Hon'ble Mr. Haradhan Mukhopadhyay, President.
The failure to pay the insurance claim of the Complainant by the OP led the Complainant to lodge this case before the Commission. The concise fact of the present case is that the Complainant Anup Kumar Ghosh insured Family Health Insurance Policy(Jeevan Arogya) with O.P. No.1 the Branch Manager, LICI, Dinhata Branch in December, 2018 vide Policy No.402563756. The Complainant paid policy amount consecutively but due to pandemic of Covid-19 he could not take appropriate steps regarding the said policy premium in 2020 in due time but afterwards the Complainant paid the policy premium. At the time of taking the policy OP assured the Complainant that medical claim would be provided on medical ground during unavoidable circumstances without any problem. During the said policy period the Complainant’s daughter had been suffering from acute female disease for which she was medically treated at P.K. Saha Hospital, Cooch Behar from 09.06.20 to 12.06.20 and thereafter at Siliguri. He incurred medical expenses for her daughter for Rs.34,220/- on 12.06.20 at P.K. Saha Hospital and also paid Rs.78,907/- on 15.06.21 to Anandaloke Hospital Siliguri for medical expenses. Thus a total sum of Rs.1,13,127/- was incurred for medical expenses of the daughter of the Complainant. Subsequently the Complainant intimated to the LICI of Dinhata Branch, O.P. No.1 about the said claim alongwith required documents. Thereafter, the Complainant received one letter from the O.P. No.2 the Divisional Manager LICI Jalpaiguri Division, Santipara, Jalpaiguri wherein the claim of the Complainant was rejected without sufficient ground. The Complainant has been facing financial crisis and suffered mental agony and irreparable loss due to rejection of the said claim. Consequently, the Complainant served a legal notice on 04.02.21 to the O.P. No.1 through his Advocate which the O.P. No.1 received on 08.02.21 but did not pay any heed to that notice. Such wilful act or omission on the part of the OP, they caused deficiency in service to the Complainant by rejection of the claim. So this case is filed. The cause of action for the present case arose on 09.06.20 and on subsequent dates till the date of filing of this case. The Complainant prayed for an award for Rs.1,13,127/- towards the mediclaim from the O.Ps, Rs. 1 Lakh towards deficiency in service, Rs.1 Lakh for mental pain and agony and Rs. 15,000/- towards cost of the proceedings.
Both the O.Ps contested the case by filing written version wherein they denied the case of the Complainant. Both the O.Ps challenged the case of the Complainant on the ground that the Complainant is not a consumer, the case is bad for non-joinder and mis-joinder of parties and not maintainable in law. The positive defence case made out in the written version to the effect that as per policy terms and condition it is clearly written that a grace period of one calendar month but not less than 30 days shall be allowed for payment of yearly or half yearly premium from the date of first paid premium. If the due premiums are not paid within the days of grace the policy will lapse and no benefit will be payable thereafter. From the premium payment history of the policy it is found that half yearly premium due on 09/2018 was paid on 07.12.18, due on 09/2019 was paid on 09.02.20 and premium due on 03/2020 was paid on 15.06.20. However, a lapse policy can be revived within 5 years from the date of unpaid premium with due payment of other charges/ late fees. So from the premium payment history it is clearly found that the Complainant did not pay half-yearly premium due on 28.09.18, 28.09.19 and 28.03.20 within specific grace period and on each occasion the policy was revived. It is clear from the premium payment history that during the period of hospitalization of Complainant’s daughter the policy remained in lapsed condition and on 15.06.20 it is revived. As per benefits Point No.08 part-C: Customer information sheet it is clearly written that if a request for revival is received by the corporation within 90 days from the due date of first unpaid premium then there shall be general waiting period of 45 days from the date of revival in respect of each insured. In response to the letter of the Complainant dated 20.11.20 the Manager, Jalpaiguri Division informed on behalf of the O.P. No.2 to the Complainant that nothing is payable. There is no cause of action. The LICI is the largest insurer of the country and caused no deficiency in service. The O.Ps claimed that the case is liable to be dismissed with cost.
The conflicting pleadings of the parties and different intricate questions involved in this case led this Commission to ascertain the following points in controversy for proper adjudication of the case.
Points for Determination
- Whether the Complainant is a consumer and the case is maintainable in its present form and prayer?
- Whether there is any deficiency in service?
- Whether the Complainant is entitled to get the relief as prayed for?
- To what other relief if any the Complainant is entitled to get?
Decision with reasons
Point No.1.
The Complainant challenged so many points. Taking all the points into consideration it is found that the Complainant purchased the insurance policy form the O.P. No.2 bearing policy No. 402563756, date of commencement 28.03.18 payable premium 904-23. There is no denial of the fact that the Complainant is not a policy holder of the O.Ps. Thus the relation between the Complainant and the OP is customer and service provider.
There is no denial of the fact that the Complainant’s daughter was medically treated for which they incurred a sum of Rs.1,13,127/- on 15.06.21 towards medical expenses. The notice was served on 04.02.21. Having been unsuccessful to get the claim the present case is filed on 23.07.21. Thus having assessed the entire facts and circumstances, it stands well established that the present case is filed within statutory limitation period, both the parties are within the territorial jurisdiction of this Commission. The pecuniary jurisdiction also covers the total claim of the Complainant. Accordingly there is nothing within the case record through which it can be considered that the case is barred by any legal point of view.
Accordingly, Point No.1 is answered in favour of the Complainant.
Point Nos. 2, 3 & 4.
All these points have very close nexus amongst them. So these are taken up together for brevity and convenience of discussion.
The Complainant in order to establish the case adduced both oral evidence in the form of evidence on affidavit and documentary evidence. There is no denial of the fact that the daughter of the Complainant was medically treated at two hospitals at Cooch Behar and Siliguri wherein the Complainant incurred total medical expenses of Rs.1,13,127/-. The Complainant proved Annexure-A being the particulars of the insurers Anup kumar Ghosh and details of the insurance coverage. Annexure-B is the medical treatment document of Dr. P.K. Shah Hospital Private Limited, Cooch Behar wherefrom it stands established that the Complainant was admitted on 09.06.20 and discharged on 12.06.20.
The Complainant further proved the medical bill of Dr. P.K. Shah Hospital through Annexure-B series.
Annexure-C supports the claim of the Complainant that his daughter was medically treated at Anandalok hospital Siliguri for the period 13.06.20 to 15.06.20. Annexure-C series are the medical bill of Anandalok hospital for incurring different medical expenses at Anandalok hospital. Annexure-D is the reminder letter given by the Complainant to the Branch Manager LICI Dinhata Branch for payment of medical claim. Annexure-E is the reply to the letter of the Complainant dated 20.11.20. Annexure-F is the legal notice of the Complainant dated 04.02.21. The OP did not prove any documents in support of their defence case.
It is the settled position of law that the Complainant has to prove his own case on the strength of his own evidence and not on the weakness of the OP.
Apart from a particular defence case the O.Ps did not challenge the fact of medical treatment of the Complainant’s daughter.
The main defence case is that the insurance policy of the Complainant was lapsed and as such he is not entitled to get the mediclaim. After perusing the documents of both the parties it transpires that the Complainant failed to pay the premium of 09/2018 which was subsequently received on 17.12.18. Again the Complainant failed to pay the premium on 09/2019 but the said premium was taken by the OP on 19.02.20 and finally the 3rd premium 03/2020 was paid on 15.06.20 which the OP accepted.
It is further important to consider that on three occasions, the OP Insurance Company accepted the premium lately but under no circumstances the OP informed that the policy was lapsed.
The OP rejected the claim of the Complainant on the soul ground that the claims false under the exclusion clause of the general waiting period and hence nothing is payable. Despite taking said specific defence plea the OP did not prefer to prove any documents regarding the said exclusion clause.
Ld. Advocate for the Complainant argued that the premium for 03/2020 could not be paid as pandemic for covid-19 was going on and as per the Central Government Moratorium an extension period the was given for the payment of all premiums. In this regard Complainant proved circular of the Finance Ministry, Government of India, which announces several relief measures relating to statutory and regulatory compliance matters across sectors the covid-19 outbreak. As per the said circular where the time limit is expiring between 20.03.20 to 29.06.20 shall be extended to 30.06.20.
Ld. Senior Defence Counsel could not contradict the said circular. So, the premium for 03/2020 also comes within the purview of the Moratorium and extension of the time extended by Govt. of India but subsequently they paid the premium.
Ld. Senior Defence Counsel repeatedly hammered during argument that the Complainant is a habitual defaulter. At the time of medical treatment the Policy was not inforce and it was lapsed. In this case further one month cannot be waited. After 45 days benefit can be given.
Ld. Advocate for the Complainant argued that the OP LIC never informed that the Policy was lapsed. On the contrary the policy premium was taken at regular interval. No letter was issued on behalf of the OP that the Policy was lapsed and it requires to be revived.
Ld. Senior Counsel further argued that the Complainant failed to comply with the terms and condition of point No.8(ii)(a).
Mere payment of premium does not mean that the benefits are revived. The argument is not acceptable in as much as the medical document discloses that the patient was discharged from Anandalok hospital on 15.06.20. As per the circular of the Central Government in respect of the covid-19 pandemic where the time limit is expiring between 20.03.20 to 29.06.20 it shall be extended till 30.06.20. Therefore, the Complainant is entitled to get the benefit of the circular passed by the Central Government. The OP could not prove any document to counter the said policy of the Central Government. There is also nothing within the case record which reveals that the OP informed the Complainant that his Policy was lapsed and he is not entitled to get the benefit extended by the Central Government of India.
It is also evident from the reply letter of the OP Manager LICI Jalpaiguri Division (being Annexure-E) that the OP even not disclosed the exclusion clause specifically in the said letter. The said claim was out right rejected by the OP Company. The said letter was issued on 20.11.20 and the Central Government Moratorium Policy was published much ahead of the issuance of the said letter and as such it was well within the knowledge of the OP Company. So, the OP Company could not ignore the policy of the Central Government. Therefore, the present claim of the Complainant is covered under the waiting period. Accordingly refusal of the claim of the Complainant by the OP tentamounts to deficiency in service.
Thus having assessed the entire evidence in the case record and in view of the observation made in the foregoing paragraph the Commissions comes to the findings that the Complainant is entitled to get the relief prayed for.
Accordingly, Point Nos.2, 3 & 4 are answered in affirmative and decided in favour of the Complainant.
Consequently, the complaint case succeeds on contest with cost.
Hence, it is
Ordered
That the complaint case No. CC/31/2021 be and the same is allowed on contest with cost Rs.5,000/-.
The Complainant do get an award for a sum of Rs.1,13,127/- towards mediclaim against the O.Ps, Rs.10,000/- towards deficiency in service and Rs.10,000/- towards mental pain and agony.
The O.Ps are directed to pay a sum of Rs.1,38,127/- to the Complainant within 30 days from the date of passing the Final Order failing which the entire award money shall carry an interest @ 8% per annum from the date of passing the Final Order till the date of its realisation. The case is finally disposed of.
D.A. to note in the trial Register.
Let a plain copy of this Order be supplied to the concerned party by hand/by Registered Post with A/D forthwith, free of cost, for information & necessary action as per rule.
The copy of the Final Order is also available in the official website: www.confonet.nic.in.
Dictated and corrected by me.
