Kerala

StateCommission

A/15/456

BRANCH MANAGER LIC OF INDIA - Complainant(s)

Versus

KUNHIRAMAN - Opp.Party(s)

ANITHA AJI

21 Oct 2016

ORDER

KERALA STATE CONSUMER DISPUTES REDRESSAL

COMMISSION  VAZHUTHACAUD, THIRUVANANTHAPURAM

APPEAL NO. 456/15

JUDGMENT DATED:21.10.2016

 

PRESENT : 

JUSTICE SHRI. P.Q. BARKATHALI                         :  PRESIDENT

SHRI.V.V. JOSE                                                          : MEMBER

1. Manager (CRM/HI),

LIC of India, Divisional Office,

PB.No.133, Jeevan Prakash, M.G.Road,                     

Ernakulam.

 

2. Manager,

LIC of India, Health Insurance Division,

4-1-898 Oasis Plaza, Tilok Road,

ABIDS, Hyderabad,                                                            : APPELLANTS

Andra Pradesh.

 

3. The Branch Manager,

LIC of India, Jeevan Kiran,

Pamban Madhavan Road,

Talap, Kannur-670 001.

 

(By Adv: Smt. Anitha Aji)

 

            Vs.

Kunhiraman @ Ramakrishnan,

Raga Sudha, Elavayoor P.O,

Varam, Kannur District,                                                    : RESPONDENT

PIN-685 612.

 

JUDGMENT

JUSTICE SHRI. P.Q. BARKATHALI  :  PRESIDENT

          This is an appeal filed by the opposite parties 1 to 3 in CC.53/12 on the file of CDRF, Kannur challenging the order of the Forum dated, April 29, 2015 directing the opposite parties 1 to 3 to pay Rs.60,000/- to the complainant towards his treatment expenses along with a compensation of Rs.5000/- and a cost of Rs.3000/-.

2.      The case of the complainant as testified by him as PW1 before the Forum and as detailed in the complaint in brief is this:-

Complainant is a holder of policy of LIC’s Health Plus Plan table policy under opposite parties 1 to 3 dated, July 31, 2009.  On July 08, 2011 complainant underwent a surgery for coronary angioplasty in the 4^th opposite party hospital.  The total cost for the said treatment was Rs.1,54,200/- out of which complainant paid only Rs.60000/- and he claimed that amount from the opposite parties 1 to 3.  They repudiated the claim on the ground that it is not listed in the surgical benefit annexure of the policy.  Therefore complainant filed the complaint claiming that amount and compensation.

3.      Opposite parties 1 to 3 are Life Insurance Corporation represented by its Manager, Divisional Office, Ernakulam and Manager, Health Insurance Division, Hyderabad and Manager of Kannur Branch.  Fourth opposite party is the Pariyaram Medical College Hospital, Kannur.  Opposite parties 1 to 3 in their version contended thus before the Forum:-

The surgery undergone by the complainant will not come under the listed surgeries of surgical benefit annexure policy.  Therefore these opposite parties are perfectly justified in repudiating the claim of the complainant.

4.      Fourth opposite party hospital contended that they are unnecessary parties to the proceedings.

Complainant was examined as PW1 and Exts.A1 to A4 were marked on the side of the complainant.  On the side of the opposite parties 1 to 3 DW1 was examined and Ext.B1 was marked.  On an appreciation of evidence Forum found that opposite parties 1 to 3 are not justified in repduating the claim of the complainant and directed them to pay Rs.60,000/- to the complainant along with a compensation of Rs.5000/- and a cost of Rs.3000/-.  Opposite parties 1 t 3 have come up in appeal challenging the said order of the Forum.

5.      Heard the counsel for the appellants.  Respondents remained absent.

6.      The following points arise for consideration:-

1. Whether opposite parties 1 to 3 are justified in repudiating the claim of the complainant?
2. Whether the impugned order of the Forum can be sustained?

7.      Counsel for the appellant argued that as the stents implanted to the complainant are in the same artery and that in the conditions of the policy only if the stents implantation is for two or more coronary arteries the claim could be allowed and that therefore opposite parties 1 to 3 are justified in repudiating the claim.  We are unable to agree.  It is the admitted case that the surgery undergone by the complainant is listed in the surgical benefit annexure.  Here two stents are implanted in the complainant but in the same artery.  The above condition in the policy of the opposite parties that only if the stent implantation is for two or more arteries the claim could be allowed appears to be unreasonable.  Since the surgery undergone by the complainant is covered by the policy, we are of the view that the opposite parties 1 to 3 are not justified in repudiating the claim of the complainant.  Thus there is clear deficiency of service on the part of the opposite parties 1 to 3. The finding of the Forum on this point is confirmed.

8.      The 4^th opposite party in their version stated that under health policy scheme of complainant, adhoc PTCA stenting with two drug eluting stents the expenditure is limited to Rs.1,30,000/-.  The scheme provides Rs.70,000/- and the balance Rs.60,000/- has to be born by the beneficiary.  Thus complainant paid Rs,60,000/- to the 4^th opposite party.  The amount in excess of Rs.1,30,000/- ie Rs.24,200/- is born by the hospital.  Thus the complainant is entitled to get Rs.60,000/- from the opposite parties 1 to 3 towards treatment expenses.  Forum ordered a compensation of Rs.5000/- and a cost of Rs.3000/-.  We find no ground to interfere with the finding of the Forum.

In the result appeal is dismissed with a cost of Rs.5000/-.

 

JUSTICE P.Q. BARKATHALI :  PRESIDENT

 

 

V.V. JOSE : MEMBER

 

VL.