R.Thirupathi Seenivasagam, v. The Senior Divisional

BEFORE THE MADURAI BENCH OF MADRAS HIGH COURT DATED: 05.11.2024

CORAM

THE HONOURABLE MR.JUSTICE G.K.ILANTHIRAIYAN and W.M.P(MD)No.18628 of 2018 P.Thirupathi Seenivasagam ... Petitioner Vs 1.The Senior Divisional Manager, Life Insurance Corporation of India, (Divisional Health Unit), Divisional Office, 9A, Punithavathiar Street, Palayamkottai, Tirunelveli - 627 002.

2.The Manager, Life Insurance Corporation of India, (Health Insurance Department ), Jeevan Prakash Divisional Office, 9A, Punithavathiar Street, Palayamkottai, Tirunelveli - 627 002.

3.The Regional Manager, Life Insurance Corporation of India, (Health Insurance Department ), Regional Office, Palayamkottai, Tirunelveli - 627 002.

... Respondents PRAYER: Writ Petition filed under Article 226 of Constitution of India, to issue a writ of Certiorarified Mandamus, calling for the records relating to the order of the first respondent dated 04.04.2017 in Ref:LIC/HI/GA and quash the same and further direct the first respondent to settle the amount due to the petitioner under 1/6

LIC's Jeevan Arogya Policy No.324290676 in claim No.16011497 with interest.

For Petitioner : Ms.Vijayakumari Natarajan For Respondents : Mr.C.Godwin

ORDER

This Writ Petition has been filed challenging the order passed by the first respondent dated 04.04.2017 thereby rejecting the claim made by the petitioner under the policy issued by the first respondent.

2.The petitioner had taken a medical Insurance policy with the respondent under the LIC's Jeevan Arogaya policy for himself and his wife commencing from 10.02.2016. The petitioner had been paying the necessary premium. While being so, in the month of August 2016, the petitioner suffered with a fever and went to Apollo Hospital, Madurai. He was advised to be admitted as an inpatient and diagnosed that the petitioner was affected by Chronic liver disease and an abscess in the left elbow. Thereafter, he was treated in the hospital and he had spent a sum of Rs.1,08,792/-. Thereafter, the petitioner approached the first respondent and submitted a claim petition along with a discharge summary and bill 2/6

details. However, it was repudiated on the ground that the policyholder did not comply with the requirements called for and the claim is pending even after repeated reminders. Hence, the claim has to be rejected instead of keeping it indefinitely. 3.Heard the learned counsel appearing on either side and perused the materials placed before this Court. 4.On perusal of the counter-affidavit filed by the first respondent and on the submissions made by the learned counsel appearing for the respondents would reveal that the petitioner was offered with all facilities under the LIC's Jeevan Arogaya policy. However, the sufferings of the petitioner do not come within the list of surgeries enumerated in the welcome kit. The surgeries come under day care surgeries. The petitioner is eligible for day care procedure benefit ie.

, 5 times of initial daily benefit in total a sum of Rs.10,000/-, but the petitioner failed to submit any details regarding for settlement of the claim. Therefore, the claim of the petitioner was rightly repudiated by the first respondent.

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'a.History and duration of Diabetes Mellitus, since when, certified by the treating Doctor, supported by the first consultation paper.

b.As per the discharge summary date of surgery was on 09.09.2016 which was out of the hospitalization. Correct date of surgery called for.

c.First consultation paper when Chronic liver disease and portal hypertension was diagnosed (as mentioned in discharge summary first time diagnosed outside).

d.The cause of chronic liver disease certified by the treating doctor.

e.The approximate causes of chronic liver disease and any personal habits of the patient.'

5.In view of the above, the petitioner is at liberty to submit a claim petition once again along with all required documents, as stated supra, within a period of two weeks from the date of receipt of a copy of this order. On receipt of the same, the first respondent is directed to consider the claim of the petitioner, on merits and in accordance with law, within a period of four weeks thereafter.

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6.With the above direction, this Writ Petition is disposed of. There shall be no order as to costs. Consequently, connected Miscellaneous Petition is closed.

05.11.2024 NCC : Yes / No Index : Yes / No Internet : Yes ps To 1.The Senior Divisional Manager, Life Insurance Corporation of India, (Divisional Health Unit), Divisional Office, 9A, Punithavathiar Street, Palayamkottai, Tirunelveli - 627 002.

2.The Manager, Life Insurance Corporation of India, (Health Insurance Department ), Jeevan Prakash Divisional Office, 9A, Punithavathiar Street, Palayamkottai, Tirunelveli - 627 002.

3.The Regional Manager, Life Insurance Corporation of India, (Health Insurance Department ), Regional Office, Palayamkottai, Tirunelveli - 627 002.

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G.K.ILANTHIRAIYAN, J.

ps Order made in 05.11.2024 6/6