State Consumer Disputes Redressal Commission
Life Insurance Corporation Of India vs 1. Ekjot Singh on 11 September, 2012
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, U.T., CHANDIGARH First Appeal No. : 184 of 2012 Date of Institution : 25.05.2012 Date of Decision : 11/09/2012 Life Insurance Corporation of India, Senior Divisional Manager, Jeevan Parkash Building, Sector 17, Chandigarh, through Authorized Officer, Smt. P. Kwatra, Manager (Legal and HPF), Life Insurance Corporation of India, Divisional Office, Sector 17, Chandigarh,. Appellant/Opposite Party No.2 V e r s u s 1. Ekjot Singh s/o Sh. Tarlok Singh, H.No.144, Sector 20-A, Chandigarh (Complainant). 2. The E-Meditek Solution Limited, Plot No. 577, Udyog Vihar, Phase-V, Gurgaon 122016 (Haryana), through authorized signatory Dr. Vasu Pawar (Opposite Party No.1). ....Respondents Appeal under Section 15 of the Consumer Protection Act, 1986. BEFORE: JUSTICE SHAM SUNDER (RETD.), PRESIDENT. MRS. NEENA SANDHU, MEMBER.
Argued by: Sh. Rajesh K. Sharma, Advocate for the appellant.
Sh.
Balwinder Singh, Advocate for respondent no.1.
Respondent No.2, already exparte.
PER JUSTICE SHAM SUNDER (RETD.), PRESIDENT
1. This appeal is directed against the order dated 09.04.2012, rendered by the District Consumer Disputes Redressal Forum-II, U.T., Chandigarh (hereinafter to be called as the District Forum only), vide which, it accepted the complaint, and directed the Opposite Parties, as under:-
Hence, according the above judgment, it is a settled law that non-supply of terms & conditions of the policy, and, thereafter, repudiating the claim of the Complainant on these terms & conditions, is a clear deficiency in service on the part of the Opposite Parties. The present complaint of the Complainant succeeds against the OPs, jointly & severally, and the same is allowed. The Opposite Parties are directed to: -
(i) Reimburse Rs.2,14,470/- the amount paid by the Complainant on his treatment.
(ii) Pay compensation of Rs.20,000/- for mental harassment and agony to the Complainant;
(iii) Litigation expenses to the tune of Rs.7,000/-;
The above said order shall be complied within 30 days of its receipt by Opposite Parties; thereafter, Opposite Parties shall be liable for an interest @18% per annum on the awarded amount Rs.2,14,470/- + Rs.20,000/-, till it is paid.
2. The facts, in brief, are that the complainant, on being advised by the agents of Opposite Party No.2, purchased LIC Health Plus Plan, on 12.7.2008 (infact 05.07.2008), bearing number 163804195, for which half-yearly premium of Rs.14,250/-, was to be paid by him. At the time of subscribing to the policy, Opposite Party No.1 was declared as Third Party Administrator (TPA), for the settlement of claim, if any. The complainant, paid premiums regularly, for 3 years, from the date of commencement of the Policy, in question. All the family members of the complainant were also covered under the said Health Plus Plan. The benefits of the complainant alone, were insured to the extent of Rs.5,00,000/. The complainant received the policy bond, TPA booklet and Health card, Annexures C-1 to C-3 (collectively). On 28.4.2011, the complainant suffered a severe pain, in his Chest, and was admitted to INSCOL Hospital, Sector 34A, Chandigarh, where the Doctor diagnosed that he had suffered from a heart attack and advised for angiography. The results of angiography revealed that one of the arteries of the complainant was blocked, and required to be stented. The complainant was operated upon by a team of Doctors, and PTCA + Stent to RCA was done. The complainant was discharged from the said Hospital on 30.4.2011. He incurred a sum of Rs.2,14,470/-, on account of his treatment, aforesaid, vide bill Annexure C-4. The complainant, immediately, lodged the claim, with Opposite Party No. 1, for reimbursement of an amount of Rs.2,14,470/-, spent by him, on his treatment, alongwith all the requisite documents. Opposite Party No.1, repudiated the claim, vide letter dated 25.5.2011, on the ground, that his claim did not fall under the purview of the Policy conditions, for the following reasons: -
i) Surgery was not listed in the allowed surgeries (1-49);
ii) Total hospitalization period was less than 52 hours; and
iii) Surgery was not listed in the allowed surgeries (1-49)
3. It was stated that, on receipt of the letter dated 25.5.2011, the complainant was completely shattered. It was further stated that the Opposite Parties, never disclosed to him, the so-called list of allowed surgeries (1-49), at the time of purchase of Policy, in question, even till the filing of the complaint. It was further stated that the repudiation of the claim, was completely illegal and arbitrary. It was further stated that Opposite Party No.1, was many a time asked to pay the amount of claim, but to no avail. It was further stated that the aforesaid acts of the Opposite Parties, amounted to deficiency, in rendering service, as also indulgence into unfair trade practice. When the grievance of the complainant, was not redressed, left with no alternative, a complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter to be called as the Act only), directing the Opposite Parties, to pay the claim amount of Rs.2,14,470/- alongwith interest @18% P.A.; Damages/Compensation to the tune of Rs.1,00,000/- on account of mental agony and physical harassment; and litigation expenses, to the tune of Rs.21,000/-, was filed.
4. Opposite Party No.1, was duly served, but no authorized Representative, put in appearance, on its behalf. Accordingly, Opposite Party No.1, was proceeded against exparte, vide order dated 23.11.2011.
5. Opposite Party No.2, in its written version, pleaded that the complaint was not maintainable, as the complainant, concealed the material facts, while filing the same. It was admitted that the Policy, aforesaid, was purchased by the complainant. It was also admitted that he continuously paid premiums for three years. It was, however, stated that the complainant was supplied the Welcome Kit containing the Policy document, and the terms & conditions thereof. It was further stated that, in case, the terms and conditions of the Policy were not acceptable, to the complainant, he could ask for the cancellation of the same, during the Cooling-off Period of 15 days, from the date of receipt of the Policy document. It was further stated that since, he did not exercise his option, during the Cooling-off Period of 15 days, from the date of receipt of the Policy document, he could not turn round and say that he was not in the knowledge of the terms and conditions of the same. It was denied that the terms and conditions of the policy were not supplied to the complainant. It was admitted that the complainant was operated upon and remained admitted in the hospital, aforesaid. It was also admitted that a Stent was implanted, in one of the arteries of the complainant, by the Doctors of the Hospital, where he remained admitted. It was further stated that Opposite Party No.2, sought the opinion of Dr. Gurvinder Singh, SCO-821-822, Sector 22A, Chandigarh, through communication dated 09.06.2011, Annexure OP-2/4/(colly), who verified that, as only one Stent was implanted, in the artery of the complainant, the same was not covered under the policy, because as per the terms and condition of the same, 40% of the coverage/sum was payable, in case 02 or more Coronary Arteries were Stented. It was further opined by Dr. Gurvinder Singh, that the hospitalization of the complainant was for 47 hours i.e. for less than 52 hours. It was further stated that in the terms and conditions of the Policy, under clause 3(1), under the heading Hospital Cash Benefit Limits, it was in clear-cut terms, written that for every hospitalization, no benefit would be paid for the first 48 hours (two days) of hospitalization, regardless of whether the insured was admitted in a general or special ward or in an intensive care unit. It was further stated that the parties were bound by the terms and conditions of the Policy. It was further stated that since the claim of the complainant did not fall within the definition of the terms and condition of the policy, the same was legally and validly repudiated. It was further stated that there was neither any deficiency, in rendering service, on the part of Opposite Party No.2, nor it indulged into unfair trade practice. The remaining averments, were denied, being wrong.
6. The complainant and Opposite Party No.2, led evidence, in support of their case.
7. After hearing the Counsel for the complainant, Opposite Party No.2, and, on going through the evidence, and record of the case, the District Forum, came to the conclusion, that it was not proved by Opposite Party No.2, that the terms and conditions of Policy were supplied to the complainant, alongwith the welcome kit, and, as such, the same could not be invoked by it, for the purpose of repudiation of the claim, submitted by the complainant. It was, thus, held by the District Forum, that the repudiation of claim of the complainant was illegal and invalid, and, this act of the Opposite Parties, amounted to deficiency, in rendering service, as also indulgence into unfair trade practice.
8. Ultimately, the District Forum, accepted the complaint, in the manner, referred to, in the opening paragraph of the instant order.
9. Feeling aggrieved, the instant appeal, has been filed by the appellant/Opposite Party No.2.
10. A Registered A.D. cover, pre-paid, for the service of respondent no.2, at the correct address was sent on 13.07.2012, but the same was not received back, with any report. Since a period of 30 days from the date of issuance of the said Registered A.D., had lapsed, in view of the proviso, engrafted to Section 28A(3) of the Act, it was deemed that respondent no.2, had been duly served, but no authorized representative, on its behalf, put in appearance. Accordingly, respondent no.2, was proceeded against ex-parte, vide order dated 16.08.2012.
11. We have heard the Counsel for the appellant, respondent no.1, and, have gone through the evidence and record of the case, carefully.
12. The Counsel for the appellant, submitted that, no doubt, the complainant, purchased the Policy, in question, and, also paid premiums, for a period of 3 years. He further submitted that it was evident, from Annexure C-1, the Policy document purchased by the complainant, that welcome kit, which was supplied to him, contained his Policy Bond and Conditions & Privileges, under the Health Plus Plan. He further submitted that, as per this document, the health card for the complainant, and his family members covered under the policy, were to be sent by Opposite Party No.1 i.e. TPA (Third Party Administrator). He further submitted that, in case, Conditions & Privileges, as mentioned in Annexure C-1, were not supplied to the complainant, he could write a letter to Opposite Party No.2, that he did not receive the same, and the same be supplied to him, and could not sleep over the matter, for a period of three years, when his claim was repudiated. He further submitted that the District Forum, failed to properly go through Annexure C-1, produced by the complainant, as a result whereof, it fell into a grave error, in holding that the Conditions & Privileges of Policy, in question, were not supplied to the complainant, by the Opposite Parties. He further submitted that the complainant only produced Annexure C-1, copy of the policy document, and Annexure C-2, the health cards, but did not produce the terms and conditions/ Conditions & Privileges, so as to wrongly claim the amount. He further submitted that since the complainant was hospitalized for less than 48 hours, he was not entitled to any benefit, as per the Conditions and Privileges of the Policy document OP-2/1/(colly). He further submitted that since, only one stent was implanted, in the artery of the complainant, this surgery did not fall within the surgeries, as mentioned in the Policy document/Conditions and Privileges of the same. He further submitted that even the complainant did not ask for the cancellation of Policy, during Cooling-off period of 15 days, as mentioned in Annexure C-1, if the terms and conditions were not acceptable to him. He further submitted that the claim of the complainant was legally repudiated, by Opposite Party No.2, but the District Forum, fell into a grave error, in allowing the complaint. He further submitted that the order of the District Forum, being illegal and invalid, is liable to be set aside.
13. On the other hand, the Counsel for the complainant/respondent no.1, submitted that the complainant had received the Policy bond, TPA booklet and Health card, Annexure C-1 to C-3 (collectively), but he did not receive the Conditions & Privileges of the Policy, in question. He further submitted that the complainant, paid premiums for a period of three years. He further submitted that, had the Conditions & Privileges, of the Policy, been supplied to the complainant, at the time of supplying Annexure C-1 to him, he would have come to know, as to which surgeries were covered under the same, and which benefit he could claim, in the event of his hospitalization, and for how much period. He further submitted that the District Forum was right in coming to the conclusion, that since the Conditions & Privileges, of the Policy, were not supplied to the complainant, the same could not be invoked by the Opposite Parties, for the purpose of repudiating his claim. He further submitted that the order of the District Forum, being legal and valid, is liable to be upheld.
14. The first question, that arises for consideration, is, as to whether, the Conditions & Privileges, under the Health Plus Policy, aforesaid, which was purchased by the complainant, were supplied to him, or not. No doubt, in the complaint, the complainant stated that he was not supplied the Conditions & Privileges, aforesaid, but was only supplied Policy bond, TPA booklet and Health card, Annexure C-1 to C-3 (collectively). No doubt, the complainant purchased the Plan on 05.07.5008, and paid premiums for a period of three years. Annexure C-1, one of the documents, which was admittedly received by the complainant, is very material. The relevant portion of Annexure C-1 reads as under:-
This `welcome kit` contains your Policy Bond, Conditions and Privileges under your Health Plus Policy. The Health cards for you and your family members covered under this policy will be sent to you by the TPA (Third Party Administrator). Health Card serves as an identity card and will be useful to you at the time of claiming benefits under the policy. The TPA will send you the details of his contact, name and address. This is also available at your servicing branch office.
15. From the afore-extracted relevant portion of Annexure C-1, it is evident, that the welcome kit, which was supplied to the complainant, contained the Policy Bond, Conditions and Privileges, of his (complainant`s), Health Plus Policy. In case, the complainant had not received the Conditions and Privileges aforesaid, alongwith the Policy document, it was required of him, to immediately approach Opposite Party No.2, to supply the same, but he did not do so. Since Annexure C-1, referred to above, was received by the complainant, it could be very well said, that he also received the Conditions and Privileges of the Policy, in question, mentioned therein. It could not be imagined, that he had not gone through the contents of Annexure C-1. For the first time, when his claim was repudiated, in the year 2011, he came up with the false version, that the Conditions and Privileges, under the Policy, in question, were not supplied to him. Had, in the document Annexure C-1, it been not mentioned that the Welcome kit sent to him, contained the Conditions and Privileges of the Policy, his version would have been found to be plausible. The bald statement of the complainant that he did not receive the Conditions and Privileges of the Policy, being contrary to the contents of Annexure C-1, cannot be believed. Even otherwise, it is settled principle of law, that if the documentary and oral evidence, on the same point, are contrary to each other, then the former shall be preferred over the latter. The District Forum, in our considered opinion, did not go through Annexure C-1, properly. Had it properly gone through Annexure C-1, it would have come to know that the Conditions and Privileges of the Policy were supplied to the complainant, alongwith the other documents, referred to above. The version, set up by the complainant, in his complaint, i.e. he did not receive the Conditions and Privileges of the Policy, alongwith Annexure C-1, is belied from this document itself, as also from the affidavit of P. Vijay Lakshmi, Manager, P & I R, LIC of India, Jeevan Parkash Building, Sector 17, Chandigarh, which was submitted by her, in support of the version of Opposite Party No.2. The findings of the District Forum, to the effect that the Conditions and Privileges of the Policy were not supplied, to the complainant, as mentioned in Annexure C-1, which document was admittedly received by him, being not based on the correct appreciation of evidence, and law, on the point, are reversed.
16. The Counsel for respondent no.1/complainant, however, placed reliance on M/s Modern Insulators Ltd. Vs Oriental Insurance Co. Ltd.I(2000)CPJ1(SC), in support of his contentions, that the contract of Insurance is based on utmost good faith, and, as such, on account of non- supply of the Conditions and Privileges including exclusion clauses, Opposite Party No.2, could not invoke the same. There is, no dispute, with the principle of law, laid down, in Modern Insulators Ltd.` s case (supra).
However, in Modern Insulators Ltd.` s case (supra), it was proved, as a fact, that the terms and conditions of the Policy, alongwith exclusion clauses, had not been supplied to the complainant. It was also proved that he was only supplied the cover-note and the schedule of the Insurance Policy. It was, under these circumstances, that the Hon`ble Supreme Court, came to the conclusion, that in the absence of supply of the terms and conditions of the Policy, to the complainant, which was proved, as a fact, from the evidence, on record, the Insurance Company could not invoke the exclusion clauses, to repudiate his claim. In the instant case, as stated above, it was proved from the document Annexure C-1, produced by the complainant, himself, that he was supplied the welcome kit, which contained the Policy Bond and its Conditions & Privileges. In the face of Annexure C-1 document, the oral evidence of the complainant contrary to the same could not be relied upon. Even the contents of document Annexure C-1, were duly corroborated by the affidavit of P. Vijay Lakshmi, Manager, P & I R, LIC of India, Jeevan Parkash Building, Sector 17, Chandigarh, furnished by way of evidence. The facts of Modern Insulators Ltd.` s case (supra), being distinguishable, from the facts of the instant case, no help can be drawn, by the Counsel for respondent no.1/complainant, from the principle of law, laid down therein. The submission of the Counsel for respondent no.1/complainant, in this regard, being without merit, must fail, and the same stands rejected.
17. Once, it has been held above that according to Annexure C-1 document, admittedly received by the complainant, he was supplied the welcome kit containing the Policy Bond and its Conditions & Privileges, now it is to be seen, as to whether, he could ask for the cancellation of the same, during the Cooling-off period of 15 days, from the date of receipt of the same, if the said conditions were not acceptable to him. In Annexure C-1, it was in clear-cut terms mentioned, that the Policy offered to the complainant, provided for a Cooling off Period for 15 days. In case, he was not satisfied with the terms and conditions of the same, he could exercise his option, for the cancellation of the same, or modification therein. He, however, did not exercise such an option. Once, the Cooling-off Period expired, and the complainant failed to exercise his option of cancellation of the Policy, within the said period, later on, he will only be governed by the terms and conditions of the same.
18. Once, it has been held that the Policy document, alongwith the Policy bond and its Conditions & Privileges were supplied to the complainant, it is to be seen, as to whether the claim of the complainant, fell within the exclusion clauses of the same, and, was, thus, rightly repudiated by Opposite Party No.2 or not. It is settled principle of law, that the parties are bound by the terms and conditions of the contract of Insurance. OP-2/1/(colly), are the Conditions and Privileges referred to, in the Policy document, produced by Opposite Party No.2. The relevant portion of clause 3 of the Conditions and Privileges of the said Policy, reads as under:-
for every hospitalization, no benefit would be paid for the first 48 hours (two days) of hospitalization, regardless of whether the insured was admitted in a general or special ward or in an intensive care unit.
19. According to the afore-extracted relevant part of clause 3 of the Conditions and Privileges of the Policy, it is evident, that for every hospitalization, no benefit would be paid for the first 48 hours (two days) of the same (hospitalization), regardless of whether, the insured was admitted in a general or special ward or in an intensive care unit. It is further evident, from Annexure C-5, a copy of the discharge summary of the complainant, that the date and time of admission mentioned therein is 28.04.2011 at 11.00 A.M., whereas the date and time of discharge is mentioned as 30.04.2011 at 09.46 A.M. It means that the complainant remained admitted in the hospital, aforesaid, for less than 48 hours. According to the afore-extracted relevant portion of Clause 3 of the Conditions and Privileges of the Policy, the complainant was entitled to any benefit, under the Policy. Opposite Party No.2, was, thus, right in coming to the conclusion, that since hospitalization of the complainant was less than 48 hours, he was not entitled to the benefits under the Policy. Repudiation of the claim by Opposite Party No.2, on this ground, being covered by the exclusion clause, could be said to be legal and valid.
20. The next question, that falls for consideration, is, as to whether, surgery undergone by the complainant, fell within the surgeries, as mentioned, in the list, attached with the terms and conditions of the Policy, or not. According to clause 7 of the list of Surgeries, at page 143 of the District Forum file, (this document forms part of the Conditions and Privileges of the Policy), the complainant was entitled to only 40% of the amount spent by him, in case two or more coronary arteries are Stented. In the instant case, only one stent was implanted in the artery of the complainant, as is evident from the record. Since 02 or more Coronary Arteries of the complainant were not Stented, according to Clause 7 of the list of surgeries, at page 143 of the District Forum file, he was not entitled to even 40% of the amount of claim. Opposite Party No.2, was, thus, right in repudiating the claim of the complainant, on this ground too.
21. No other point, was urged, by the Counsel for the appellant and respondent no.1.
22. In view of the above discussion, it is held that there was neither any deficiency, in rendering service, on the part of the Opposite Parties, nor they indulged into unfair trade practice. The complainant was not entitled to the amount claimed, as per the terms and conditions/Conditions and Privileges and exclusion clauses of the Policy, duly received by him. The claim was, thus, legally and validly repudiated by Opposite Party No.2. The District Forum was wrong in holding to the contrary.
23. The order passed by the District Forum, being not based, on the correct appreciation of evidence, and law, on the point, suffers from illegality and perversity, warranting the interference of this Commission.
24. For the reasons recorded above, the appeal is accepted, with no order as to costs. The order of the District Forum is set aside
25. Certified Copies of this order, be sent to the parties, free of charge.
26. The file be consigned to Record Room, after completion Pronounced.
September 11, 2012 Sd/-
[JUSTICE SHAM SUNDER(RETD.)] PRESIDENT Sd/-
[NEENA SANDHU] MEMBER Rg