untenable. It is the duty of the policy holder to well aware of the terms and conditions of the policy on the basis of which, he has entered into the contract. Furthermore, the conditions with regard to the insurance policies including medi-claim policies are designed by the IRDA. And the conditions are same in all medical policies of such nature. In our view, we cannot attribute any deficiency in service on the part of opposite party. Point No.1 finds accordingly.
Point No.2
In view of the findings in Point No.1, complaint is dismissed. No cost is ordered.
Pronounced Open Forum on this the 6th day of December, 2014
Hon’ble Mr. Bose Augustine, President Sd/-
Hon’ble Mr. K.N. Radhakrishnan, Member Sd/-
Hon’ble Mrs. Renu P. Gopalan, Member Sd/-
Appendix
Documents of the petitioner
Ext.A1 : Photocopy of LIC’s Health Plus Plan policy no.394569118
Ext.A2 : Photocopy of lawyers notice dtd. 03/01/12addressed to opposite party
Ext.A3 : Copy of letter dtd.06/01/12 addressed to petitioner.
Documents of the opposite party
Ext.B1 : Photocopy of LIC Health Plus Plan Policy no. 394569118.
Ext.B2 : Photocopy of claim settlement letter dtd.16/12/11 to petitioner by Medi
Assit India Pvt. Ltd.
By Order
Senior Superintendent
