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Judgment
V.K.Jain, Presiding Member
The petitioner/complainant took a mediclaim policy known as 'One health Protection Plus Plan' from the respondent LIC of India. He was admitted in Shriram Cardiac Centre, Joshi Hospital, Jalandhar on 11.12.2014 with complaint of severe chest pain. He having been advised primary PTCA, underwent successful PTCA plus IC Stent and was discharged on 14.12.2014. He submitted a claim of Rs.1,60,000/- to the respondent. The claim however, was approved only to the extent of Rs.3,450/-. The complainant sent a legal notice to the respondent demanding payment of Rs.1,60,000/- from the respondent. The legal notice was replied vide letter dated 29.03.2016 which, to the extent, it is relevant, reads as under:
We have received the legal notice dated 22.03.2016 in respect of above claim for Hospitalization/Major Surgical/Day Care/Other Surgical benefits on the life of Sh. Rakesh Kumar Sharma for the hospitalization during the period from 11.12.2014 to 14.12.2014.
We may inform you that the benefits under the policy are not directly related to the actual expenses incurred by the insured. The benefits are calculated on the basis of
Initial Daily Benefit opted by insured in the proposal form, on the life of the beneficiary/insured Member referred above and
The period Hospitalization and/or
Eligibility for the surgery performed as per "permissible list of surgeries" listed in the Policy Conditions & privileges attached to the policy bond.
The claim has been processed and the benefits are admitted and settled as per terms and conditions of the policy as follows,:
S. No.
Type of Claim
No. of days
Amount Rs.
1.
HCB for period spent in ICU (previous policy year)
2.
HCB for period spent in non-ICU (previous policy year)
3.
HCB for period spent in ICU (current policy year)
4.
HCB for period spent in non-ICU (current policy year)
5.
Major Surgical Benefit
TOTAL
3450.00
Being aggrieved from the respondent not reimbursing the expenses incurred by him on his procedure, the complaint approached the concerned District Forum by way of a Consumer Complaint.
The complaint was resisted by the respondent which inter-alia stated in its reply that as per the terms and conditions of the policy, the complainant was entitled to benefit of the policy only in respect of 49 surgeries and HCB as stated in the policy. It was further stated in the written version that only one stent was implanted in the artery of the complainant, whereas the benefit in respect of Cardiograph system was admissible only in case of Coronary Angioplasty with implantation of two or more stents. Since the expenditure incurred on the Angioplasty with one stent was not payable under the policy, the claim was settled by paying a sum of Rs.3,450/- to the complainant as per the policy conditions.
The District Forum having allowed the Consumer Complaint, the respondent LIC of India approached the concerned State Commission by way of an appeal. Vide impugned order dated 11.06.2019, the State Commission allowed the appeal and consequently, dismissed the Consumer Complaint. Being aggrieved, the complainant is before this Commission.
It is not in dispute that as per the terms and conditions of the mediclaim policy issued to the complainant, the benefit in respect of Coronary Angioplasty was payable only in case two or more stents were implanted. It is also not in dispute that only one stent was implanted in the artery of the complainant. Therefore, going by the terms and conditions of the policy taken by the complainant, the expenditure incurred by him on his Angioplasty was not payable.
The contention of the learned counsel for the complainant/petitioner is that the terms and conditions of the policy having not been supplied to the complainant, he was not aware and therefore, cannot be bound by them. A perusal of the insurance policy issued to the complainant/petitioner would show that the said policy specifically referred to the conditions of the policy. The kit sent with the policy contained those terms and conditions. Admittedly, no letter was sent by the complainant to the respondent stating therein that the terms and conditions of the mediclaim policy had not been supplied to him. Had the said terms and conditions not been supplied to him, he would immediately have written so to the respondent.
As noted earlier, in the reply sent to the legal notice, the respondent specifically referred to the terms and conditions of the policy taken by the complainant. Even in the Consumer Complaint, the complainant did not plead that the terms and conditions of the policy were not made available to him and therefore, he was unaware of the same. This was also not his allegation even in the legal notice sent to the respondent. In these circumstances, the inevitable inference would be that he had received the terms and conditions sent in a kit alongwith the policy issued to him. Therefore, he was bound by the terms and conditions of the policy which did not entitle re-imbursement in respect of Angioplasty with only one stent implanted in the body.
For the reasons stated hereinabove, the view taken by the State Commission does not call for any interference by this Commission in exercise of its revisional jurisdiction. The Revision Petition is therefore, dismissed with no order as to costs.