DISTRICT CONSUMER DISPUTES REDRESSAL FORUM PALAKKAD
Dated this the 16th day of May 2018
Present : Smt.Shiny.P.R. President
: Smt.Suma.K.P. Member Date of filing: 28/07/2016
: Sri.V.P.Anantha Narayanan, Member
(C.C.No.115/2016)
C.Krishnadasan,
S/o Chellappan (Late),
Aymunni House,
Kallekulangara Post,
Palakkad – 678 009 - Complainant
(By Adv.A.V.Ravi)
V/s
LIC of India,
Branch No.1,
LIC Building, - Opposite party
Shornur Road,
Near KSRTC Bus Station,
Palakkad – 678 014.
(Rep.By Branch Manager)
(By Adv.T.P.George)
O R D E R
By Smt.Suma.K.P. Member
The complainant has subscribe the Asha Deep Policy of the opposite party as per policy number 772863362 and the same has been renewed upto date from the date of subscription itself by the complainant. On 29.07.2014, the complainant has undergone an open heart surgery for Mitral Valve Repair at Kovai Medical Centre Hospital, Coimbatore. The complainant has spent an amount of Rs.2,10,000/- towards hospital expenses. At the time of subscription of the above said policy, the opposite party promised the complainant that the complainant is entitled to get an amount of Rs.1,50,000/- towards expenditure for the aforementioned treatment. Due to the promise offered by the opposite party the complainant joint the aforesaid policy and subscribed the same. It was also promised by the opposite party that after effecting the surgery, no single penny is required to be paid as premium for the said policy. On the basis of the promise given by the opposite party the complainant remitted the premium amount regularly to the aforesaid policy. Subsequently, on 19.09.2014, the complainant submitted the claim petition before the opposite party but, that was rejected without any valid reason contending that the treatment as well as surgery in this case is not coming under the policy and therefore the claim petition has been summarily rejected by the opposite party. A communication to that effect has been given to the complainant on 03.12.2014. Thereafter, the complainant issued a lawyer notice to the opposite party on 18.06.2016 for which a reply has been sent by the opposite party on 30.06.2016 with false contentions. The complainant submits that he is legally entitled for the aforesaid claim submitted by him. Even after repeated demand, the opposite party rejected the claim without any legal sanctity and the rejection of the claim according to the complainant is totally baseless, unilateral and arbitrary. The complainant alleges that the act of the opposite party amounts to deficiency in service and unfair trade practice. The opposite party has no privilege to reject the claim of the complainant. Hence, the complainant had approached before this Forum for the redressal of his grievances.
The opposite party entered appearance upon notice from the Forum and filed their version denying the entire allegation stated in the complaint. It was submitted that the complainant had submitted a proposal for availing the policy on 22.12.1996. The complainant had gone through the proposal form and understood all the definitions of the diseases covered under the policy and their benefits and exclusions and also signed a declaration to the effect that he had understood all the definitions and signed after fully understanding all the questions. It is not disputed that the complainant had undergone surgery for Mitral Valve Repair on 31.07.2014. He has submitted a claim, but the same was rejected because the said surgery is not covered under the policy. The policy issued to the complainant is Asha Deep-II with specific defined benefits. The benefits payable under this policy are clearly printed in the schedule of the policy document. According to the policy schedule “if the policy is in force for full sum assured, one of the two benefits, (A) or (B) defined herein below will be provided subject to the conditions mentioned herein. Either of the benefits is payable only one during the term of the policy. Benefit (A) – The sum assured with vested bonus, if any, is payable in the event of the life assured surviving the stipulated date of maturity or at his death, if earlier. Benefit (B) – If any one of the contingencies given in para 11 (b), subject however to the conditions mentioned in para 11 (a) of the conditions & privileges” within referred to occurs during the term of the policy, then the following benefits will be available. (i) Immediate payment of 50% of the sum assured. (ii) Payment of balance 50% of the sum assured along with vested bonus. If any, in the event of the life assured surviving the stipulated date of maturity or at his death, if earlier. (iii) Payment of an amount equal to 10% of the sum assured, every year, connecting from the policy anniversary falling on or immediately after the date of eligibility for benefit (B) and ending with the policy anniversary preceding the stipulated date or maturity or the date of death of the life assured, whichever is earlier. (iv) Waiver of premiums, if any, (including accident premium) due from the policy anniversary falling on or immediately after the date of eligibility for benefit (B). Further as per para 11 (b) of the conditions and privileges of policy document, Benefit B of the policy schedule shall be available only on the occurrence of (i) If the life assured undergoes Open Heart Bye Pass Surgery performed on significantly narrowed/occluded coronary arteries to restore adequate blood supply to heart and the surgery must have been proven to be necessary by means of coronary angiography. All other operations (eg. angioplasty and Thrombolysis by coronary artery catheterization) are specifically excluded.
OR (ii) the life assured undergoes Renal Dialysis as defined.
OR (iii) the life assured suffers from cancer as defined.
OR (iv) the life assured suffers from paralytic stroke as defined.
It is clear from the above that payment of Benefit A is not applicable in this case. Benefit B is payable only if the life assured undergoes any surgery as defined under para 11 (b). Admittedly, the surgery undergone by the complainant is Mitral Valve Repair which is not listed under the eligible surgeries and hence the claim could not be considered. Even in the case of Benefit B for eligible cases, an immediate payment of only 50% of the sum assured is payable as lumpsum amount and payment of the balance 50% of the sum assured along with vested bonus is payable on date of maturity or date of death whichever is earlier. Also payment of an equal amount of 10% of the sum assured every year from the date of eligibility of Benefit B and waiver of premium from the policy anniversary falling immediately after the date of benefit B is allowed. All these details are mentioned in para 11 (2) of the policy bond itself. In this case the surgery undergone by the complainant is one which is not covered under the policy. On 29.08.2013 vide Reference No.CO/CRM/CLAIMS/2013-14/31 the opposite party corporation had decided to include “Value Replacement” as an eligible disease for claiming Benefit B. But the surgery underwent by the complainant i.e; Mitral Valve Repair does not come under the extended category also. Hence the complainant is not eligible to get any of the benefits mentioned either in clause 11 of the policy or the extended provisions. hence this opposite party has repudiated the claim of the complainant. Hence there is no deficiency of service on the part of the opposite parties.
Complainant and opposite party filed chief affidavit. Complainant also filed an application as IA 28/2017 seeking permission to cross examine opposite party. Opposite party was cross examined as DW1. Exts.A1 to A6 was marked from the side of the complainant. Exts.B1 to B6 were marked from the side of the opposite party. Complainant filed another application as IA 230/2017 to receive the witness list along with witness list. IA was allowed and notice was issued to the witness for examination. Since the witness was absent, Forum directed to file application for the examination of the witness by an advocate commissioner. Accordingly complainant filed application to appoint an advocate commissioner to examine the witness. The witness was examined through advocate commissioner as PW1. Evidence was closed and the matter was heard.
The following issues that arise for consideration are.
- Whether there is any deficiency of service from the part of opposite parties?
- If so, what are the relief and cost?
Issues No.1 & 2
The case of the complainant is that he had undergone an open heart surgery at Kovai Medical Centre Hospital, Coimbatore but, the amount covered as per Ext.A1 was not paid to him by the opposite party, even after repeated demands which amounts to deficiency in service and unfair trade practice. According to PW1 the purpose of the surgery is to make the valve competent so that the blood doesn’t leak back in to the heart.
According to the opposite party as per the policy schedule Ext.B2 “if the policy is in force for full sum assured one of the two benefits, (A) or (B) defined herein below will be provided subject to the conditions mentioned herein. Either of the benefits is payable only one during the term of the policy. Benefit (A) – The sum assured with vested bonus, if any, is payable in the event of the life assured surviving the stipulated date of maturity or at his death, if earlier. Benefit (B) – If any one of the contingencies given in para 11 (b), subject however to the conditions mentioned in para 11 (a) of the conditions & privileges” within referred to occurs during the term of the policy, then the following benefits will be available. (i) Immediate payment of 50% of the sum assured. (ii) Payment of balance 50% of the sum assured alongwith vested bonus. If any, in the event of the life assured surviving the stipulated date of maturity or at his death, if earlier. (iii) Payment of an amount equal to 10% of the sum assured, every year, connecting from the policy anniversary falling on or immediately after the date of eligibility for benefit (B) and ending with the policy anniversary preceding the stipulated date or maturity or the date of death of the life assured, whichever is earlier. (iv) Waiver of premiums, if any, (including accident premium) due from the policy anniversary falling on or immediately after the date of eligibility for benefit (B). Further as per para 11 (b) of the conditions and privileges of policy document, Benefit B of the policy schedule shall be available only on the occurrence of (i) If the life assured undergoes Open Heart Bye Pass Surgery performed on significantly narrowed/occluded coronary arteries to restore adequate blood supply to heart and the surgery must have been proven to be necessary by means of coronary angiography. All other operations (eg angioplasty and Thrombolysis by coronary artery catheterization) are specifically excluded.
OR (ii) the life assured undergoes Renal Dialysis as defined.
OR (iii) the life assured suffers from cancer as defined.
OR (iv) the life assured suffers from paralytic stroke as defined.
It is clear from the above that payment of Benefit A is not applicable in this case. Benefit B is payable only if the life assured undergoes any surgery as defined under para 11 (b). Admittedly, the surgery undergone by the complainant is Mitral Valve Repair which is not listed under the eligible surgeries and hence the claim could not be considered. Even in the case of Benefit B for eligible cases, an immediate payment of only 50% of the sum assured is payable as lumpsum amount and payment of the balance 50% of the sum assured along with vested bonus is payable on date of maturity or date of death whichever is earlier. Also payment of an equal amount of 10% of the sum assured every year from the date of eligibility of Benefit B and waiver of premium from the policy anniversary falling immediately after the date of benefit B is allowed. All these details are mentioned in para 11 (2) of the policy bond itself. In this case the surgery undergone by the complainant is one which is not covered under the policy. On 29.08.2013 vide Reference No.CO/CRM/CLAIMS/2013-14/31 the opposite party corporation had decided to include “Value Replacement” as an eligible disease for claiming Benefit B. But the surgery underwent by the complainant i.e; Mitral Valve Repair does not come under the extended category also. Hence the complainant is not eligible to get any of the benefits mentioned either in clause 11 of the policy or the extended provisions. hence this opposite party has repudiated the claim of the complainant.
Dr.Prasanth Vijayanath, Director, Cardiothoracic Surgery, Kovai Medical Centre, Coimbatore, who has done the surgery, was examined through Advocate Commissioner appointed by this Forum on 15.01.2018 at Kovai Medical Centre. Doctor had deposed that the complainant had this problem of leakage of valve for the last 11 years and gradually had the position was deteriorating to the state where he required the operation. As a result of the operation leakage of blood was prevented. Doctor had also explained the reason that the complainant was diagnosed as a case of Mitral Valve prolapsed with severe regurgitation/leakage. Doctor in cross examination had dropped in clear and categorical terms that this is not an operation done on narrowed/occlude coronary artery. In this case angiography was also not done. Benefit B of the policy schedule is available only on the occurrence that the life assured undergoes Open Heart Bye Pass Surgery performed on significantly narrowed/occluded coronary arteries to restore adequate blood supply to heart and the surgery must have been proven to be necessary by means of coronary angiography. So the rejection of the claim was correct as per the terms and conditions of the policy. The only issue to be decided in this case is whether the surgery undergone by the complainant qualifies for the benefits under the policy or not. It is very clear from the policy conditions that the policy is intended to cover only Open Heart Bye Pass Surgery performed on significantly narrowed/occluded coronary arteries to restore adequate blood supply to heart and the surgery must have been proven to be necessary by means of coronary angiography. All other modes of surgery are specifically excluded from the purview of risk cover. The complainant’s contention that he has undergone Open Heart Bye Pass Surgeries do not qualify for the benefit. The surgery performed by the life assured is to repair the Mitral Valve prolapsed which is totally different from what is prescribed in the policy contract. Dr.Prasanth Vijayanath who conducted the surgery has categorically deposed in his cross-examination that this is not an operation done on narrowed/occlude coronary artery. This clearly establishes that surgery undergone by the complainant is not part of policy benefits. It is submitted that even in eligible claims, the lumpsum amount payable is only 50% of the sum assured. The sum assured in the complainant’s policy is only Rs.50,000/-. There is no provision to reimburse the total treatment expenses and the policy is not designed for that purpose. Hence the complainant’s prayer seeking Rs.2,10,000/- with 12% interest as claim amount and Rs.1,00,000/- as compensation is baseless. The allegation in para 1 of the complaint that the complainant had undergone an open heart surgery for Mitral Valve Repair at Kovai Medical Centre Hospital and he had spent Rs.2,10,000/- and at the time of subscription of the policy the opposite party promised the complainant that he is entitled to get an amount of Rs.1,50,000/- towards expenses for treatment and only on that promise complainant had joined the policy and also further promised that after surgery no single penny is required to be paid as premium for the said policy and only on that promise complainant had remitted the premium amount regularly and the claim petition was rejected, contending that the surgery is not coming under the policy etc. are baseless and raised only for the purpose of this complaint. The contention of the complainant that this opposite party had promised Rs.1,50,000/- for meeting the expenses in connection with the treatment is baseless and untrue as the sum assured itself is only Rs.50,000/-. All such allegations are specifically denied by this opposite party as untrue and baseless. Furthermore, the rulings of Apex Forums also substantiate the stand taken by the opposite party.
- In a very similar case, the Hon’ble NCDRC in their order dated.18.02.2016 in RP 167/2016 LIC of India vs Madan Gopal has held that “the complainant’s claim was rejected on the ground that the medical treatment undergone by him was not covered under the policy taken by him. The said procedure was among the exclusions for the purpose of reimbursement under the policy and hence was not payable to him”.
- In LIC of India vs Niwas Bansal (RP No.2333/2012). The Hon’ble NCDRC held that “on account of specific exclusion of Angioplasty, the complainant is not entitled to reimbursement of medical expenses and complainant has not committed any deficiency in repudiating claim, but District Forums has committed error in allowing complaint and learned State Commission has committed error in dismissing appeal”.
- The Hon’ble Supreme Court has held in Oriental Insurance Company Ltd. Vs Soney Cherian (AIR 1999 SC 3252) that “ The Insurance Policy between the insurer and the insured represents a contract between the parties. Since the insurer undertakes to compensate the loss suffered by the insured on account of risks covered by the insurance policy the terms of agreement have to be strictly construed to determine the extent of liability of the insurer. The insured cannot claim anything more than what is covered by the insurance policy”.
- The LIC of India vs Anu Mohanat (II (1997)CPJ 129 (NC), the Hon’ble NCDRC has held that “ Policy of insurance is a contract of insurance and the terms thereof have to be strictly cons trued by collecting the intention of the parties from the language employed. The courts and tribunals cannot make a new contract, however reasonable, if the parties to the contract have not made it themselves”.
- The Hon’ble National Commission has held in LIC of India vs Ramesh Chandra 1997 (2) CPR 8 (NC) that “ The Construction of policy bond which is the basis of the contract of insurance, is a question of law and its true interpretation would give jurisdiction to the FORA to pronounce upon deficiency in service, if any. The DF and SCDRC had no jurisdiction to go beyond the terms and conditions of the policy”.
In the light of the above discussions we are not in a position to go beyond the terms of contract of the policy. Hence the above complaint is dismissed without cost.
Pronounced in the open court on this the 16th day of May 2018.
Sd/-
Shiny.P.R
President
Sd/-
Suma.K.P
Member
Sd/-
V.P.Anantha Narayanan
Member
Appendix
Exhibits marked on the side of complainant
Ext.A1 - Copy of Policy – Asha Deep Policy II issued by opposite party
Ext.A2 - Photocopy of Discharge summary of the Hospital Kovai Medical
Centre and Hospital Limited, Coimbatore dated.05.08.2014
Ext.A3 - Photocopy of request sent by the complainant to the opposite party
Ext.A4 - Reply sent by opposite party to the complainant dated.03.12.2014
Ext.A5 series - Notice dated.18.06.16 issued by the complainant to the opposite
party along with postal receipt and acknowledgement card
Ext.A6 - Reply from LIC dated.30.06.2016
Exhibits marked on the side of Opposite parties
Ext.B1 - Proposal form of the Insurance on Own Life
Ext.B2 - True copy of policy No.772863362 with conditions and privileges
Ext.B3 - True copy of Claim Form AD (CABG) – 1, 2 & 3 submitted by the
complainant
Ext.B4 - True copy of Discharge summary from Kovai Medical Centre and Hospital
Limited dated.05.08.2014
Ext.B5 - True copy of reply letter dated,03.12.2014
Ext.B6 - True copy of reply to legal notice daed.29.06.2016
Witness examined on the side of complainant
PW1 - Dr.Prasanth Vaijyanth
Witness examined on the side of opposite party
Nil
Cost
Nil
