BEFORE THE DIST. CONSUMER DISPUTES REDRESSAL FORUM, DHENKANAL
C.C.Case No. 14 of 2015
Dr. Pradyot Kumar Behera, aged about 46 years
S/o Gopabandhu Behera, MIG-16,
Town Planning Colony, Dhenkanal …………….Complainant
Versus
1) Life Insurance Corporation of India having its Central Office,
At 4th Floor, West Wing, Yogakshema,
P.B.No.19953, Jeevan Bhima Marg,
Nariman Point, Mumbai-400021
2) Manager (Health Insurance), Life Insurance Corporation of India,
Division Office (Under Central Zone) At: Nuapatna, Mangalabag, Cuttack
3) Branch Manager, Life Insurance Corporation of India,
Rathagada, Dhenkanal
4) Niranjan Sahoo, aged about 55 years
S/o late Gangadhar Sahoo, Near Phatabandha, Banamaliprasad,
PO: Mangalpur, Dist: Dhenkanal ………..Opp. Parties
Present: Sri Badal Bihari Pattanaik, President,
Miss Bijayalaxmi Satapathy, Member
Sri Purna Ch. Mishra, Member
Counsel: For the complainant: Sri Sibasai Mohapatra & Associates
For the Opp. Parties: Sri Diptish Prasad Patanaik
Date of hearing argument: 20.12.2017
Date of order: 4.1.2018
JUDGMENT
Sri Purna Chandra Mishra,Member
The complainant has filed this case U/s 12 of the C.P.Act, 1986 challenging the repudiation of the medi-claim claimed to by the O.Ps and for a direction to the O.Ps. to pay a sum of Rs. 2,58,000/- with interest @ 18% per annum from the date of intimation for Surgery, a sum of Rs. 1,00,000/- towards severe mental and physical agony and a sum of Rs. 20,000/- towards cost of litigation.
1) Breif facts leading to the case is that the petitioner had obtained a Health Insurance Policy (Jeevan Arogya) bearing No. H058/599217507/01 from Life Insurance Corporation through Dhenkanal Branch. Towards the end of 2013 he experienced severe and unbearable pain around the neck and shoulder region accompanied by tingling sensation and numbness in arms and fingers of both the hands. Being an Orthopedic and Spine specialist he suspected it to be a trouble in Spine and took medicines and made exercise to get relief from the pain he was feelings. Since the medicines and exercise did not yield any result, he made up mind to go for MRI test and prior to availing the MRI test he consulted the Heads of the Department of Orthopedic and Spine at Sum Hospital, Bhubaneswar who advised him to go ahead with the test. After conducting the MRI test on 10.2.2014 it was detected that he is suffering from grave kind of Myelopathy. Being advised by him for further treatment he left for New Delhi within two days and consulted international renounced Orthopedic and Spine Surgeon Dr. Shankar Acharya and also Professor P. Sarath Chandra at AIIMs, New Delhi. After thorough analysis and checkup it was decided to go for Surgery on 28.2.2014. Since the petitioner was having a medi-claim policy, as per the rules of the Policy he gave intimation to the O.P.No.3 prior to the operation in the prescribed form regarding illness, kind of treatment to be availed, name of the doctor and hospital and other details as per the requirements of the O.Ps. Inspite of intimation given to the O.P.No.3 he did not raise any objection and the petitioner proceeded for his treatment and finally surgery was conducted at AIIMs.
2) After the treatment was completed on his return to Dhenkanal he made a claim of Rs. 2,58,000/- which was rejected by the O.P.No.2 vide his letter dated 8.5.2014 in which the O.P’s Corporation intimated him that since this disease is covered under waiting period of two years his claims is rejected as the policy has not completed two years from the date of its inception. It is the specific case of the petitioner that he was suffering from Myelopathy and there are two causes leading to Myelopathy. The first one is presence of Osteophytes between C5-6 and the second is slip disc at C6-7 level. Since it was the case of Myelopathy the Osteophytes present between C5-6 were removed and the slip disc was removed and in its place an artificial disc was implanted into the spine. Since Osteophytes and slip of disc had caused his disease and slip of disc is not the only reason the rejection of the claim is illegal on the part of the O.Ps. The O.P.No.3 while receiving the intimation prior to his surgery even though was aware of such conditions he did not raise it nor intimated the petitioner and rejected the claim only after all the procedure and process was over for which he has challenged the action of the O.Ps praying therein for the reliefs as prayed for in the complaint petition.
3) The Opp. Parties appeared through their Advocate and filed their written statement. In their written statement the O.Ps admitted that the petitioner has availed this policy which was in force from 22.2.2013. The Jeevan Arogya plan of the Insurance Company is specifically designed to get benefit of hospitalization for the policy holder with certain limitations and there is specific waiting period for some diseases as mentioned in Column-6 of the Policy condition. The petitioner has taken treatment of disc replacement on 28.2.2014. Since the waiting period is for two years, the policy holder has completed one year and six days only for which it is not possible on the part of the Insurance Company to allow the claim and therefore, it was rejected. It is further stated that the petitioner is a learned doctor and he has got adequate knowledge to know about the diseases mentioned in the exclusion clause of two years and even after knowing of these things he has filed this petition and since there is a violation of the policy condition the O.Ps have rightly rejected the claim and therefore pleaded for dismissal of the complaint petition with cost.
4) That the petitioner in support of his case has filed copy of the claim intimation form, copy of the letter dated 8.5.2014, copy of the status report, copy of the terms mentioned under specific waiting period, copy of the MRI report, copy of the O.PD ticket, copy of the prescriptions of Dr. S. Acharya, copy of the hospital treatment form, copy of the money receipt, copy of the discharge summary and Xerox copy of the medical dictionary explaining the word Myelopathy and has filed the evidence of Dr. P.K. Behera in support of his case in shape of affidavit. On the other hand the Opp. Parties have filed the copy of the L.I.C Jeevan Arogya policy of the petitioner with its annexures and copy of the discharge summary issued by the Department of Neuro Surgery, AIMS of the petitioner and has also filed the evidence in chief of one Ashok Behera in support of their case.
5) That the only point to be adjudicated in this case is whether the disease for which the petitioner has been treated is covered under the waiting period as specified in Sl. 6 of the Jeevan Arogya Policy? It is the specific case of the petitioner that he was treated for Myelopathy and it is the specific case of the O.Ps that the petitioner has undergone surgery for slip disc. The O.Ps in support of their case has filed the copy of the discharge Summary of the Department of Neuro Surgery, AIMs in which the disease has been diagonised as C5-6 and C6-7 PIVD with Myelopathy. The claim rejection letter dated 8.9.2014 of the O.P. No.2 in the reason for rejection has specified that the claim is being denied on account of C5-6 and C6-7 PIVD with Myelopathy. So there is no dispute regarding the fact that the petitioner was diagonised for the disease C5-6 and C6-7 PIVD Myelopathy. As seen from Sl. 6 the specific waiting period of two years does not cover this disease i.e. C-5-6 and C6-7 PIVD with Myelopathy. The O.Ps have not filed a single document nor have adduced any expert opinion nor have produced any medical literature to show that this disease is covered under the specific waiting period of two years. In the absence of any documents or evidence to this effect we are unable to hold that the rejection of the claim of the petitioner by the O.Ps is justified. Since the O.Ps have rejected the claim of the complainant without any just and genuine reason which is beyond the disease mentioned in Column-6 of the policy, the O.Ps have caused deficiency in service and are liable to compensate the petitioner for the expenses and loss incurred by him
6) The Opp. Party has relied on a decision of the Hon’ble National Consumer Disputes Redressal Commission in the case of Kamelsh Gupta Vrs. I.C.I.C Lumbard General Insurance and others in F.A. No. 1450/2014. In this case the Hon’ble National Commission have held that in the event of the disease is covered under exclusion clause the claim cannot be allowed. This decision is not applicable to the facts of the case at hand. Similarly the petitioner has relied on two decision which are also not applicable to the facts of his own case. Now therefore, taking into consideration of the factual aspects into consideration the complainant is entitled to get relief and hence the order.
ORDER
The complaint petition is allowed on contest against the O.P. No- 1, 2 & 3 and dismissed against Op. No-4 . and the O. P. No- 1 , 2, & 3 are directed to pay a sum of Rs. 2,58,000/- (Rupees two lakhs fifty eight thousand) only to the petitioner with interest @ 6% per annum from the date of order and to pay a sum of Rs. 5,000/- (Rupees five thousand) towards harassment and deficiency in service and a sum of Rs. 2,000/- (Rupees two thousand) only towards cost of the litigation. The cost and compensation as ordered be paid within a period of 30 days from the date of receipt of this order failing which it will carry 12% interest on the whole amount thereafter.
(Miss Bijayalaxmi Satapathy) (Badal Bihari Pattanaik) (Purna Chandra Mishra)
Member President Member
