State Consumer Disputes Redressal Commission
Smt.Kalpana Shrivastava vs Lic on 1 September, 2023
Daily Order M. P. STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PLOT NO.76, ARERA HILLS, BHOPAL FIRST APPEAL NO. 1592 OF 2017 (Arising out of order dated 06.07.2017 passed in C.C.No.265/2015 by District Commission, Jabalpur-1) SMT. KALPANA SHRIVASTAVA, W/O SHRI SHANKAR SHRIVASTAVA, R/O ITI CHUNGI NAKA, OPPOSITE POLICE STATION-MARHATAAL, JABALPUR (M.P.) ... APPELLANT. Versus 1. CHIEF MANAGER, LIFE INSURANCE CORPORATION OF INDIA, DISTRICT BRANCH NO.18, SECOND FLOOR, CIVIC CENTRE, MARHATAAL, JABALPUR (M.P.) 2. SENIOR DIVISIONAL MANAGER, LIFE INSURANCE CORPORATION OF INDIA, DIVISIONAL OFFICE, NAGPUR ROAD, JABALPUR (M.P.) 3. CHAIRMAN, LIFE INSURANCE CORPORATION OF INDIA, CENTRAL OFFICE, JEEWAN SANCHAR, MUMBAI (M.S.) ... RESPONDENTS. BEFORE : HON'BLE SHRI JUSTICE SHANTANU S. KEMKAR : PRESIDENT HON'BLE DR. (MRS) MONIKA MALIK : MEMBER
COUNSEL FOR PARTIES :
Shri Arun Kumar Jain, learned counsel for the appellant.
Shri Pravesh Shobhani, learned counsel for the respondents.
O R D E R (Passed on 01.09.2023) The following order of the Commission was delivered by Dr.(Mrs) Monika Malik, Member:
This appeal by the complainant/appellant (hereinafter referred to as 'appellant') is directed against the order dated 06.07.2017 passed by the District Consumer Disputes Redressal Commission, Jabalpur-1 -2- (hereinafter referred to as 'District Commission') in C.C.No.265/2015, whereby the District Commission has dismissed the complaint filed by her.
2. Briefly put, facts of the case are that on 04.07.2013 the appellant under the health insurance scheme had obtained 'Jeevan Arogya' policy bearing no. 356902086 from the opposite parties-Life Insurance Corporation of India (hereinafter referred to as 'LIC') after paying yearly premium of Rs.6,253/-. Thorough medical investigation was carried out by the LIC before issuing the subject insurance policy. It is alleged that the appellant slipped in her house and all of a sudden she experienced pain in her both knees. She approached Dr. Amit Jain on 11.06.2014, who after investigations asked her to undergo knee surgery and subsequently, the appellant got her knees operated in Shalby Hospital, Ahmedabad (Gujarat). The appellant's husband submitted the claim along with requisite documents to the LIC but LIC denied the claim citing waiting period, regarding which the appellant was never informed earlier. Therefore, alleging deficiency in service against the LIC, the appellant approached the District Commission, seeking relief.
3. The opposite parties-LIC resisted the complaint on the ground that the insured appellant had undergone Bilateral Total Knee Replacement after getting hospitalized in Shalby Hospital, Ahmedabad from 03.07.2014 to 09.07.2014. There is specific waiting period for availing the aforesaid -3- treatment. Since the appellant had undergone aforesaid surgery within waiting period of two years, her claim was not payable.
4. Heard.
5. Learned counsel for the complainant/appellant argued that the appellant suffered slip in her house due to which problem arose in her knees and after consulting a physician she was advised Total Knee Replacement. The appellant was never aware of any condition, which she had suppressed in order to obtain subject policy cover. Also, the appellant had no information that there was two years' waiting period regarding surgery undergone by her. In the circumstances, the impugned order deserves to be set-aside and this appeal deserves to be allowed. Learned counsel for the appellant placed reliance on the judgment of Hon'ble Supreme Court in M/S Modern Insulators Ltd. Vs Oriental Insurance Co. Ltd. I (2000) CPJ 1(SC), the judgments of Hon'ble National Commission in New India Assurance Co. Ltd. Vs Dr. N. K. Bohra & Ors 2016 (4) CPR 116 (NC), Arun Kumar Vs New India Assurance Co. Ltd. & Ors 2016 (4) CPR 33 (NC), Oriental Insurance Co.Ltd. Vs Mr. Vidya Sagar Vohra & Ors. 2015(3) CPR 66 (NC) and a decision of M.P. High Court in Mohd. Syed Vs Hindustan Petroleum IV (2004) CPJ 696 (DB).
6. Learned counsel for the opposite party/respondent-LIC argued that the documents available on record clearly suggest that the appellant -4- was suffering from 'Osteoarthritis'. She had undergone Total Knee Replacement of both knees owing to the aforesaid ailment from which she was suffering. As per policy, claim for aforesaid surgery was not tenable up to two years. Since the appellant has undergone aforesaid surgery within waiting period of two years, her claim was rightly denied by the LIC and therefore, this appeal deserves to be dismissed.
7. Upon careful perusal of the record of the District Commission, we find that the 'patient summary' of the Shalby Hospital, Ahmedabad suggests that the patient was operated for Total Knee Replacement of both knees. The LIC has denied her claim on the ground that she was diagnosed with 'Osteoarthritis' of both knees and there was two years' waiting period regarding payment of claim with regarding treatment/surgery for aforesaid illness. The LIC has also produced terms and conditions of the subject insurance policy wherein there is two years' waiting period regarding treatment for Degenerative Joint Conditions and the same is stipulated under clause 6 (XII).
8. The plea of the appellant that the appellant was never informed regarding terms and conditions of the policy is not acceptable as the appellant herself has filed copy of 'LIC's Jeevan Arogya' policy annexed as 'P-1' in the record of the District Commission wherein it is inscribed that "It is hereby declared that this Policy of Assurance shall be subject to the -5- 'Conditions and Privileges' attached herewith........." In case, the appellant was not aware of the policy terms and conditions she ought to have asked for the same from the LIC.
9. Another plea of the appellant that she had slipped and was thus advised surgery for 'Total Knee Replacement' is also not acceptable in absence of any cogent evidence. The insurance company has specifically stated that the appellant had 'Osteoarthritis' and due to this condition, she had undergone aforesaid surgery. Further the repudiation letter spells that while filing claim no mention has been made about any accident. We find that the appellant has not specifically challenged the aforesaid submission of the insurance company.
10. The counsel for appellant has referred to judgment of the Hon'ble National Commission in the case of New India Assurance Vs Dr. N. K. Bohra (supra), but in the said judgment the insured had suffered fracture after falling at home and therefore she was advised for joint replacement on account of injury and that joint replacement was not due to degenerative condition. The facts of the other referred cases also are different from the case in hand and thus they too are not applicable in the instant manner.
-6-11. In view of the foregoing discussion, we conclude that the District Commission has rightly dismissed the complaint and has not committed any irregularity while doing so.
12. The impugned order which is not found to be suffering from any illegality is affirmed. This appeal, being devoid of any merit is dismissed, with no order as to costs.
(JUSTICE SHANTANU S. KEMKAR) (DR. MONIKA MALIK) PRESIDENT MEMBER