IMPORTANT POINT
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.

ORDER

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—

1. Initial Daily Benefit opted by insured in the proposal form, on the life of the beneficiary/insured Member referred above and

2. The period Hospitalization and/or

3. 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:

2. 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.

3. 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.

4. 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.

5. 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.

6. 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 complai