Andhra Pradesh

East Godwari-II at Rajahmundry

CC/6/2013

Guthala Eswararao - Complainant(s)

Versus

The Senior Divisional Manager, L.I.C Of India - Opp.Party(s)

I. Rambabu

07 Oct 2015

ORDER

                                                                                                                                                         Date of filing:   09.01.2013

                                                                                                                                                          Date of Order: 07.10.2015

 

BEFORE THE DISTRICT CONSUMER FORUM-II, EAST GODAVARI

DISTRICT AT RAJAHMUNDRY

 

                                                       PRESENT:   Smt H.V. Ramana, B.Com., L.L.M.,   PRESIDENT(FAC)

                      Sri A. Madhusudana Rao, M.Com., B.L., MEMBER          

    

                         Wednesday, the 7^th day of October, 2015

 

 C.C.No.6 /2013

Between:-

 

Guthala Eswararao, Advocate,

S/o. Jayaram, 9^th mile Stone,

Mummidivaram.                                                          …        Complainant

 

                And

 

The Senior Divisional Manager,

L.I.C. of India,

Divisional Office,

Rajahmundry.                                                             …        Opposite party

 

 

            This case coming on 29.09.2015 for final hearing before this Forum in the presence of Sri I. Rambabu, Advocate for the complainant and Sri P.L.N. Prasad, Advocate for the opposite party, and having stood over till this date for consideration, this Forum has pronounced the following:  

 

O R D E R

[Per Smt.H.V. Ramana, President(FAC)] 

This is a complaint filed by the complainant U/Sec.12 of Consumer Protection Act 1986 to direct the opposite party to pay Rs.50,000/- with subsequent interest at 12% p.a. towards medical claim; pay compensation of Rs.10,000/- towards deficiency in service and award costs of the complaint.

2.         The case of the complainant is that he obtained the insurance policy Asha Deep Benefit policy from the opposite party for a sum assured of Rs.1,00,000/- and quarterly premium of Rs.1227/- on 1.4.2001. The claim covered for the policyholder 50% and every year paid 10% of the sum assured.  On 18.4.2012, the complainant undergone for heart surgery and he submitted the entire medical record to the opposite party who refused the claim on the ground that Mitral valve replaced is not covered under the insurance policy.  On 31.8.2012, the complainant represented to the opposite party requesting to consider the claim, but the opposite party refused the claim. When the policy is accepted by the opposite party, bound to pay the claim and compensation as per the conditions and privileges.  The medical record of the complainant is satisfied and totally for the claim and he is entitled for medical claim. Hence, the complaint.

3.         The opposite party filed its written version and denied all the allegations made by the complainant.  It is submitted that the complainant is not a consumer as defined under Section 2(d) of the Consumer Protection Act and the complainant does not come under purview of the consumer dispute in section 2(e) of C.P. Act. The Hon’ble Forum has no jurisdiction to entertain the present complaint and the same is dismissed in limini.   It is true that the complainant Guthula Eswara Rao took a Asha Deep-ii policy 800189394 from Amalapuram Branch under Rajahmundry division table and terms 121 and 125, date of commence from 1.4.2001 on quarterly premium amount of Rs.1227/- and the policy maturity date is 04-2026 and his wife Smt. G. Kumari show as nominee under the policy, the benefits as follows:

Benefit – A	Benefit – B
The sum assured with vested Bonus is payable either on the date of maturity or on earlier death of provided policy is in full force.	A sickness benefit claim can be made for one of the following contingencies throughout duration of the policy, provided policy is in full force as on the date of occurrence of illness

 

Under the policy four major ailments covered under the policy.  Open Heart Coronary bypass surgery life assured under goes open heart coronary artery bypass surgery performed bon significant narrowed/occluded coronary arteries to restore adequate blood supply to heart. The Surgery must have been proves to be necessary by means of coronary angioplasty.  Exclusion all other operations like Balloon angioplasty and Thrombosis by coronary artery catheterization are excluded. Also direction rot ablator, laser coronary angioplasty and directional coronary atherectony are also excluded. Other three major ailments renal dialysis or renal (kidney) transplantation, cancer, and paralytic stroke are not relevant in this particular case. This opposite party is not aware about that the complainant undergone for Heart surgery on 18.4.2012 the surgery done as chest Opened Median Sterntomy Systemic Heparinization done with 3mg.Kg Heparin Cardio Pulmonary Bypass Established with Aortic.  This fact was known by this opposite party only after receipt of the entire medical record on 18.7.2012 from Amalapuram branch for settlement of sickness benefit claim. Immediately after receipt of the medical record and claim forms, on scrutiny, it is found that underwent surgery is not covered as per the policy terms and conditions and the same was communicated to the Amalapuram Branch in turn the Branch informed the same fact to the complainant. The said decision was also communicated to the complainant. It is submitted that the complainant send another representation to the opposite party on 31.8.2012 for settlement of his claim, after receipt of the representation, this opposite party referred all the medical record to its Divisional Medical Referee (DMR) to Dr.A.V. Subba Rao MDDM, on 7.9.2012 after verifying the entire medical treatment records of the complainant of the surgery, he gave his opinion that MVR (mitral valve replacement) done and not covered under Asha Deept Claim may be repudiated. This opposite party had repudiated the claim of the complainant for the money due under the above policy. The repudiation is legally valid and binding. This opposite party has communicated its decision to the complainant after complete investigation and enquiry in the matter and advised the complainant to continue payment of premiums and keep the policy in force through its letter dt.14.9.2012. The transaction between the policyholder and opposite party is fully covered and governed under terms and conditions agreed between the parties through insurance contract. Hence, there is no deficiency of service on the part of the opposite party and the complaint is liable to be dismissed with costs.  

4.         The proof affidavit filed by the complainant and Exs.A1 to A4 have been marked on behalf of him. The proof affidavit filed by the opposite party and Exs.B1 to B7 have been marked on behalf of them.  The opposite party filed written arguments.

5.         Heard both sides.

6.         Points raised for consideration are:

 

1. Whether there is any deficiency in service on the part of the opposite party?

            2. Whether the complainant is entitled for the reliefs asked for?

            3. To what relief?

         

 

The admitted facts are that the complainant obtained the insurance policy by name Asha Deep Benefit Policy vide Ex.B3 from the opposite party and the sum assured for that policy is of Rs.1,00,000/-.  The complainant paid Rs.1,227/- as quarterly premium vide Ex.A3. In this policy, there is an additional benefit to the policyholders in case of any medical emergency or any disability.  The complainant obtained the policy in the year 2001 and paying the premiums regularly. The complainant had a heart problem and underwent heart surgery on 18.4.2012 and the discharge summary is herewith filed vide Ex.A1.  The complainant came to know that there is medical benefit in the policy, therefore, he wrote a letter to the opposite party by claiming the above said amount from the opposite party vide Ex.A2.  The opposite party gave a reply vide Ex.A4 that the said surgery is not covered under the policy conditions.

The opposite party filed the proposal form vide Ex.B1 and also filed the medical examination report of the complainant vide Exs.B2 & B6. They also filed the self-declaration given by the complainant with regard to his health vide Ex.B4. The revival review slip herewith filed by the opposite party vide: Ex.B5.  The opposite party filed a letter which was written to Dr. A.V. Subbarao, whether the said surgery comes under the benefit of Asha Deep Policy, in which he made a note that M.V.R. Surgery will not cover under Asha Deep claim and may be repudiated.       

7.  POINT Nos.1 & 2: The main contention of the complainant is that he obtained life insurance policy which is having an additional benefit of medical emergency reimbursement.  The opposite party contended that only after receipt of the entire medical record of the complainant, they came to know that he undergone heart surgery done as Chest Opened Median Sterntomy Systemic Heparinization with 3 mg. kg. Heparin Cardio Pulmonary Bypass Established with Aortic.  After scrutiny, the opposite party found that this surgery is not covered as per the policy terms and conditions and the same is communicated to their Amalapuram Branch and the same is informed to the complainant.  When the complainant made another representation, this opposite party referred the medical record to its Divisional Medical Referee i.e. Dr. A.V. Subbarao.  After verifying the medical treatment record of the complainant, he gave an opinion that the said surgery will not covered under Asha Deep claim and also informed, it may be repudiated.  This opposite party informed the same to the complainant and the repudiation is only based on the terms and conditions of the policy.

The opposite party relied on the following judgment in “Life Insurance Corporation of India Vs. Dr. Thota Srinivasa Babu: Revision Petition No.3886 of 2014 (NC)”, in which it was held that considering the specific terms and conditions of the policy issued to the complainant, there is no escape from the conclusion that since the complainant did not actually suffer a Paralytic Stroke, he was not entitled to Benefit B of the policy taken by him.  Consequently, the view taken by the forum below cannot be sustained. As a result, the impugned orders are set aside and the complaint is dismissed with no order as to cost.         

After perusing the material on record, when we observed that Condition 11 (i) of the terms and conditions, in which it is mentioned that “the Life Assured undergoes Open heart By-pass surgery performed on significantly narrowed/occluded coronary arteries to restore adequate blood supply to heart and the surgery must have been proven to be necessary by means of coronary angiography.  All other operations (e.g. angioplasty and Thrombolysis by Coronary Artery Catheterization) are specifically excluded.

But, in this case, after perusing the medical record of the complainant, we observed that the complainant also undergone a By-pass surgery by replacing Mitral Valve and a detailed procedure was given by Bollineni Hospitals.  As seen from the medical record, we opined that the complainant is entitled 50% of the amount prescribed in policy conditions, as he was undergone a major open heart surgery, which is related to the heart valve. 

The citation filed by the opposite party is not relevant to the present case on hand.  The discussion held supra, it is just and necessary to pay the 50% of the sum assured to the complainant for his medical claim. 

 

8.   POINT No.3:  In the result, the complaint is allowed in part, directing the opposite party to pay Rs.50,000/- towards the medical claim to the complainant and we further direct the opposite party to pay Rs.1,000/- towards the costs of the complaint to the complainant.  Time for compliance is two months from the date of this order.   

 

Typed to dictation, corrected and pronounced by us in open Forum, on this the           

7^th day of October, 2015.

    

                Sd/-xx                                                                                           Sd/-xx

              MEMBER                                                                              PRESIDENT(FAC)

         

 

APPENDIX OF EVIDENCE

WITNESSES EXAMINED

 

FOR COMPLAINANT: None.                                         FOR OPPOSITE PARTY: None.

 

DOCUMENTS MARKED

 

FOR COMPLAINANT:

 

 

Ex.A1    Operation notes and Discharge summary.

Ex.A2   Regd. Legal notice.

Ex.A3    Premium Receipt dt.30.11.2012.

Ex.A4    Letter from L.I.C. of India.

FOR OPPOSITE PARTY:-    

Ex.B1    Photocopy of the proposal form dt.12.6.2001.

Ex.B2    Photo copy of the Medical Examination of complainant report dt.12.6.2001.

Ex.B3    Photocopy of the policy.

Ex.B4    Self Declaration Statement dt.30.4.2002.

Ex.B5    Revival letter dt.30.4.2002.

Ex.B6    Photocopy of the Medical Examination report dt.30.4.2002.

Ex.B7    Photo copy of DMR opinion for considering the claim dt.12.9.2012.

 

                Sd/-xx                                                                                          Sd/-xx

              MEMBER                                                                              PRESIDENT(FAC)