Hon’ble Mrs. Dipa Sen (Maity), Presiding Member

The instant Appeal U/s. 17 of the Consumer Protection Act, 1986 has been filed by the LICI against the final order dated 11-12-2017 passed by the Ld. DCDRF, Murshidabad in connection with the complaint case being No.CC/91/2013 whereby the complaint case was allowed in part on contest against the Opposite Party No.1 and ex-parte against Opposite Party No.2 with the direction to the Opposite Party No.1/Branch Manager, present Appellant LICI to make payment of actual treatment cost of Rs.59,409/- (Rupees Fifty Nine thousand four hundred & nine).  Being aggrieved and dissatisfied with the said impugned Judgment the Appellants/LICI have preferred this memo of Appeal for setting aside the Judgment dated 11-12-2017 passed by the Ld. Forum below. 

The brief fact of the case is that the Complainant/present Respondent/Santosh Kumar Paul has filed the complaint case against the LICI alleging deficiency in service for repudiating LIC policy claim of Rs.59,409/-(Rupees Fifty nine thousand four hundred & nine) only for the treatment of Complainant’s wife Sutapa Paul.  The wife of the Complainant/Respondent was admitted to Delona Nursing Home and Diagnostics Centers Pvt. Ltd. on 12-11-2012 and was undergone surgery for fibroid Uterus on 14-11-2012.  The Complainant purchased one “Jeevan Arogya” Health Insurance Policy No.429167207 commencing from 28-09-2011 against yearly premium of Rs.7,398/- (Rupees Seven thousand three hundred & Ninety eight) only for himself and his wife Sutapa Pal.  The claim for cost of treatment for his wife of Rs.59,409/-( Rupees Fifty nine thousand four hundred & nine) only was submitted by the Complainant/Respondent on 08-01-2013.  The same was rejected on 20-02-2013 under Clause “W-01”- claim submitted after 30 days from the date of discharged from hospital and “W-06” - the specific waiting period is applicable under Clause 6 of “LIC”s Jivan Aragya condition and privileges.  After hearing both parties the Ld. Forum below allowed the case of Complainant. 

Ld. Counsel for the Appellant has preferred the present Appeal and thereby stated that the Ld. Forum below without even perusing the terms and conditions of the concerned policy passed the impugned order in favour of the Complainant and thereby directed the present Appellant LICI to release the claim amount of Rs.59,409/-( Rupees Fifty nine thousand four hundred & nine) only.   Complainant’s wife has undergone surgery for her fibroid Uterous within the waiting period of two years from the commencement of policy.  Respondent Santosh Kumar Paul failed to submit the claim papers within 30 days from the date of release from the Nursing Home.  The Ld. Counsels appearing for the Appellant/O.P/LICI has stated that the Ld. Forum below has passed an order without considering the terms and conditions of Jeevan Arogya Health   Insurance Policy which is annexed here with the Memorandum of Appeal. 

It also appears from the perusal of Final Order/Judgment passed by the Ld. DCDRF that the Forum below admitted the fact that the said order passed without considering the terms and conditions of the policy as none of the parties submitted the terms and conditions of the said policy in question.   The Forum passed their decision and allowed the same in part without considering terms & conditions of the subject policy and only considered the benevolent nature of the Consumer Protection Act as a beneficial legislature. 

In view of the above mentioned fact and circumstances, we do hereby set aside the impugned order dated 11-12-2017 passed by the Ld. DCDRF, Murshidabad in connection with complaint case being No.CC/91/2013.  Consequently, the Appeal is allowed.

The case is remitted on remand with the direction upon the parties to appear before the Ld. District Forum within August 2023 and the Ld. District Forum is requested to proceed further in accordance with law and on the basis of the terms and conditions of Jeevan Arogya Health Insurance Policy which is annexed here with the Memorandum of Appeal. 

Let a copy of this Judgment and Order be supplied to both the contesting parties free of cost.

Interim order, if any, be vacated at once.

With the above observation the Appeal stands disposed of.

The Registrar of this Commission is directed to send the copy of order to the DCDRF, Murshidabad for information and compliance.

Accordingly, the Appeal is allowed on contest.