BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT BANGALORE URBAN

 10^th DAY OF FEBRUARY 2016

O R D E R

SRI. P.V SINGRI, PRESIDENT

The complainant has filed this complaint U/s.12 of the Consumer Protection Act, 1986 against the Opposite Party (herein after referred as OP) claiming a sum of Rs.62,398-30 together with interest @ 18% p.a, Rs.20,000/- towards deficiency in service and cost of litigation.

2. The brief averments made in the complaint are as under:

The complainant had obtained LIC’s Jeevan Arogya policy bearing No.698308222 on 06.01.2012 with yearly premium of Rs.6,424/-.  The beneficiaries under the said policy are the complainant as well as his wife Smt.M.Prameela.  The complainant was remitting premium every year and as on the date of filing of the complaint, he had made total remittance of Rs.19,403/-.  As per the advice of the doctors at M/s.Sagar Hospital, Bannerghatta Road, Bangalore, the complainant underwent “Laparoscopic Total Extraperitoneal Bilateral Inguinal Hernioplasty Surgery on 06.03.2014.  After the surgery, the complainant was discharged on 07.03.2014.  The complainant incurred expenses of Rs.67,898-30 for the said surgery.  The complainant thereafter submitted a claim to the OP together with required documents.  However, the OP did not made any communication with the complainant regarding his claim.  But the OP has remitted a sum of Rs.5,500/- to the SB account of complainant held in ING VYSYA Bank, Bommanahalli Branch, Bangalore on 24.03.2014.

In the month of April 2014, the complainant met the officials of OP at their Indiranagar office and made enquires, at which time he was informed that, he is entitlement is only Rs.5,500/- as per the terms and conditions of the policy and is not entitled to the entire amount spent by him towards the said surgery.  The complainant thereafter wrote a letter to the OP on 19.04.2014 demanding reimbursement of the entire amount spent by him for the said surgical process.  However, the OP did not comply the demands made in the said letter.  Therefore, the complainant was compelled to file this complaint.

For the aforesaid reasons, the complainant prays for an order directing the OP to pay him a sum of Rs.62,398/- together with interest @ 18% p.a and Rs.20,000/- towards mental agony, inconvenience suffered by him together with litigation cost.

3. The OP entered their appearance through their advocate and filed their version contending in brief as under:

As per the terms and conditions of the said LIC’s Jeevan Arogya Policy, the complainant is entitled to the benefit as provided in the said policy.  The claim of the complainant is against the terms and conditions of the policy.  The insurance claim can only be granted within purview of the terms and conditions of the concerned policy.  The OP has already paid Rs.5,500/- to the complainant as per the terms and conditions of the policy.  The complainant is not entitled to anything more than Rs.5,500/- in pursuance of the terms and conditions of the policy.  The complainant as per the discharge summary of the Sagar Hospital was diagnosed with “Bilateral Direct Inguinal Hernia” and has undergone surgery of “Laparoscopic Total Extraperitoneal Bilateral Inguinal Hernioplasty”.  Since, the said surgery is not covered, neither under the listed ‘Major Surgery’ nor ‘Day Care Procedure Benefit’, the claim of the complainant has been considered under the “Other Surgical Benefit” as per the terms and conditions of the policy.  Accordingly, the complainant was paid a sum of Rs.5,500/-.  The said amount was directly paid to the complainants’ Bank account with information to the complainant.  During his visit to the office of the OP, the complainant has been explained as to his entitlement in terms and conditions of the policy.  Other than Rs.5,500/- already paid to the complainant, he is not entitled to any other amount.  Therefore, the claim of the complainant cannot be entertained at all.  The OP is not liable to pay any compensation etc., to the complainant since there is no deficiency in service on the part of OP.

For the aforesaid reasons, the OP prays for dismissal of the complaint.

4. After the version was filed by the OP, the complainant was called upon to file his affidavit evidence.  Accordingly, he filed his affidavit evidence in lieu of oral evidence.  Thereafter, the OP filed affidavit evidence of one Mr.M.Suresh Babu, Manager, Legal & HPF department in support of the averments made in the version.  Both the parties have submitted certain documents in support of their respective case and also written arguments.

5. The points that arise for our determination in this case are as under:

        6. Perused the allegations made in the complaint, the averments made in the version, the sworn testimony of both the parties, various documents filed by both sides and written arguments submitted by the complainant as well as OP.

7. Our answer to the above points are as under:

REASONS

8. OP admits that the complainant obtained a Insurance policy with a sum assured of Rs.1,00,000/- and also payment of premium as claimed by the complainant.  It is also not in dispute that the complainant underwent a surgical procedure at Sagar Hospital on 06.03.2014 and during the process he was hospitalized from 05.03.2014 to 07.03.2014.  It is also not in dispute that the complainant incurred expenses in a sum of Rs.67,898/- towards the said surgical operation which is also evident from the bill dated 07.03.2014 produced by the complainant.  The complainant claims that in terms of the insurance policy, he is entitled for reimbursement of the entire money he has spent for the said surgical procedure and the OP is not justified in paying him Rs.5,500/- only.

9. The OP justified their action in paying Rs.5,500/- against the claim of Rs.67,898-30 on the ground that the surgical procedure underwent by the complainant is not covered either under the list “Major Surgery” or under the list “Day care Procedure Benefit”.  Therefore, it is contended by the OP that, the claim of the complainant has been considered under the “other surgical benefit” as per the terms and conditions of the policy.  The OP considering the claim of the complainant under ‘other surgical benefit’ has calculated hospitalization cash benefit for one day at Rs.1,100/- and Rs.4,400/- towards other surgical benefit for two days @ of Rs.2,200/-, thus the OP has restricted the claim to Rs.5,500/-. 

10. Now, it has to be seen whether the OP is justified in restricting the claim of the complainant to Rs.5,500/- on the ground that the surgical procedure underwent by the complainant is neither listed under ‘major surgery’ nor ‘day care procedure benefit’.  To substantiate their contention the OP produced copy of LIC’s Jeevan Arogya Condition and Privileges.  The terms and conditions which govern the LIC Jeevan Arogya Policy are mentioned in the said document.  It has been mentioned in the said document/annexure as to what particular surgery is falls under the head ‘Medical Surgical Benefit’ and other surgical benefit.  The said terms and conditions also provides as to under what circumstances and day care procedure benefit can be extended to the life assured.  The benefit limits and condition have also been provided in the said annexure.  The list of major surgery has been provided in the said annexure.  It is contended by the OP that, the operation/surgical procedure underwent by the complainant does not fall in the list of ‘major surgery’ provided in the above mentioned annexure/document.  Admittedly, the complainant was admitted in the Sagar Hospital with complaints of swelling in the both the groin and was diagnosed as suffering with ‘Bilateral Direct Inguinal Hernia’.  The complainant has underwent ‘Laparoscopic Bilateral Inguinal hernia mesh repair’ on 06.03.2014.  The complainant has produced a certificate issued by Dr.Munireddy M, Consultant (General Surgeon) of Sagar Hospital who conducted the said operation.

11. The learned advocate for the complainant pointed out that the surgical procedure underwent by the complainant falls under the category/list of ‘major surgeries’ as mentioned in the annexure produced by the OP.  The list of major surgeries entitled for major surgical benefit have been provided in the said annexure.  In the said list at serial No.36 ‘Diaphragmatic/Hiatus Hernia Repair’ has been included.  Thus a surgery conducted for Hernia Repair is treated as major surgery as per the said annexure.  The Hernia can occur on any part of the body including groin.  When the Diaphragmatic/Hiatus Hernia Repair is treated as major surgery for providing major surgical benefit, the ‘Laparoscopic Bilateral Inguinal hernia mesh repair’ conducted on the complainant has also to be treated as “major surgery”.  Therefore, we are of the opinion that the OP is not justified in denying the reimbursement of the expenses incurred by the complainant for the above mentioned surgical procedure.  The Learned Advocate for the OP did not substantiate as to how the hernia mesh repair conducted on the complainant is different from the ‘hernia repair of Diaphragmatic/Hiatus’ mentioned in the list of major surgeries in the annexure.  Therefore, we are of the opinion that the OP has to be directed to provide reimbursement of the expenses incurred by the complainant treating the surgical procedure underwent by the complainant as one falling in the list of ‘Major Surgeries’.  As could be seen from the said annexure the life assured is entitled to 60% of sum assured for hernia repair.  Therefore, the OP is liable to pay 60% the total expenses incurred by the complainant towards surgical procedure underwent by him.  The conduct of OP in restricting the claim to Rs.5,500/- amounts to deficiency in service.  The said conduct of OP in not entertaining the claim of the complainant in terms and conditions of the policy must have put the complainant to great hardship, inconvenience and mental agony for which OP has to be directed to pay compensation of Rs.10,000/-.

12. Since the OP has already paid a sum of Rs.5,500/-, they shall pay the remaining amount together with interest @ 9% p.a from the date they paid Rs.5,500/- to the complainant till the date of realization with litigation cost of Rs.5,000/-.

13. The order could not be passed within the stipulated time due to heavy pendency.

14.  In the result, we proceed to pass the following:

O R D E R

The complaint filed by the complainant U/s.12 of the Consumer Protection Act, 1986 is allowed in part.  OP is directed to reimburse 60% of expenses incurred by the complainant deducting Rs.5,500/- already paid together with interest @ 9% p.a from 24.03.2014 till the date of realization together with compensation of Rs.10,000/- and litigation cost of Rs.5,000/-.

OP shall comply the said order within six weeks from the date of communication of this order.

Furnish free copy of this order to both the parties.

(Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Forum on this 10^th day of February 2016)

MEMBER                           MEMBER                     PRESIDENT

Vln* 

Witnesses examined on behalf of the complainant dated 21.11.2014.

1. Sri.Munireddy M.

Documents produced by the complainant:

Witnesses examined on behalf of the Opposite party dated 21.11.2014.

1. Sri.M.Suresh Babu

Documents produced by the Opposite Party:

MEMBER                            MEMBER                    PRESIDENT

Vln*