STATE CONSUMER DISPUTES REDRESSAL COMMISSION KERALA FIRST APPEAL NO. SC/32/A/461/2017 MANAGER, LIC (HEALTH INSURANCE)

PRESENT ADDRESS - LIFE INSURANCE CORPORATION OF INDIA,HEALTH INSURANCE DEPARTMENT, JEEVAN PRAKASH, PB NO-177, LIC ROAD, KOZHIKODE. ,KERALA.

.......Appellant(s)

Versus ANIL C M PRESENT ADDRESS - CHAKKAM PARAMBIL HOUSE, ATHALUR.P.O, THAVANUR(VIA), PIN-

679573 ,KERALA. .......Respondent(s)

BEFORE:

HON'BLE MR. JUSTICE SRI.B.SUDHEENDRA KUMAR , PRESIDENT HON'BLE MR. SRI.AJITH KUMAR.D , JUDICIAL MEMBER FOR THE APPELLANT:

NEMO FOR THE RESPONDENT:

NEMO DATED: 10/06/2025

ORDER

KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSION VAZHUTHACAUD, THIRUVANANTHAPURAM APPEAL No.461/2017 JUDGMENT DATED: 10.06.2025 (Against the order in C.C.No.506/2015 on the files of DCDRC, Malappuram)

PRESENT:

HON’BLE JUSTICE SRI. B. SUDHEENDRA : PRESIDENT KUMAR SRI. AJITH KUMAR D. : JUDICIAL MEMBER SRI. K.R. RADHAKRISHNAN : MEMBER APPELLANT:

The Manager, Life Insurance Corporation of India, Health Insurance Department, Divisional Officer, Jeevan Prakash P. B. No. 177, LIC Road, Kozhikode.

(by Adv. Anitha Aji )

Vs.

RESPONDENT:

Anil C. M., Chakkam Parambil House, Athalur P.O., Thavanur (Via),

Pin-679 573

(by Adv. C. A. Veeramani & Sreevaraham G. Satheesh)

JUDGMENT

SRI. K.R. RADHAKRISHNAN: MEMBER This is an appeal filed under section 15 of the Consumer Protection Act, 1986 by the opposite party in C.C.No.506/2015 on the files of the District Consumer Disputes Redressal Commission, Malappuram (the “District Commission” for short). As per the order dated

31.12.2016 the District Commission allowed the complaint and directed as under:

1. The opposite party shall pay Rs.70,000/-(Rupees Seventy Thousand only) to the complainant, the amount spent by him for the treatment of his daughter.

2. The amount already paid by the opposite party under day care benefit scheme can be deducted from the above amount.

3. The opposite party shall pay Rs.25,000/-(Rupees Twenty Five Thousand only) as compensation to complainant for their deficiency of service together with cost of Rs.5,000/-(Rupees Five Thousand only).

4. The opposite party shall pay the amount within 30 days from the date of receipt of copy of this order failing which they shall pay the said amount with interest at the rate of 9% per annum from that date till realization.

The opposite party challenges the said order.

2. Brief details of the complaint are as follows: The complainant had taken a Health Insurance Policy No.798215828 (‘Jeevan Arogya’ - Table 903) from the opposite party on 25.01.2013. The policy covers the complainant and his daughters. The amount of premium for the policy is Rs.5,133/-(Rupees Five Thousand One Hundred and Thirty Three only), payable annually. Due date of payment of last premium is 25.01.2044. On 27.03.2014 daughter of the complainant, who is covered under the policy, sustained fracture on left radius and ulna while playing basketball. She was admitted in Sun Rise Hospital, Kakkanad for treatment and she had undergone surgery on the same day for ‘Closed Titanium Elastic Nailing under General Anaesthesia’. She was discharged on 28.03.2014. The complainant spent an amount of Rs.70,000/-(Rupees Seventy Thousand only) towards treatment expenses. He claimed the expenses through hospital authorities, which was rejected by the opposite party stating that there was no hospitalization for 28 hours. According to the complainant, the opposite party should have considered the surgery under day care procedure benefit. Repudiation of the claim amounts to deficiency in service and hence, he filed the complaint claiming Rs.70,000/-(Rupees Seventy Thousand only) towards treatment expenses with compensation and costs.

3. Notice was issued to the opposite party who entered appearance and filed version. The opposite party submitted that the complaint has become infructuous since they have already paid the claim as per ‘day care procedure benefit’. The policy is not in force as the complainant discontinued the remittance