The complainant files this case U/S 12 of the Consumer Protection Act, 1986. The fact of the case in brief is that the complainant/petitioner, Bishnu Charan Chandra, S/O Late Biswanath Chandra, permanent resident of Vill. Haragouritala, Near Bolpur Police Station, P.O and P.S. Bolpur, Dist. Birbhum, PIN 731234, purchased an insurance policy namely LIC’s Health Plus Plan from OP/LICI being policy No 468797195 dated 15/12/2009. The expiry date of the said policy was 15/12/2031, sum assured Rs.3,00,000/-.

 It is the further case of the complainant that the complainant having cardiac problem i.e CORONARY ARTERY DISEASE had been Apollo Hospital Enterprise Ltd of No19, Bishop Gradens, Raja Annamalaipuram, Chennai-600028 for his treatment.He was admitted therein on 26-06-2019 under Dr Prakash Chand Jain, Cardiologist,MD,DNB,FICC(Cardio) and ELECTIVE PTCA 2.75x28MM XIENCE EPEDITION STENT ACROSS LCX-OM LESION. Was done upon the complainant by Dr Prakash Chand Jain at Apollo Hospital Enterprise Ltd on 27/06/2019 andhe was discharge on 29/06/2019.

It is the nest case of the complainant that before starting the treatment in the aforesaid hospital he informed the OP insurance company in writing. The complainant incurred expenses amounting of Rs. 1,97,631/- for the aforesaid treatment vide Bill No: CMH-ICR-79606.After discharging from the hospital the complainant submitted his claim along with all relevant documents before the OP/LICI.

(1/5)

 It is the specific case of the complainant that OP/LICI paid Rs.2175/- instead of Rs.1,97,631/-. The OP/LICI did not repudiate the claim and did not clarify why they did not settle the claim amount of Rs. 1,97,631/- in favour of the complainant.

 Hence, after finding no other alternative, the complainant files the instant case praying following relief/reliefs:

a) To pass order directing the OP to pay a sum of Rs.197631/- as insurance claim.

b) ) To pass order directing the OP to pay interest @ 12% P. A. on Rs.197631/- since 27/06/2019.

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c) To pass order directing the OP to pay compensation of Rs.50000/- for mental agony and harassment caused by the OP.

 d) To pass order directing the OP to pay litigation cost of Rs.20000/-.

 e) Other relief/ reliefs.

 OP/LICI filed their written version (W/V) and some relevant documents in support of their case.

 OP/LICI stated in page -4 of their written notes on argument as:

“Elective PTCA was done on 27/06/2019 with Xience Xpedition stent across LCX-OM lesion 01(One) Xience Xpedition Stent was used as per record.

Major Surgical Benefit(MSB) was not considered by LIC of India as 01(One) Xience Xpedition Stent was used during Elective PCTA, of the Complainant.

As per list of surgical procedures in case of “Coronary Angioplasty with Stent implantation(two or more coronary arteries must be stented)” 40% sum assured is payable as Major Surgical Benefit(MSB).

Hence Single Stent PTCA surgery is not eligible for MSB.”

Complainant’s side submitted evidence-in-chief. Both the parties submitted written notes on argument. Some documents have also been filed by the complainant’s side and those have been compared with the original ones. The OP insurance company did not file any evidence-in-chief in support of their case. Thought, they filed some documents with firisti. Thereafter, respective Ld. Advocates for the OP and the complainant made oral arguments in support of their case.

Heard Ld. Advocate for both parties.

            Considered.

 Perused all the documents.

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Points for determination/Issues

1) Whether the complainant is a consumer as per definition of the term ‘Consumer’ of the C.P Act. ?

2) Whether this Commission has jurisdiction to try this case?

3) Whether there is any deficiency in service on the part of the Op?

4) Whether the complainant is entitled to get any other relief or reliefs as prayed for?

Decision with reasons

Point No. 1:

In this case, the complainant purchased an insurance policy vide policy No. 468797195 dated 15/12/2009, which was valid from 15/12/2019 to 15/12/2031. Thus, the complainant is a consumer under the OP insurance company and the OP insurance company is the service provider. Hence, the complainant is a consumer as per Sec. 2(1)d(ii) of the Consumer Protection Act, 1986.

Point No. 2:

Pecuniary jurisdiction of this Forum/Commission as per Sec. 11(1) of the Consumer Protection Act, 1986 is Rs. 20,00,000/-. OP LICI has branch office which is situated at Bolpur in Birbhum District i.e. within the territorial jurisdiction of this Forum/Commission as per Sec. 11(2) of the Consumer Protection Act, 1986. So, this Forum/Commission has territorial and pecuniary jurisdiction, over the issue.

In this case, the cause of action arose from 27/06/2019 and the case has been filed on 30/06/2020 i.e. before implementation of C.P. Act, 2019and as such it can be said that the complainant has filed this case within the statutory period of the C.P. Act, 1986 and as such the instant complaint is not barred by limitation U/S 24A of the C.P. Act, 1986.

Point No.3:

It appears from the documentary evidence as available in the case record that thecomplainant purchased an insurance policy named LICI Health Plus Plan vide policy No. 468797195 dated 15/12/2009 . The Expiry date 15/12/2031. Sum assures Rs. 1,97,631/-.

The complainant incurred expenses Rs. 197631/- for his cardiac treatment but the OP/LICI paid Rs. 2175/- instead of Rs. 1,97,631/-.

The OP/LICI argued that as per listof surgical procedures in case of “Coronary Angioplasty with Stent implantation(two or more coronary arteries must be stented)” 40% sum assured is payable as Major Surgical Benefit(MSB).

Hence Single Stent PTCA surgery is not eligible for MSB.”

(3/5)

OUR OBSERVATION:

In the instant case , ELECTIVE PCTA 2.75 X 28mm XIENCE EPEDITION STENT ACROSS LCX-OM LESION. was done upon the complainant by Dr Prakash Chand Jain, Cardiologist, MD, DNB, FICC( Cardio).

This commission is of view that Dr Prakash Chand Jain has sufficient knowledge,personal skill and qualification in the above field. In this case, only doctor will decide that how many stent will be needed in that small space of the Coronary arteries of the complainant. The doctors’ decision will be final as he is the expert in this field.Nowadays, the quality of the treatment has improved and the quality of stent has also improved. So in this case,it may happen that one stent will work as two stent. Hence, one stent is considered as sufficient.Doctor will not do the treatment as per the policy condition of the insurance company.The doctor will use his latest technique. The policy condition of the OP insurance company is of long ago. But, the treatment methods are improving day by day. So, in the case, implanting one stent for the complainant,only in this condition, the complainant is entitled to get 40% of the sum assured as insurance claim.OP insurance company should change their policy conditions according to the improved treatment method.

From the above discussion, this Commission is of the view that the OP insurance company’s stand not to agree to pay the entire cost of repairing or treatment as claimed by the complainant and cause shown by the OP side for repudiation of the said claim is baseless, vexatious and whimsical one, having no reasonable nexus.

It is proved beyond all reasonable doubts that the aforesaid act of the OP insurance company amounts to deficiency in service as per Sec. 2(1) (g) of C.P. Act, 1986 .

Hence, from the above discussion it is proved that the complainant has established his case beyond all reasonable doubts that there is deficiency in service on the part of the OP members.

Point No.4:

As such, the complainant is entitled to get relief or compensation as prayed for.

Thus, all the points are decided in favour of the complainant.

     (4/5)

Hence, it is,

       O R D E R E D,

    OP/LICI is directed to pay 40%of the sum assured = 40% of RS. 3,00,000/- = Rs. 1,20,000/- ( One Lakh Twenty Thousand Only ) to the complainant as insurance claim and Rs. 5000/- ( Five Thousand Only ) as litigation cost to the complainant.

The entire decree will be complied by the OP /LICI within 45 (Forty five) days from this date of order, from this date of order, failing which entire amount shall carry interest @ 9% p.a. till its realization.

If the OP /LICI failed to comply the decree, the complainant is at liberty to put this order to execution in accordance with law.

The instant case is thus disposed of.

Let a copy of this order be given/handed over to the parties to this case free of cost.