DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BATHINDA

CC.No.194 of 28-05-2015

Decided on 24-02-2016

Suresh Kumar aged about 51 years S/o Ram Parshad R/o Singla Street, Rampura Phul, Tehsil Phul, District Bathinda.

........Complainant

Versus

1.Life Insurance Corporation of India, Divisional Office, CRM Department, Jeevan Prakash, Phase-I, Dugri, Ludhiana, through its Chief Regional Manager.

2.Life Insurance Corporation of India, Branch Office Jeevan Jyoti Building, Bibiwala Road, Bathinda, through its Branch/Senior Manager.

.......Opposite parties

Complaint under Section 12 of the Consumer Protection Act, 1986

QUORUM

Sh.M.P Singh Pahwa, President.

Smt.Sukhwinder Kaur, Member.

Sh.Jarnail Singh, Member.

Present:-

For the Complainant: Sh.Ritesh Singla, Advocate.

For opposite parties: Sh.Gaurav Aggarwal, Advocate.

ORDER

M. P. Singh Pahwa, President

1. The complainant Suresh Kumar (here-in-after referred to as complainant) has filed complaint U/s 12 of Consumer Protection Act, 1986 against opposite parties Life Insurance Corporation of India and Other (here-in-after referred to as opposite parties).

2. Briefly stated, the case of the complainant is that he has purchased one medical insurance policy No.301870875 dated 17.11.2009 under LIC's Health Plus Plan for the period of 19 years i.e. upto 31.12.2028. He is required to deposit the premium of Rs.19,500/- per annum and life assured is entitled to Rs.1500/- as initial daily hospital cash benefit and Rs.3 lac as major surgical benefit. Since the date of purchase of policy, he has been regularly depositing the premium amount with opposite parties.

3. It is alleged that unfortunately, the complainant fell ill due to sudden heart problem on 7.4.2012 and got admitted in Delhi Heart Institute & Research Centre, Namdev Marg, 40 ft. Road, Bathinda on 7.4.2012 and was diagnosed for Acute AWMI (CART SVD) and undergone PTCA (Stenting) from Delhi Heart Institute & Research Centre, Bathinda. He remained admitted in the hospital upto 12.4.2012 and was ultimately discharged from the hospital. He spent an amount of Rs.2 lacs approximately on his treatment including PTCA Charges, hospital charges, nursing care and medicines. Thereafter he lodged the claim with opposite parties, they have been demanding different documents from him for honouring his claim. He has furnished all documents from time to time and has already furnished all the original bills, receipts and other documents as demanded by opposite parties, but they have failed to settle his claim and have paid him only a sum of Rs.16,500/- on 5.7.2012.

4. It is further alleged that opposite parties assured the complainant that they will make the payment of balance amount of his insurance claim as earlier as possible, but they have failed to settle his claim till date. Opposite parties have been putting off the matter on one or other pretext. Due to this illegal and arbitrary act of opposite parties, he has been suffering from great mental tension, agony, botheration, harassment and has suffered financial losses.

   On this backdrops of fact, the complainant has alleged deficiency in service and unfair trade practice on the part of opposite parties and has prayed for reimbursement of insurance claim of Rs.3 lacs on account of his operation and medical treatment after adjusting the amount of Rs.16,500/- and has claimed compensation to the tune of Rs.1 lac on account of mental tension, botheration and harassment etc. and Rs.11,000/- as cost of litigation. Hence, this complaint.

5. Upon notice, opposite parties appeared through counsel and contested the complaint by filing their joint written version. In written version, they have raised legal objections that this complaint is barred by law of limitation. They have settled the claim of the complainant as per recommendations of TPA vis a vis terms and conditions of insurance policy on 14.6.2012 by way of issuing cheque dated 14.6.2012 of Rs.16,500/- drawn on Axis Bank, which was encashed by him on 4.7.2012. He has accepted the claim by way of encashing the abovesaid cheque. The complaint is bad for non-joinder of necessary party. He failed to implead 'Mediassist India Pvt. Ltd., TPA i.e. Third Party Administrator, who has settled his claim. The complainant is not a consumer as defined under 'Act'. He has purchased LIC's Health Plus Insurance Plan, which offers health insurance coupled with ULIP benefits by investing savings in the form of units in Health Plus Fund, as such he is not a consumer under 'Act'. The complaint is not maintainable in its present form. It is false, frivolous and vexatious to the knowledge of the complainant. He has raised many disputed and complicated facts, which require voluminous evidence, which cannot be adjudicated in this Forum. No proper court fee is paid by him.

6. On merits, it is pleaded that policy No.301870875 is a LIC's Health Insurance Plan. The complainant and his wife Renu Bala are insured. Sum assured for the complainant is Rs.5 lacs and his wife is Rs.3 lacs. Initially, daily befits for complainant is Rs.2500/- and his wife is Rs.1500/-.

7. It is reiterated that the complainant has purchased LIC's Health Plus Insurance Plan, which offers health insurance coupled with ULIP benefits by investing savings in the form of units in Health Plus Fund, as such he is not a consumer under 'Act'. Opposite parties have settled his claim as per recommendations of TPA by way of issuing cheque dated 14.6.2012 of Rs.16,500/- drawn on Axis Bank, which was encashed by complainant on 4.7.2012. He has accepted this amount. He remained silent for about 3 years, which also corroborates the fact that he was satisfied with the claim settled by opposite parties as per recommendations of TPA.

   After controverting all other averments, opposite parties prayed for dismissal of complaint.

8. Both the parties were afforded opportunities to produce evidence.

9. In support of his claim, the complainant has tendered into evidence his own affidavit dated 8.10.2015, (Ex.C1); photocopy of policy, (Ex.C2); photocopy of certificate, (Ex.C3); photocopy of discharge summary, (Ex.C4); photocopies of receipts, (Ex.C5 and Ex.C14); photocopy of detail, (Ex.C6); photocopy of passport, (Ex.C7); photocopies of retail invoice, (Ex.C8 to Ex.C13) and photocopy of bill, (Ex.C15).

10. In order to rebut this evidence, opposite parties have tendered into evidence affidavit of K.L Khichi dated 24.11.2015, (Ex.OP1/1); photocopy of policy terms and conditions, (Ex.OP1/2) and affidavit of Sri S.R Bhat. AP dated 18.12.2015, (Ex.OP1/3).

11. We have heard learned counsel for the parties and gone through the file carefully.

12. Learned counsel for complainant has reiterated his stand as taken in the complaint and detailed above. It is further submitted by the learned counsel for complainant that the complainant has placed on record LIC's policy, (Ex.C2), which proves that he was insured from 31.12.2009 to 31.12.2028. Moreover this fact is not disputed by opposite parties. The complainant has also produced discharge summary, (Ex.C4) to prove that he was discharged on 7.4.2012. The bill, (Ex.C6) proves that he remained admitted in Delhi Heart Institute & Research Centre, Bathinda from 7.4.2012 to 12.4.2012. He has spent an amount of Rs.75,000/- for PTCA Procedure and Angiography. Bills, (Ex.C8 to Ex.C14) prove that he has spent various amounts for purchase of medicines. Ex.C15, proves that medicines purchased by the complainant for Rs.75,000/-. Opposite parties were to reimburse his claim, but they reimbursed amount only to the extent of Rs.16,500/-. Of-course, the complainant has accepted this amount, but he was told that it is part of claimed amount. There is nothing to show that it was full and final payment of his claim. He is entitled to balance amount out of claimed amount. He is also entitled to compensation as claimed by him in addition to litigation expenses.

13. On the other hand, learned counsel for opposite parties has submitted that as per complainant himself, he took treatment from 7.4.2012 to 12.4.2012 and payment of Rs.16,500/- was paid to him vide cheque dated 14.6.2012. If the complainant was not satisfied with the amount paid to him, he was to approach before this Forum within 2 years as complaint was filed on 28.5.2015. This complaint is patently time barred.

14. It is further submitted by learned counsel for opposite parties that the complainant himself has placed on record policy titled as 'LIC's Health Plus Insurance Plan'. It is categorically mentioned that the investment risk in investment portfolio is borne by policyholder. The complainant has only produced part of policy document, (Ex.C2). He has not produced the complete document. Opposite parties have produced the entire policy document as Ex.OP1/2. It is a 'Unit Linked Health Insurance Plan Policy'. The investment made by the complainant was speculative and to earn profit. Therefore, he is not covered under the definition of 'consumer'. As such, this Forum cannot adjudicate the matter involved in this case.

    Even otherwise, as per Clause 2 of policy document, initially, daily benefits for complainant is Rs.2500/- and no charges is payable for first 48 hours. He remained admitted in the hospital from 7.4.2012 to 12.4.2012. He remained in hospital 5 days and was entitled to Rs.2500/- per day for 3 days i.e. Rs.7500/-. He was also entitled to 5% of IDV after completion of first year and 5% of IDV after completion of 5 years i.e. Rs.250/- per day, total payable amount was Rs.2750/- and in case, hospitalization in ICU, the amount payable is double of the normal amount i.e. Rs.5500/-. He remained admitted in ICU. Therefore, he was entitled to Rs.5500/- per day i.e. Rs.16,500/- and this amount has already been paid to him.

15. It is further submitted by learned counsel for opposite parties that the complainant has also claimed for major surgery, but he was admitted with Myocardial Infraction (Heart Attack). He was also diagnosed with single vessel disease for which PTCA to LAD (Single stent was used for LAD artery). Therefore, the surgery undergone by him is not included in MSB i.e. Major Surgical Benefit. Hence, he was denied this claim.

    To support his version, learned counsel for opposite parties has cited cases Ram Lal Aggarwalla Vs. Bajaj Allianz Life Insurance Company Limited, 2013(3) CPJ 203 and Smt.Paramjit Kaur Vs. Aviva Life Insurance Company India Limited, Consumer Complaint No.96 of 2011, Decided on 4.7.2014 in respect of claim under 'Unit Linked Insurance Policy', consumer complaint is not maintainable and money investment is speculative.

16. We have given careful consideration on these submissions and have gone through the cases law cited by learned counsel for opposite parties.

17. From the rival arguments, the following points have emerged for determination by this Forum:-

    (i) Whether the complainant is 'consumer' under 'Act' or not;

    (ii) Whether the complaint is within the limitation or not;

    (iii) Whether the claim stands satisfied or not.

    As per complainant himself, he remained admitted in the hospital up to 12.4.2012. Thereafter he lodged the claim regarding his treatment. He received cheque of Rs.16,500/- dated 14.6.2012. There is nothing on record to show that he has accepted this cheque under protest or any undue influence or coercion. Therefore, cause-of-action has accrued to him in the month of June 2012 when he received the cheque. He was to file complaint within 2 years. He filed complaint in the month of May 2015, which is beyond 2 years. Therefore, the complaint is time barred.

18. Case of the complainant is based on policy, copy of which is brought on record as (Ex.OP1/2). It is LIC's Health Plus Insurance Plan and in the very first heading, it is mentioned that it is a 'Unit Linked Health Insurance Plan'. The complainant has also placed on record part of this policy as Ex.C2. In the heading of this policy also, it is categorically mentioned that the investment risk in investment portfolio is borne by policyholder. Therefore, it is a 'Unit Linked Insurance Policy' and element of speculation is involved therein.

    As per law laid down in case Ram Lal Aggarwalla Vs. Bajaj Allianz Life Insurance Company Limited (Supra) in respect of claim under 'Unit Linked Insurance Policy', consumer complaint is not maintainable and money investment is speculative. In case M/s ICICI Prudential Life Insurance & Other Vs. David Garg, First Appeal No.943 of 2014, Decided on 7.12.2015 Hon'ble State Commission has held in Para No.9:-

    “In Ram Lal Aggarwalla’s case (supra), the District Forum recorded the finding that the Policy, having been taken for investment of the premium amount in share market, which is a speculative gain, the complaint does not come within the purview of the Consumer Protection Act, 1986, and while recording that finding, it relied upon the decision of the State Commission, Odisha, rendered in F.A. No.162 of 2010 (Smt. Abanti Kumari Sahoo Vs. Bajaj Allianz Life Insurance Company Ltd.) and that finding of the District Forum was upheld by the said State Commission. When the matter went before the Hon’ble National Commission, the order passed by the State Commission was upheld. Thus, ratio of the above said judgment makes it very much clear that where the Policy has been taken for investment of the premium amount in the share market, which is for speculative gain, the complaint did not come within the purview of the Act. It was for the District Forum to ascertain, whether the complaint was maintainable or not, even if no objection had been taken to that effect by the opposite parties. It failed to perform that onerous duty and without deciding that question first, entertained the complaint and decided the same on merits. It should have been dismissed; being not maintainable.”

    This above observation is also followed by our State Commission in case Smt.Paramjit Kaur Vs. Aviva Life Insurance Company India Limited, (Supra). As such, the complainant does not fall within the definition of 'consumer'.

19. For the reasons recorded above, the complainant does not fall within the definition of 'consumer'. Therefore, this Forum is not required to record the findings on the main claim of the complainant regarding reimbursement. Hence, this complaint is hereby dismissed without any order as to cost.

20. The complaint could not be decided within the statutory period due to heavy pendency of cases.

21. Copy of order be sent to the parties concerned free of cost and file be consigned to the record.

    Pronounced in open Forum:-

    24-02-2016

    (M.P Singh Pahwa)

    President

     

     

    (Sukhwinder Kaur)

    Member

     

     

    (Jarnail Singh)

    Member