State Consumer Disputes Redressal Commission
Life Insurance Corporation Of India & ... vs Suresh Kumar Dhir on 28 November, 2023
STATE CONSUMER DISPUTES REDRESSAL COMMISSION
PUNJAB, DAKSHIN MARG, SECTOR -37 A, CHANDIGARH
First Appeal No.202 of 2021
Date of Institution : 07.06.2021
Reserved on : 27.10.2023
Date of Decision : 29.11.2023
1. Life Insurance Corporation of India Yogakshema, Jewan Bima
Marg, Post Box No.19953, Mumbai-400021, through its
Managing Director.
2. Life Insurance Corporation of India, Jeevan Parkash, City B O
IV, Ground Floor PB No.148, Divisional Office, Model Town
Road, Jalandhar-144001, through its Divisional Officer.
3. Life Insurance Corporation of India, Branch 2, Unit II, Jiwan
Jyoti Building, Opposite Tehsil Complex, Jalandhar, through its
Senior Branch Manager.
........Appellants/Opposite Parties
Versus
Suresh Kumar Dhir (since deceased) through his LR's :-
1. Kiran Dhir Wife of Suresh Kumar Dhir ;
2. Nidhi Dhir, daughter of Suresh Kumar Dhir ;
3. Lovely, daughter of Suresh Kumar Dhir ;
4. Gaurav Dhir son of Suresh Kumar Dhir ;
All residents of H.No.313, Panj Peer, Near Sita Mata Mandir, Neem
Wali Gali, Jalandhar.
.....Respondents/Complainants
Appeal under Section 41 of Consumer
Protection Act, 2019 to challenge the
order dated 16.03.2021 passed by the
District Consumer Disputes Redressal
Commission, Jalandhar in C.C. No.119 of
2017.
Quorum:-
Hon'ble Mrs. Justice Daya Chaudhary, President
Ms. Simarjot Kaur, Member
Present:-
For the appellants : Sh. Piyush Sharma, Advocate 2 First Appeal No.202 of 2021 For the respondents : Sh. Vipul Sachdeva, Advocate
1) Whether Reporters of the Newspapers may be allowed to see the Judgment? Yes/No
2) To be referred to the Reporters or not? Yes/No
3) Whether judgment should be reported in the Digest? Yes/No JUSTICE DAYA CHAUDHARY, PRESIDENT:-
The appellants/opposite parties i.e. Life Insurance Corporation of India & others have filed the present appeal under Section 41 of the Consumer Protection Act, 2019 (in short the 'Act') being aggrieved by the impugned order dated 16.03.2021 passed by the District Consumer Disputes Redressal Commission, Jalandhar (hereinafter referred as the "District Commission"), whereby the complaint filed by the respondent-complainant had been partly allowed by directing the OPs to pay an amount of Rs.81,709/- to the complainant on account of expenses incurred on the treatment of the complainant and also to pay an amount of Rs.15,000/- towards compensation and litigation expenses. The compliance of the order was to be made within a period of 45 days from the date of receipt of the copy of the order.
2. Briefly, the facts of the case as made out by the respondent/complainant before the District Commission are that the OPs by explaining the benefits of Medical Health Insurance Policy contacted the complainant by elaborating the plans and their privileges of said Health Insurance Policy including the relief of cash benefit during the period of hospitalization. It was also stated that the 3 First Appeal No.202 of 2021 premium of said Insurance Policy was to be paid for at least a continuous period of five years from the date of commencement of the policy by covering the health benefits of the insured for a period of 31 years from the date of its commencement. Being convinced by the assurance given by the OPs, the complainant had purchased LIC Health Protection Plus having Table No.902 from OP No.3 on 10.05.2011 with installment premium of Rs.750/- per month. Thereafter, the complainant had paid installments/premiums to the OPs without any break upto the period i.e. June, 2016. The complainant had contacted Development Officer of the OPs in the Month of June, 2016 and informed that he had paid all the monthly premiums for the period of five years and now he was not required to pay more. Thereafter, the complainant had stopped to pay monthly installments/premiums to the OPs. Thereafter, in the month of January 2017, the complainant while visiting Bhavnagar in the State of Gujarat for business purposes suffered pain on 23.01.2017 at about 06.00 p.m. in the left arm and there was numbness. He immediately rushed to HCG Hospital Bhavnagar with the help of his close relative and there he suffered a severe paralysis attack. He was got admitted in the hospital and remained admitted in ICU for a period of three days and thereafter he was shifted to the room on recovery of the health. He was discharged from the Hospital on 28.01.2017. The complainant had spent an amount of Rs.1,00,000/- on his treatment and at the time of discharge from HCG Hospital on 28.01.2017, the bill amount of Rs.77,709/- was paid by him. 4 First Appeal No.202 of 2021 Thereafter also the complainant was not able to move his left arm and leg and he started to take treatment from Sharda Medical Center, Tehsil Nalagarh, District Solan (HP) and he was recovered after a period of 5/6 appointments with the Doctor. Thereafter, he was able to move freely. He had spent an amount of Rs.50,000/- on his treatment at Solan (HP). Thereafter, in the month of March, 2017 the complainant contacted OP No.3, requesting about the claim of the Health Insurance Policy. The official of OP No.3 asked him to fill up the Form. The complainant went to the concerned hospital and the said Form was given to the treating Doctor who filled up that Form and signed alongwith the stamp of the Hospital. The complainant submitted the bills for reimbursement for an amount of Rs.77,709/- and Rs.50,000/- but the official of the OPs told him that Company could pay only Rs.11,000/-. Thereafter, it was informed that nothing could be done.
3. By considering the act and conduct of the OPs in not paying the amount and in not treating him properly was stated to be a case of 'deficiency in service' and 'unfair trade practice' on the part of the OPs.
4. The complaint was filed with the prayer to issue directions to pay an amount of Rs.77,709/- alongwith expenses of Rs.50,000/- incurred on his treatment at Sharda Medical Center, Solan as well as Rs.50,000/- as compensation and Rs.5500/- for causing mental harassment and Rs.5500/- as cost of litigation. 5 First Appeal No.202 of 2021
5. Notice was issued in the complaint filed by the complainant and on being served, the OPs appeared before the District Commission and filed written reply wherein certain preliminary objections were raised stating therein that the complainant was not having any locus standi to file the complaint and as such it was not maintainable. On merits also the averments made in the complaint were denied. It was also mentioned in the reply that the policy issued to the complainant was not a Mediclaim Policy but it was an Investment cum Health Insurance Policy. Net Asset Value (NAV) of said policy was to be returned to the policy holder immediately on attaining the age of 75 years. Certain medical expenses were specified in the terms and conditions of the policy incurred for the specified surgeries. Other averments made in the complaint were also denied and the prayer was made for dismissal of the complaint.
6. The complainant had tendered into evidence his affidavit Ex.C-A alongwith copies of documents Ex.C-1 to C-14. Similarly, the OPs had also tendered into evidence an affidavit of Vijay Gill, Manager Health Insurance as Ex.OP-A alongwith the copies of the documents Ex.OP-1 to OP-9.
7. By considering the averments as made in the complaint by the complainant, reply thereof filed by the OPs and on considering the documents/evidence available on the record as well as oral arguments raised by the counsel representing all the parties, the complaint filed by complainant was partly allowed vide order dated 6 First Appeal No.202 of 2021 16.03.2021. The relevant portion of the impugned order is reproduced as under :-
"From perusal of entire record of the case and after hearing submissions of counsel for the parties, we are considered opinion that the complainant is entitled for Rs.77,709/- as per copy of bill of HCG Hospitals Ex.C-10 produced by the complainant A Unit of Healthcare Global Enterprises Ltd, this document is of the complainant and he himself placed on record. The complainant is also entitled for the amount of Rs.4,000/- as per bill dated Ex.C-13 on record.
8. In the light of our above detailed discussion, we partly allowed the complaint of the complainant and directed the OPs to pay Rs.81,709/- to complainant on account of expenditure on his treatment. The complainant is also entitled for Rs.15,000/- as compensation and litigation expenses. The opposite parties are also directed to deposit Rs.5,000/- as costs in the Consumer Legal Aid Account maintained by this Commission."
8. Being aggrieved by the said order dated 16.03.2021, the appellants/OPs have approached this Commission by way of filing the present appeal by raising a number of grounds.
9. There was a delay of 25 days in filing of the appeal. M.A. No.635 of 2021 was filed for condonation of delay, which was allowed vide order dated 16.06.2021 and delay was condoned and the said M.A. was disposed off accordingly.
10. M.A. No.1210 of 2021 was filed for bringing on record the LRs of respondent/complainant Suresh Kumar Dhir (now deceased). It was also mentioned that there are no other LRs except the applicants as mentioned in para No.2 of the application. Said application was allowed vide order dated 25.11.2021 and the Registry was directed to make necessary note in the memo of parties in the 7 First Appeal No.202 of 2021 appeal with red ink. The LRs as mentioned in the application were brought on record and M.A. was disposed off accordingly.
11. Mr. Piyush Sharma Advocate, learned counsel for the appellants at the very outset has submitted that the controversy involves in the present case is squarely covered by the judgment of this Commission passed in case tiled as "Madhu Bansal Vs. Life Insurance Corporation of India & another", F.A. No.42 of 2019, decided on 26.11.2021, wherein the appeal filed by the insured was dismissed and the order passed by the District Commission in favour of the Insurance Company was upheld. Learned counsel has vehemently argued that the District Commission had partly allowed the complaint without taking into consideration a material fact that it was not a case of any surgery and the impugned order has been passed contrary to the terms and conditions of the policy. Learned counsel has further submitted that the treatment of paralysis was not falling under the category of Surgery and the insured was not entitled for the amount which has been awarded. Learned counsel has further submitted that the District Commission has ignored the material facts that the complainant had not submitted all the documents at the time of submission of his claim. The benefits were granted only on the basis of the fact that the patient had remained admitted in the hospital for a period of more than 48 hours. It was not a mediclaim policy but still the District Commission had awarded reimbursement of all the bills incurred on the treatment of the insured. The claim had been allowed only on the ground that the complainant had remained 8 First Appeal No.202 of 2021 admitted in ICU whereas it was not a case of any surgery. Learned counsel has also relied upon following judgments in support of his averments :
(i) "Shree Ambica Medical Stores & other Vs. Surat People's Co-operative Bank Limited & others" (2020) 13 SCC 564 and
(ii) "National Insurance Co. Ltd. Vs. Rameshwar Lal"
2019(4) C.P.R. 133
12. Learned counsel for the respondents has submitted that the order had been passed by the District Commission by considering all the documents/evidence as available on the record. The benefit was granted as per the terms and conditions of the policy applicable to the case of the insured. It has wrongly been mentioned that some of the documents were not supplied whereas all the relevant documents were supplied to the Insurance Company. Even as per the hospital record which is an admitted fact, the complainant was admitted in the HCG Hospital, Bhavnagar on 23.01.2017 and was discharged on 28.01.2017 and thereafter remained admitted for a period of five days and had also remained admitted in the ICU of the Hospital for a period of three days. As per terms and conditions of the policy i.e. Clause 2 (Hospital Cash Benefit) the amount so incurred was required to be paid to the complainant (since deceased). As per Clause 15 of the policy, the Hospital Cash Benefit was to be continued/extended to the complainant party regardless of the fact even in case the installments were not paid well in time. The policy was for a longer term and not like other insurance policies where 9 First Appeal No.202 of 2021 installments were to be paid annually. As per clause 15 of the Policy, the respondents, the LRs of the complainant (since deceased), were entitled to all the benefits as sought in the complaint. At the end, learned counsel has submitted that the order passed by the District Commission is based on proper appreciation of evidence as available on the record and all the facts and documents/evidence were taken into consideration while passing the impugned order and as such no interference is required.
13. We have heard the arguments raised by learned counsel for both the parties. We have also carefully perused the relevant documents available on the record.
14. Facts relating to filing of the complaint by the complainant, reply thereof and order dated 16.03.2021 passed by the District Commission by partly allowing the complaint and thereafter filing of appeal by the appellants Insurance Company are not in dispute. It is also not in dispute that the complainant got insured vide insurance policy No.133280920 wherein the installment/premium was of Rs.750/- per month and the complainant had also paid the amount of all installments/premiums to the OPs without any default. This fact was also informed to the Development Officer of the OPs that all the monthly installments/premiums for the period of five years were paid.
15. The complainant had suffered pain on his left arm on 23.01.2017 and thereafter got admitted in HCG Hospital Bhavnagar where he had suffered a severe paralysis attack and remained 10 First Appeal No.202 of 2021 admitted in ICU for a period of three days. Thereafter, he was shifted to the general room and after some recovery, he was discharged from the said hospital on 28.01.2017. It is also not in dispute that the insured had spent an amount of Rs.77,709/- on his treatment at HCG Hospital Bhavnagar. The complainant had spent more than Rs.50,000/- on his treatment at Sharda Medical Centre, Tehsil Nalagarh, District Solan (HP). As per the version of the learned counsel for the respondents all documents were supplied and bills were also submitted but still the amount was not reimbursed by the Insurance Company which was contrary to the terms and conditions of the policy. The officials of the OPs had badly treated the complainant and had informed that only an amount of Rs.11,000/- was to be reimbursed whereas the complainant had spent an amount of Rs.1,50,000/- on his treatment.
16. On the other hand, as per the version of the learned counsel for the appellants/OPs the treatment of paralysis was not falling under the list of Surgeries as mentioned in Annexure-II of the policy document and as such the complainant was not entitled to any claim. It is also the version of the appellants that the complainant had not supplied the required documents for release of Hospital Cash Benefit under the policy. The appellant has challenged the order passed by the District Commission mainly on the ground that the respondent/complainant had not undergone any kind of surgery and as such the amount incurred on the treatment was not covered as the treatment of paralysis was not falling in the list of surgeries as per the 11 First Appeal No.202 of 2021 terms and conditions of the policy. It is pertinent to mention here that the appellant/OP has mentioned that complainant treatment was not covered under the terms and conditions of the policy whereas on the other hand the OP had paid Rs.18,300/- on 08.05.2017 under the Head of the Domiciliary Treatment Benefit.
17. We have perused the terms and conditions of the policy. The relevant conditions No.1(xi) and 2 (I)(b) are reproduced as under:-
"1. (xi) Hospitalization means the Insured's required stay as an inpatient in a Hospital within India for medically necessary treatment following and due to Accidental Bodily Injury or Sickness;
2. (I)(b) In case of Hospitalisation in the Intensive Care Unit of a Hospital : Two times the Applicable Daily Benefit reckoned under clause 2(i)(a) and its sub clauses above for each conditions period of 24 hours or part thereof (after having completed the 48 hours as above) provided any such exceeds a continuous period of 4 hours of Hospitalization in the Intensive Care Unit of a Hospital during any period of Hospitalization necessitated solely, by reason of the said Accidental Bodily injury or sickness shall be payable."
Now the issue for determination by this Commission is as to whether it is a case of accidental bodily injury or sickness and the expenses incurred on the treatment are to be reimbursed by the Insurance Company or not?
18. In the present case, the complainant had suffered from sickness i.e. paralysis attack and had remained admitted in the ICU of Hospital at Bhavnagar (Gujarat) for a period of three days and thereafter he was shifted in the room. The appellant/OP has not 12 First Appeal No.202 of 2021 brought on record any evidence that the complainant had not suffered from above said sickness/paralysis attack. The complainant had remained admitted in the ICU for a period of three days and thereafter two days in the room of the hospital and was discharged on 28.01.2017. As such the claim of the complainant has covered under the terms and conditions of the policy as mentioned above. The Hon'ble Supreme Court of India in case titled as "United India Insurance Company Limited Vs. M/s Harchand Rai Chandan Lal"
IV (2004) CPJ-15 (SC) has held as under :-
"that the terms of the policy have to be construed as it is and we cannot add or subtract something. Howsoever liberally we may construe the policy but we cannot take liberalism to the extent of substituting the words which are not intended."
The case of the complainant falls under Clause 1 (xi) and Clause 2 (I)(b) of the terms and conditions of the policy whereas as per the version of the appellant/OP the claim was falling under other clause as such the District Commission has rightly appreciated the terms and conditions of the policy and partly allowed the complaint.
19. Learned counsel for the appellant/OP has vehemently argued that the respondent/complainant had not paid the premium of the policy regularly as it was to be paid upto 10th April, 2032 whereas it was paid only upto June 2016. In case of default of any premium a notice was required to be sent to the policyholder but the appellant/OP has not placed on record any such document/evidence in support of his averments that he sent any notice/reminder to the 13 First Appeal No.202 of 2021 complainant to pay the defaulted premium. It is relevant to mention here that an amount of Rs.18,300/- had already been paid to the respondent/complainant without raising any objection of irregular payment of premiums. This act of the appellant/OP does not appear to be justified as it is in itself is contradictory.
20. The District Commission has considered all the aspects including the legal issues and the averments as made in the reply filed by the appellant/OP and by considering the ratio of judgments of a number of cases. Not only the detailed findings have been recorded but the version of the appellant/OP has also been considered.
21. In view of the reasons mentioned above we do not find any merit in the contentions raised by learned counsel for the appellant/OP as the order passed by the District Commission is based on proper appreciation of evidence/documents and no interference is required. The appeal being devoid of any merit is hereby dismissed but no order of costs.
22. The appellant had deposited an amount of Rs.50,855/- at the time of filing of the appeal with this Commission. Said amount, alongwith interest which has accrued thereon, if any, shall be remitted by the Registry to the District Commission forthwith. The respondents /complainants (LRs) may approach the District Commission for the release of the same and the District Commission may pass appropriate order in this regard in accordance with law. 14 First Appeal No.202 of 2021
23. Since the main case is decided, the pending applications, if any, are also disposed of.
24. The appeal could not be decided within the stipulated period due to heavy pendency of Court cases and due to pandemic of Covid-19.
(JUSTICE DAYA CHAUDHARY) PRESIDENT (SIMARJOT KAUR) MEMBER November 29, 2023 (MM)