IN THE CONSUMER DISPUTES REDRESSAL FORUM, ALAPPUZHA
Tuesday 29th day of March, 2016
Filed on 21.10.2013
Present
- Smt. Elizabeth George (President)
- Sri. Antony Xavier (Member)
- Smt. Jasmine D (Member)
in
C.C.No. 322/2013
between
Complainant:- Opposite Parties:-
P.A Aboobakkar, 1. Branch Manager,
Puthan Veedu, LIC of India,
Kottaraparambil, (LIC Health Plus Plan),
Palace Ward, Sreevalsam Building, Alappuza. Kidangamparambu,
(By Adv. K. Najeeb. Alappuzha.
2. Regional Manager,
Divisional Officer,
LIC of India,
(LIC Health Plus Plan),
Ernakulam.
(By Adv. P.K. Mathew – for Opposite parties 1 and 2)
O R D E R
SMT. JASMINE D. (MEMBER)
The case of the complainant in short is as follows:-
The complainant has taken a policy LIC Health Plus Plan from the opposite party on 04.03.2008 and the opposite party issued policy certificate vide No. 393893747 on 19.03.2008. While so when the policy was in existence the complaint was felt chest pain and was admitted at Lakeshore Hospital. There he underwent angioplasty and the total expenses for the treatment was Rs. 1,30,000/-. The complaint has sent a letter to the opposite party for getting the medical expenses incurred by him. But the opposite party issued a cheque for Rs. 1725/- only and which was not encashed by the complainant. The complainant sustained much mental agony and hence filed this complaint.
2. The version of the opposite parties is as follows:-
The complaint is not maintainable. The complaint has taken unit linked health insurance plan which provides Hospital Cash Benefit (HSB) Major Surgical Benefit (MSB) and Domiciliary Treatment Benefit (DTB). The opposite party further contended that unlike medi-claim policy LIC’s Health Plus Policy gives benefits like savings through units apart from providing HSB, MSB, DTB benefit. The complainant is eligible to claim his hospital cash benefit. It is submitted that the surgery undergone by the complainant was not covered by the policy. As per conditions No.3(II) (VII) regarding major surgical benefit limits “No payment shall be made under this benefit for the operations performed which are not list in the surgical benefit annexure. In this case insurer was hospitalized on 14.11.2011 and was discharged on 17.11.2011 for the first two days no benefit is payable. Hence the policy holder is eligible for only one day hospitalization and the applicable daily benefit Rs- 1725/- and was paid vide cheque No. 71867 dated 16.12.2011. As per the terms and conditions of the Surgical Benefit Annexure under the head “Cardiovascular System”. 40% of the sum assured is payable for coronary angioplasty with stent implantation only if two or more coronary arteries are stented. In this case only single stent was deployed. Hence the Major surgical Benefit claimed by the petitioner was rejected and hence there is no deficiency on the part of the opposite party and the complaint is to be dismissed.
3. The complainant was examined as PW1. One witness was examined as PW2 and document Ext A1 to A10 were marked. The opposite party was examined as RW1 and document Ext.B1 to B5 were marked.
4. Considering the allegations of the complainant and contentions of the opposite parties the Forum has raised the following issues:-
1) Whether there is any deficiency in service on the part of the opposite parties?
2) Whether the complainant is entitled to get the reliefs as prayed for?
5. Points 1 and 2:- The complainant is a policy holder of LIC Health Plus policy when the policy was inexistence the complainant was admitted at Lakeshore Hospital and there he underwent Coronary Angioplasty. The complainant claimed for the re-imbursement of the total expense incurred by him. But the opposite party refused the surgical benefit and issued a cheque of Rs.1725/- only. Hence the complainant filed this complaint for getting medical expenses of Rs. 1,30,000/- incurred by him along with compensation of Rs.2,00,000/-. The complainant was examined as PW1 and documents Exts.A1 to A10 were marked. Ext.A1 is the Policy Certificate, Ext.A2 is the letter dated 16.10.2012, Ext.A3 is the reply notice dated 9.3.2012 issued by the opposite party, Ext.A4 is the lawyer’s notice dated 18.1.2013, Ext.A5 is the reply notice dated 1.2.2013, Ext.A6 is the Acknowledgement Cards, Ext.A7 is the cheque issued by the opposite party for Rs.1725/-, Ext.A8 is the copy of claim card, Ext.A9 is the hospital bills and Ext.A10 is the Brochure. The opposite party was examined as RW1 and the documents Exts.B1 to B5 were marked. Ext.B1 is the original claim form, Ext.B2 is the original of the particulars submitted by the complainant along with claim form, Ext.B3 is the original of the certificate of the doctor who conducted the surgery, Ext.B4 is the discharge summary and Ext.B5 is the original of the policy conditions in respect of the policy issued to the complainant.
6. According to the opposite party the insured will get the surgical benefit only for the surgery mentioned in the surgical benefit. From the Ext.A9 brochure it can be seen that the surgery mentioned is coronary angioplasty with stent implantation (two or more coronary arteries must be stented) so the insurer will get the surgical benefit for coronary angioplasty only if two or more coronary arteries must be stented. In the instant case, it can be seen from Ext.B3 that the complainant has CAD single vessel disease and from Ext.B4 it can be seen that coronary Angioplasty promote upon showed single vessel disease. Further on perusal of hospital bill Ext A9 it can be seen that they charged only for one stent. Page 3 of the Ext A9 under item description 71 it is clear that they charged only for one stent. So it is clear that the surgical procedure undergone by the complainant was not the one which was mentioned in the list of surgical procedure covered. According to the opposite party the claim for hospital cash benefit was sanctioned Rs. 1725/- to the complainant. According to the complainant he was unaware of the policy condition but it cannot be taken into consideration since brochure Ext. A10 was produced by the complainant which shows that the surgical procedure covered is “Coronary Angioplasty with stent implantation (two or more coronary arteries must be stented).” In the light of the above discussion we can’t find any deficiency in service on the part of the opposite party. There is no proof for deficiency in service on the part of the opposite party. Since there is no deficiency in service on the part of the opposite party the question of compensation does not arise for consideration. The complainant is not entitled to get compensation. The complainant fails.
In the result the complaint is dismissed.
Pronounced in open Forum on this the 29th day of March, 2016.
Sd/- Smt. Jasmine D (Member)
Sd/- Smt. Elizabeth George (President)
Sd/- Sri. Antony Xavier (Member)
Appendix:-
Evidence of the complainant:-
PW.1 - Aboobakker (Witness)
PW.2 - Dolly Joseph (Witness)
Ext.A1 - Policy Certificate
Ext.A2 - Notice letter dated 16.10.2012
Ext.A3 - Reply Notice issued dated 09.03.2012
Ext.A4 - Lawyer’s notice dated 18.02.2013
Ext.A5 - Reply notice dated 01.02.2013
Ext.A6 - A.D Cards
Ext.A7 - Cheque issued by the opposite party for Rs. 1725/-
Ext.A8 - Copy of Claim Card
Ext.A9 - Hospital Bill
Ext.A10 - Brochure
Evidence of the opposite party:-
RW.1 - Mini. S. Nair (Witness)
Ext.B1 - Original Claim form
Ext.B2 - Original of the particulars submitted by the complainant along with claim Forum
Ext.B3 - Original of the certificate of the doctor who conducted surgery
Ext.B4 - Discharge summary
Ext.B5 - Original of the policy conditions in respect of the policy issued to the
Complainant
// True Copy //
By Order
Senior Superintendent
To
Complainant/Opposite parties/S.F.
Typed by:- pr/-
Compared by:-
