Adv. For the Complainant: - Self
Adv. For O.Ps :- Mr. Asit Sarangi
Date of filing of the Case :- 24.04.2023
Date of Order :- 30.11.2023
JUDGMENT
Smt. Jyotsna Rani Mishra , Member
Fact of the case:
Malia Gadua , The complainant had taken out a POORNA SURAKSHYA of SBI Life Insurance Co. Ltd. Bearing policy No.2F629105210.on dt.14.10.2020 with a premium of Rs.66,712.84 ( Sixty Six thousand seven hundred twelve and Eighty four paisa) for ten years. And As per the policy the SBI life insurance co.ltd assured complainant to give critical illness Benefit and Death Benefit of a sum of Rs.4,60.000/-(four Lakhs sixty thousand ) and Rs.23,00,000/- ( Twenty three lakhs) respectively and no return benefit is available to the policy holder after completion of ten years if no critical or death of policy holder, And was continuing as per policy rules.
During the above ten year complainant deposited three number of premium for a period of three year out of ten years through auto debit system from saving Account No.113419224218 SBI Main Branch, Bolangir
During the policy period. Complainant suffered from a heart disease and was admitted to a corporate hospital (Amri Hospital) , Bhubaneswar, Odisha state on dt.24.09.2022 and subsequently dt.26.09.2022 for treatment complainant treated with critical care cardiovascular and under went an angioplasty produce.
Complainant submitted a mediclaim on dt.15.10.2022 to SBI Life Insurance Co. td for the medical expenses incurred due to his heart disease. However the claim was denied by the insurance company on the grounds that the angioplasty prouder was not covered under the policy .
That being a heart patient, complainant been cheated tortured and harassed by the opposite parties since last three months. So complainant claimed for compensation from the OPs.
Complainant relied on the following Documents-
1. Discharge certificate.
2. Discharge Certificate.
3. Copy of Policy Bond.
4. Rules of Critical illness.
5. Bills/Vouchers.
6. Angiography.
7. Test Report of health before commencement of policy.
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Having gone through the complainant its accompanied documents and hearing the complainant prima facie , it seemed to be a genuine case hence admitted and notice to the OPs were served and in response they appear through their advocates and filed their written version.
To counter the charge in rival contention SBI Life Insurance Co. Ltd. filed their written statement admitting that illness suffered by the complainant does not fulfill the definition as per the critical illness rider mentioned in the policy document. Hence the claim under critical illness benefit rider is not admissible. It is specifically denied that the complainant applied for mediclaim on 15.10.2022 . So OPs is not liable to pay Rs.4,60,000/- towards mediclaim or Rs.10,00,000/- towards harassment, fortuned, response and mental agony as demanded by the complainant.
Issues –
The main issue in this case is whether the angioplasty procedure is covered under the Poorna Surakhya Insurance Policy.
Analysis-
In the view of above fact and circumstances the Poorna Surakhya Insurance Policy does not explicitly cover angioplasty produces. However the policy does cover critical care cardiovascular treatment. The angioplasty produce was a necessary and essential part of complainant treatment for his heart disease. Therefore , the angioplasty procedure should be considered cover under the policy, and I find that SBI Life Insurance Co. Ltd . was wrong to deny complainant claim for medical expenses incurred due to his heart disease. Hence Order.
ORDER
I directed OPS to pay complainant the following Rs.4,60,000/- for medical Expenses. Rs.30,000/- for harassment and mental agony. Rs.3,000/- for Litigation Expenses. I further directed OPs to pay complainant interest on the amount awarded at the 12% per annum from the dt of Judgment until the dt of payment.
No award as to cost.
PRONOUNCED IN THE OPEN COMMISSION TO-DAY 30th day of November ‘2023.
