The National Consumer Disputes Redressal Commission (NCDRC) mandated the Life Insurance Corporation of India (LIC) to pay Rs 1,60,812 after an 8-year-long dispute with a policyholder of the ‘Jeevan Arogya’ insurance policy. The contention arose due to LIC officials deeming the hernia surgery, for which the claim was made, as non-major, leading to a dispute over the reimbursement amount.
Jeevan Arogya Health Insurance Policy:
As of January 30, 2024, the Jeevan Arogya health insurance policy offers comprehensive coverage, including financial protection during hospitalization and surgery, increasing health cover annually, lump sum benefits, no-claim benefits, flexible benefit limits, and varied premium payment options.
Policy Features:
The policy encompasses features such as Hospital Cash Benefit (HCB), Major Surgical Benefit (MSB), Day Care Procedure Benefit, Other Surgical Benefit, Ambulance Benefit, and Premium Waiver Benefit (PWB). For instance, the annual premium for a 30-year-old person with a sum assured of Rs 1 lakh stands at Rs 2242.9.
Claim Submission and LIC’s Response:
The complainant, after completing her father’s treatment in Chennai, submitted a claim of Rs 2,16,827 to the LIC’s Agartala Branch on August 8, 2016. LIC, while not outrightly rejecting the claim, reduced the reimbursement amount to Rs 17,100, arguing that ‘ventral hernia’ surgery wasn’t considered a major surgery. They also asserted that the complainant failed to disclose her father’s pre-existing health conditions.
District Forum’s Order (2019):
In an order dated June 28, 2019, the District Forum ruled in favor of the complainant, stating that the denial of insurance benefit for the ‘Ventral Hernia Surgery’ was unjust, considering the policy’s waiting period for such surgeries.
State Consumer Commission’s Decision (2020):
Following an appeal by LIC, the State Consumer Commission, on January 18, 2020, upheld the previous decision, emphasizing that if ‘ventral hernia’ surgery falls within the policy’s scope, the insured is entitled to the entire actual cost of treatment.
NCDRC’s Verdict (2024):
Unsatisfied with the State Consumer Commission’s decision, LIC filed an appeal with the NCDRC. On January 12, 2024, the NCDRC upheld the previous decisions, rejecting LIC’s contentions and finding no illegality or material error in the State Commission’s order.