BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM ::
KADAPA Y.S.R DISTRICT
PRESENT SRI V.C. GUNNAIAH, B.Com., M.L., PRESIDENT
SMT. K. SIREESHA, B.L., LADY MEMBER
SRI M.V.R. SHARMA, MEMBER.
Friday, 17th October 2014
CONSUMER COMPLAINT No. 01/ 2014
Shaik Shamshuddin,
S/o Shaik Mahammed Dastageer,
aged 50 years, Residing at D.No. 15/418,
Habibulla Street, Kadapa – 516 001. ….. Complainant.
Vs.
1. The Branch Manager,
Life Insurance Corporation of India, R.S. Road,
Rajampet – 516 115, Kadapa District.
2. The Chief Manager,
Life Insurance Corporation of India, Branch Office,
R.S. Road, Kadapa (659),
Kadapa city and Town – 516 001. ….. Respondents.
This complaint coming on this day for final hearing on 09-10-2014 in the presence of Sri A. Arogyadass, Advocate for complainant and Sri D. Lakshminarayana, Advocate for Respondents and upon perusing the material papers on record, the Forum made the following:-
O R D E R
(Per V.C. Gunnaiah, President),
1. The complainant filed complaint under section 12 of Consumer Protection Act 1986 (for short herein after called as C.P. Act) praying this forum to direct the respondents to pay Rs. 3,00,000/- towards medical expenses spent by him for his cardiac disease with interest @ 6% p.a. and Rs. 50,000/- towards mental agony and Rs. 10,000/- towards costs of this complaint.
2. The averments of the complaint in brevity are that the complainant has taken insurance policy by name Ashadeep-2 policy with profits on 01-8-2004 from respondent No. 1, in policy No. 653666381. He was regular in payment of policy premium amount and the policy was in force. While so the complainant suddenly fell sick, due to severe pain in chest and was admitted to the local hospital at Kadapa on 01-4-2013 and on the advice of the medical authorities he was shifted to Star Hospital, Hyderabad for better treatment on 02-4-2013. In Star Hospital, Hyderabad Cardiac specialist Dr. Ramesh Gudapati attended the complainant and various medical tests are done for proper diagnosis and treatment and the complainant was confirmed that he is suffering from LV disfunction, with double vessel disease and Global Systolic LV function severely impaired, which resulted in narrowing the coronary arteries impairing the sufficient / proper blood supply to heart and causing heavy pain in heart and chest. This was resulted by coronary angiography and MRI report. The complainant was advised for immediate admission into hospital for conducting operations to rectify the defect to overcome the life danger. On the advice of Dr. Ramesh Gudapati, Cardiac Specialist he was admitted as inpatient in Star Hospital, Hyderabad for operation on 15-4-2013 and the doctor operated the complainant and arranged PTCA + stunt to right Coronary Artery successfully and after observation, the complainant was discharged on 17-4-2013 as inpatient, on medical management.
3. During the course of treatment the complainant was forced to spend huge amounts as outpatient and inpatient in Star Hospital, Hyderabad to the tune of Rs. 3,00,000/-. The complainant approached the respondents on 28-5-2013 for reimbursement of money spent by him, by furnishing all details and policy bond. But the respondents rejected the claim of the complainant vide letter, dt. 02-7-2013, stating that the competent authority has rejected Ashadeep Sick benefit under the complainant’s policy as the treatment taken by him is not covered under the policy of the complainant bearing No. 653666381. The repudiation of the mediclaim by respondents is arbitrary by wrongly interpreting the excluding clause in the policy and it is against the object of the insurance policy and principles of natural justice. Hence, the complaint is filed for necessary reliefs as mentioned above.
4. The respondent No. 2 filed counter and the same was adopted by respondent No. 1 by filing memo.
5. Respondent No. 2 filed counter stating that the complaint is unjust and not maintainable, as there is no deficiency of service on the part of the respondents and the respondents corporation has acted with due diligence while repudiating the claim of the complainant strictly in accordance with the conditions of the policy. The complainant policy carries an endorsement with suitable conditions and restrictions and exclusions including basis and eligibility for the claim under different categories. As per clause No. G, four types of diseases are covered under Asha Deep sickness benefit claim. They are (1) Open Heart Coronary Artery Bypass Surgery, (2) Renal Dialysis or Renal Kidney Transplantation, (3) Cancer (malignant) and (4) Paralytic stroke. In open heart coronary artery bypass surgery, it has got an exclusion clause as all other operations like balloon angioplasty and Thrombolysis by coronary artery are excluded and also directional rotablator, laser coronary angioplasty and directional coronary atherectomy are also excluded. Even as per policy condition No. 11 (b) (1) excludes the claim of the complainant. Since the complainant’s treatment was by way of angioplasty the same is specifically excluded. The surgery underwent by the complainant was PTCA + Stunt as per discharge summary issued by the Star Hospital, Hyderabad and it is balloon angioplasty, which shows within the meaning of exclusion clause as mentioned in the policy conditions together with its endorsement. Therefore, the repudiation of the complainant’s claim in the instant case does not suffer from any legal impediments as treatment of the complainant is not open heart surgery. The complainant has full knowledge about the nature of conditions of the subject policy, while obtaining the same and entered in to contract of insurance. Hence, the terms and conditions binds the complainant. The complainant has filed the policy only but without endorsement of the policy. Therefore, the forum may be pleased to dismiss the complaint with exemplary costs.
6. On the basis of the above pleadings the following points are settled for determination.
- Whether there is any negligence and deficiency of service on the part of the respondents?
- Whether the complainant is entitled for the relief’s as prayed for?
- To what relief?
7. No oral evidence has been let in by either party. On behalf of the complainant Ex. A1 to A5 documents are marked and on behalf of the respondents Ex. B1 to B6 are marked by consent.
8. Heard both sides.
9. Heard arguments and considered the written arguments filed by the parties.
10. Point Nos. 1 & 2. Since these two points are connected to one another, they have taken up for discussion together for better appreciation.
11. Learned counsel for the complainant submitted that the complainant underwent various tests for his heart disease in Star Hospital, Hyderabad and atlast Dr. Ramesh Gudapati, Cardiologist operated the complainant and arranged PTCA + Stunt to right Coronary Artery on 15-4-2013, through it is not bypass surgery as per policy, but still covers the insurance policy under Ex. A1. Therefore, the respondents cannot repudiate the contract of insurance on the ground that the complainant had not undergone bypass surgery as per policy conditions No. 11 (b) (1). In support of his contention the learned counsel for the complainant relied on Hari Om Agarwal Vs. Oriental Insurance Co. Ltd., AIR 2008 Delhi 29.
12. On the other hand learned counsel for the respondents contended that the claim of the petitioner has been rightly repudiated as the policy under Ex. A1 (equal to Ex. B1) does not cover the diseases as per condition No. 11 (b) (1) of the policy, as such there is no either deficiency of service or negligence on the part of the respondents. Therefore, the claim is not entitled by the complainant and since the subject matter of policy itself is in dispute the complainant has to approach civil court for civil action, as such the complainant is not entitled for the amount claimed. In support of their contention the respondents relied on 1999 CJJ 949 (SC) Saushish Diamonds Ltd., Vs. National Insurance Co. Ltd.,
13. There is no dispute between the parties that the complainant is the policy holder under name and style Ashadeep-2 policy with profits in policy No. 653666381, dt. 01-08-2004 and the same is inforce, which is mediclaim policy. The complainant filed Ex. A1 insurance policy dt. 01-8-2004, Ex. A2 photostate copies of outpatient test reports from Star Hospital, Hyderabad dt. 2-4-2013, 3-4-2013, 20-5-2013 and 21-5-2013, Ex. A3 is the discharge summary issued by Star Hospital, Hyderabad authorities. Ex. A4 is hospital bills 5 numbers and Ex. A5 is reply notice dt. 2-7-2013 by respondent No. 2. The above documentary evidence has been placed by the complainant to show that he had undergone tests from Star Hospital, Hyderabad for his chest pain and after tests Dr. Ramesh Gudapati, Cardiologist operated the complainant on 15-4-2013 and arranged PTCA + Stunt to right coronary artery as the complainant was suffering from severe LV disfunction with double vessel disease and he spent Rs. 3,00,000/- towards medical expenses. According, to the complainant he is entitled to reimbursement for all amount of Rs. 3,00,000/- spent by him towards medical expenses for his cardiac disease as per policy under Exhibits A1 and B1 obtained by him from respondent No.2.
14. On the other hand it is the specific case of respondents though the complainant obtained policy under Exhibits A1 & B1, but the treatment undergone by him does not cover the diseases mentioned in Exhibits A1 & B1 policy as per condition No. 11 (b) (1). In support of their case the respondents filed ex. B1 copy of policy together with endorsement, Ex. B2 copy of discharge summary issued by Star Hospital, Hyderabad, Ex. B3 claim form AD (CABG)-2 issued by Star Hospital, Hyderabad, Ex. B4 claim form AD (CABG)-3 issued by Star Hospital, Hyderabad, Ex. B5 opinion of medical referee of Respondents Corporation and Ex. B6 is copy of repudiation letter dt. 2-7-2013 with acknowledgement of complainant.
15. It is necessary to refer and examine Exhibits A1 & B1 insurance policy and the endorsement there to in this case to know whether the treatment for the disease undergone by the complainant has been covered under the policy Exhibits A1 & B1 with endorsement. Ex. A1 is photostate copy of policy filed by the complainant is not visible with regard to conditions of the policy. The complainant has not filed endorsement attached to the policy Ex. A1. Whereas the respondent No. 2 filed visible photostate copy of policy with endorsement which is marked as Ex. B1. A perusal of Ex. B1 policy conditions 11 (b) (1) runs thus:-
11 (b) Benefit (B) of the policy schedule shall be available on the occurrence of any of the following contingencies.
- The life assured undergoes open heart bypass surgery performed on significantly narrowed occluded coronary arteries is restored adequate blood supply and the surgery must have been to be necessary by means of coronary angioplasty. All other operations example angioplasty and thrombolysis by coronary artery are specially excluded. In the endorsement attached to Ex. B1 policy clause No. (G) is Ashadeep Sickness benefit claim. The above Ashadeep sickness benefit claim is covered four major ailments. They are 1) Open Heart Coronary Artery bypass surgery. It is mentioned in this open heart coronary artery bypass surgery as follows. The life assured undergoes an open heart coronary artery bypass surgery performed on significantly narrowed occluded coronary arteries is restored adequate blood supply to heart. The surgery must have been proof to be necessary by means of coronary angioplasty.
Exclusion:- All other operations like balloon angioplasty and Thrombolysis by coronary artery are excluded and also directional rotablator, laser coronary angioplasty and directional coronary atherectomy are also excluded.
16. The complainant had not undergone open heart surgery in this case. The complainant had undergone operation PTCA + Stunt to right coronary artery on 15-4-2013, it is only an angioplasty. The operation was done in balloon process as per discharge summary. Therefore, the treatment for the disease undergone by the complainant comes under the exclusion clause of Ex. B1 policy conditions issued by respondent No. 2, as angioplasty and Thrombolysis by coronary artery are specifically excluded. Ex. B5 clearly goes to show that PTCA is not open heart bypass surgery. Therefore, claim by the complainant has been rightly repudiated under Ex. B5 by respondent No.2. As such I hold there is no negligence or deficiency of service on the part of the respondents towards policy claim of the complainant. Though the complainant, undergone treatment for heart disease, but still it is not open heart surgery and the same does not cover the diseases mentioned in Exhibits A1 & B1 clause 11 (b) (1) and endorsement (G), the complainant is not entitled for the claim from the respondents, thus the respondents are not liable to pay an amount of Rs. 3,00,000/- and compensation for mental agony and costs as claimed by the complainant, hence complaint is liable to be dismissed.
17. The complainant relied on Hari Om Agarwal Vs. Oriental Insurance Co. Ltd., AIR 2008 Delhi 29 for the proposition as per the policy content the complainant is entitled for compensation. I have gone through above judgement, the above judgement is not applicable to the facts and circumstances of this case.
18. The respondents relied on 1999 CJJ 949 (SC) Saushish Diamonds Ltd., Vs. National Insurance Co. Ltd., for the proposition that the policy under Ex. B1 itself is in dispute regarding to the subject matter, so no relief can be granted to the complainant. In the above judgement it is held by the Apex court, the very interpretation of the policy itself is a subject matter of dispute, the respondents can repudiate the claim and direction for civil action is proper.
19. In the present case also the very interpretation of the policy clause 11 (b) (1) endorsement (G) is itself subject matter. Therefore, the claim is not entitled by the complainant. Accordingly, the points 1 & 2 are answered against the complainant.
20. Point No. 3. In the result. The complaint is dismissed, but in the circumstances no costs.
Dictated to the Stenographer, transcribed by him, corrected and pronounced by us in the open forum, this the 17th October 2014
MEMBER MEMBER PRESIDENT
APPENDIX OF EVIDENCE
Witnesses examined.
For Complainant NIL For Respondent : NIL
Exhibits marked for Complainant : -
Ex. A1 Insurance policy certificate Ashadeep-2 policy with profits
dt. 01-8-2004
Ex. A2 Xerox copies of Star Hospitals, Hyderabad outpatient test reports
dt. 2-4-2013, 3-4-2013, 20-5-2013 and 21-5-2013.
Ex. A3 Xerox copies of discharge summary of Star Hospitals, Hyderabad
inpatient admission and treatment, certificates issued by the
hospital authorities.
Ex. A4 Xerox copies of the bills, paid to the Star Hospitals, Hyderabad
by the complainant 5 nos.
Ex. A5 Reply letter dt. 2-7-2013 addressed to the complainant by the
respondent No. 2.
Exhibits marked for Respondents: -
Ex. B1 Copy of the policy together with copy of endorsement.
Ex. B2 Copy of discharge summary issued by Star Hospitals, Hyderabad.
Ex. B3 Claim form AD (CABG)-2 issued by Star Hospitals.
Ex. B4 Claim form : AD (CABG)-3 issued by Star Hospitals.
Ex. B5 Opinion of medical referee of Respondent Corporation.
Ex. B6 Copy of repudiation letter dt. 2-7-2013 with acknowledgement of
the complainant.
MEMBER MEMBER PRESIDENT
Copy to :-
- Sri A. Arogyadass, Advocate for complainant.
- Sri D. Lakshminarayana, Advocate for respondents.
B.V.P. - - -
