State Consumer Disputes Redressal Commission
Surinder Pal, vs Lic Of India on 30 July, 2013
2nd Addl. Bench
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB
DAKSHIN MARG, SECTOR 37-A, CHANDIGARH
First Appeal No. 1181 of 2009
Date of institution: 20.8.2009
Date of decision : 30.7.2013
Surinder Pal, aged about 45 years, son of Gurdass Ram r/o Flat No. 6, LIC
Complex, Nangal Township, Tehsil Nangal, Distt. Ropar now posted as
HGA in the office of LIC of India Branch at Nangal Township, Tehsil
Nangal, Distt. Ropar.
.....Appellant
Versus
1. LIC of India, Branch Nangal Township, Tehsil Nangal, Distt.
Ropar through its Branch Manager.
2. LIC of India, Divisional Office, Sector 17-B, Chandigarh through
its Manager.
3. The New India Assurance Co. Ltd., Divisional Office-I (350100),
SCO No. 36-37, Sector 17-A, Chandigarh through its Senior
Divisional Manager.
.....Respondents
First Appeal against the order dated 10.7.2009
passed by the District Consumer Disputes
Redressal Forum, Ropar.
Before:-
Shri Piare Lal Garg, Presiding Member
Shri Jasbir Singh Gill, Member Argued By:-
For the appellant : Sh. Naveen Batra, Advocate
For respondents No.1&2 : Sh. A.K. Bakshi, Advocate for
Sh. Deepak Arora, Advocate
For respondent No.3 : Sh. P.S. Bedi, Advocate
PIARE LAL GARG, PRESIDING MEMBER
This is an appeal filed by the appellant/complainant- Surinder Pal(hereinafter called 'the appellant') against the order dated 10.7.2009 of the District Consumer Disputes Redressal Forum, First Appeal No. 1181 of 2009 2 Ropar(hereinafter called the 'District Forum') vide which the complaint of the appellant was dismissed by the District Forum.
2. Brief facts of the case are that the appellant was employee of LIC of India and his salary roll was 153156. The appellant was insured under Group Medical Claim Insurance Policy, which was taken by Life Insurance Corporation of India for the period of 1.4.2008 to 31.3.2009. All the employees of the LIC anywhere in India were insured under the Policy bearing No. 120700/34/08/12/00000049. The premium was deducted by respondent No. 1 from the salary of the appellant. It was further pleaded that son of the appellant, namely, Arpit was suffering from hearing problem since September, 1999. The ENT Specialized Doctor's team after examining the son of the appellant prescribed the digital hearing aid machine worth Rs. 70,000/-. The same was purchased by the appellant for an amount of Rs. 70,000/- as per invoice Ex. C-7 from Beltone, Chandigarh. The claim of the same was submitted by the appellant with respondents No. 3 through respondents No. 1 & 2. The claim of the appellant was repudiated by respondent No. 3 vide letter dated 24.10.2008 being against the terms and conditions of the policy. The complaint was filed with the prayer that the respondents may be directed to pay Rs. 70,000/- i.e. cost of the hearing machine, Rs. 10,000/- as compensation for harassment and Rs. 10,000/- as litigation expenses alongwith interest @ 18% per annum.
3. Upon notice, reply was filed by respondents No. 1 & 2 admitting that the appellant was covered under the Group Medical First Appeal No. 1181 of 2009 3 Scheme with respondent No. 3 with his family members. It was also admitted that claim was submitted by the appellant for the treatment/invoice of hearing machine and the same was forwarded by the answering respondents to respondent No. 3 but the same was repudiated under the exclusion clause 4.6 of the Policy. There was no deficiency in service on the part of the answering respondents and prayed for the dismissal of the complaint.
4. Reply was also filed by respondent No. 3 taking preliminary objections that the complaint was not maintainable, there was no deficiency in service or unfair trade practice on the part of the answering respondent. It was admitted that Group Medi-claim Insurance Policy was purchased by the LIC from the answering respondent. Claim was lodged by the appellant with respondents No. 1 & 2, who forwarded the same to the answering respondent regarding the reimbursement of the claim, but as per the exclusion clause 4.6 of the Policy, the claim was not payable and as such, the same was rightly repudiated. The appellant had no locus-standi to file the complaint and the claim does not fall within the terms and conditions of the policy. The paras of the complaint on merits were also denied as wrong and the same reply was reiterated on merits.
5. After hearing the counsel for the parties and going through the record, the complaint of the appellant was dismissed by the District Forum.
6. Aggrieved from the order of the District Forum, the present appeal is filed by the appellant on the grounds that the order of the District Forum is against the evidence on record and dismissed First Appeal No. 1181 of 2009 4 the complaint relying upon exclusion clause 4.6 of the terms and conditions of the policy which is illegal and unjustified. Respondent No. 3 illegally, wrongly, arbitrarily rejected the claim of the appellant, terms and conditions were not supplied to the appellant, as such, the appellant was not bound by the same. The order of the District Forum is liable to be set-aside and prayed for acceptance of the appeal.
7. We have gone through the pleadings of the parties, grounds of appeal, perused the record of the learned District Forum and heard the arguments of the counsel for the parties.
8. It is admitted case of the appellant that his son was suffering from hearing problem since 1999 and as per the advice of the team of the specialist of ENT Doctors, the appellant purchased the digital hearing aid (machine) for an amount of Rs. 70,000/- vide bill Ex. C-7 and submitted the claim with respondent No. 3 through respondents No. 1 & 2, which was repudiated by respondent No. 3 vide repudiation letter Ex. C-10 dated 24.10.2008 under clause 4.6 of the terms and conditions of the policy. As per Clause No. 1 of the terms and conditions, the claim was payable only if during the period stated in schedule or during the continuance of the policy by renewal any insured person shall contract any disease or suffer from any illness or sustain any bodily injury through accident but it is admitted by the appellant that his son was suffering from hearing problem since 1999 and policy was started to cover the insured only on 1.4.2008, as such, the son of the appellant was suffering from the problem of hearing before the purchase of the policy. First Appeal No. 1181 of 2009 5
9. There is an exclusion clause 4.6, which deals with the claims, which are not payable, which is reproduced:-
"4.6 - Cost of spectacles and contact lenses, hearing aids, dentures, caps & clips, braces and belts. Equipment for external prosthetic devices, eye glasses including cochlear implants and durable medical equipments, surgery for correction of eye sight."
10. We have perused the complaint. There was no pleading regarding non-supply of the terms and conditions of the policy. Only this objection was taken by the appellant in the grounds of appeal.
11. As per the perusal of the above policy condition, it is clear that cost of hearing aids was not payable as per Clause 4.6 of the terms and conditions of the policy and the claim of the appellant was rightly repudiated by the respondents.
12. The order of the District Forum is legal, valid and speaking one and there is no ground to interfere with the same. The appeal being without any merit is dismissed and the impugned order of the District Forum is affirmed and upheld. No order as to costs.
13. The arguments in this appeal were heard on 22.7.2013 and the order was reserved. Now the order be communicated to the parties.
14. The appeal could not be decided within the statutory period due to heavy pendency of Court cases.
(Piare Lal Garg)
Presiding Member
July 30, 2013. (Jasbir Singh Gill)
as Member
First Appeal No. 1181 of 2009 6