BEFORE THE DISTRICT FORUM: KURNOOL
Present: Sri. T.Sundara Ramaiah , B.Com B.L., President
And
Sri. M.Krishna Reddy , M.Sc., M.Phil., Male Member
Monday the 14th day of February, 2011
C.C.No 131/10
Between:
Sagam Sheshadri Reddy, S.C.Rami Reddy,
D.No.1-34a, Peruru (V), Yerraguntla (Post).
…..Complainant
-Vs-
1. LIC of India,Rep. by its Divisional Manager,
Divisional Office, P.B.No.10,
College Road, Kadapa.
- LIC of India,
Rep. by its Branch Manager, Jammalamadugu - 518 510.
3. LIC of India,Rep. by its Branch Manager,
6th River View Colony, Kurnool - 518 001.
…OPPOSITE PARTies
This complaint is coming on this day for orders in the presence of Sri. M.Sivaji Rao, Advocate for complainant, and Sri. L. Hariharanath Reddy, Advocate for opposite party No.1,2 and 3 upon perusing the material papers on record, the Forum made the following.
ORDER
(As per Sri. M.Krishna Reddy, Male Member)
C.C. No. 131/10
1. This complaint is filed by the complainant under section 11 and 12 of C. P. Act, 1986, (the complainant filed this complaint) seeking a direction on opposite parties to pay
(a) The sum assured and other benefits as mentioned in the policy.
(b) To pay Rs25,000/- as compensation for causing mental agony.
(c) The cost of the complaint.
2. Briefly the case of the complainant, that he is an illiterate agriculturist. He took Asha Deep – 2 policy from opposite party No.2 for the sum assured Rs.1,00,000/- on 28-08-2004 paying 1st premium of Rs.5,291/-. The policy No is 653387467 under the table and term of 121 – 20. The mode of premium payment is yearly. The policy covers medical benefit for certain health contingencies. In the month of December 2009, the complainant got heart pain. Immediately he consulted Dr. S.Venugopal Reddy at Alamur PHC in Kurnool District vide O.P.No.12115. The doctor referred the complainant to CARE Hospital, Hyderabad for better treatment. On 26-12-2008 the complainant took treatment under the case of Dr.K.Sarada of CARE Hospital, Hyderabad. Dr.K.Sarada referred the complainant to a cardio - thoracic surgeon diagnising Rheumatic heart decease and advising him to go for Mitral Valve repair. The complainant underwent operation on 11-02-2009 and was discharged on 18-02-2009. As the surgery is covered under the policy benefits, the complainant submitted his claim to Ops claiming the assured amount of 1,00,000/-. But to the surprise of the complainant, he received a letter on 18-11-2009 from OP.No.2 intimating that OP.No.1 repudiated the claim for the reason that Mitral Valve repair does not fall with in the conditions of Asha Deep – 2 policy. Hence this case is failed before the Honorable Forum seeking an order for appropriate reliefs from Ops.
3. Sworn Affidavit and documents marked as Ex.A1 to A4 are filed by the complainant is support of his claim.
4. After the receipt of the notice of the forum opposite party No.1 filed written version and denied his liability. The opposite party No.1 avered that complainant taking Asha Deep LIC policy for RA.1,00,000/-, covering the benefit for any health contingences, suffered from heart pain in the month of December 2009, consulted Dr.S.V.G.Reddy at Alamur PHC vide OP.No.12115, referred to CARE Hospital, Hyderabad, consulted Dr.K.Sarada at CARE Hospital on 07-02-2009 who advised to undergo surgery for value repair, got operated at CARE on 11-02-2009 for the Mitral Valve repair are all strickly need documentary proofs. However the OP.No.1 admitted that the complainant took the policy No.653387467 on 28-08-2004 from OP.No.2 for the sum assured Rs.1,00,000/- under the plan and term 121 - 20 opting the payment of premium yearly. The OP.No.1 submitted that as per the terms of the policy if it is in force till the date of maturity one of two benefits (A) or (B) defined in the benefits payable under the policy will be provided subject to the conditions mentioned in 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) and 11 (c) of the “conditions and privileges” within referred to occur during the term of the policy, then the following benefits will be available.
- Immediate payment of 50% of the sum assured,
- 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 this death, if earlier,
- Payment of any amount equal to 10% of the sum assured, every year, commencing from the policy anniversary falling on or immediately after date of eligibility for benefit (B) and ending with the policy anniversary preceding the stipulated date of maturity or the date of death of life assured, which were is earlier.
In the present case the complainant applied for the benefits of the Asha Deep policy. The medical certificates produced by the complainant issued by CARE Hospital, Hyderabad confirm that the complainant under went Mitral Valve repair with 29mm Duran Annuloplasty Ring on 11-02-2009. But as per the policy condition under the benefit (B), the policy holder gets the benefit only the policy holder if under goes open heart By - pass surgery and all other operations are specifically excluded. In this case the complainant under went Mitral Valve repair but not open heart By - pass surgery. Hence he is not entitled for the benefit under Asha Deep policy. The Divisional medical referee also gave his opinion that Mitral Valve repair does not come under Asha Deep benefit (B) Para 11 (b). Further the complainant took the policy from OP -2 branch situated at Jammalamadugu of Kadapa District and the entire treatment was taken at CARE Hospital, Hyderabad. Hence this Forum has no jurisdiction to entertain the complaint, and as such there is no deficiency of service on the part of the OP. Therefore it is prayed for the dismissal of the complaint.
5. OP 2 and OP 3 adopted the written version of OP -1.
6. Documents marked as Ex.B1 to B5 and sworn affidavit are filed by OP.No.1 to substantiate his case.
7. The complainant and OP filed their written arguments.
8. Hence the parties for consideration are:
(i) Where the complainant made out any deficiency on the part of opposite parties substantiating its liability to his claim.
(ii) What is the amount of compensation that can be awarded to him?
9. Point No.1:- Ex.A1/B1 is the photo copy of the Asha Deep policy issued to the complainant. The policy is in force and as per the condition of the policy under benefit (B). The complainant is entitled for the benefit if he under goes By-Pass surgery on the advice of a Cardiologist. The benefit of the policy is not extended if non surgical techniques such as the use of either a be-loon or leser via a catheter introduced through the arterial system. Ex.B2 and B3 are the attested copy of terms and conditions of the policy. EX.A3 is the photo copy of O.P bearing No.12115 issued to the complainant by the in-charge doctor of PHC Alamur. It shows that the complainant was diagnosed with Rheumatic heart disease and referred to CARE Hospital to under go Mitral Valve repair. Ex.A2/B5 in the photo copy of discharge summary card issued by CARE Hospital, Hyderabad. As per EX.A2/B5 the complainant under went the operation procedure of Mitral Valve repair with 29 mm Duran Annuloplasty Ring under the care of Dr.N.V.N.Varma, M.S.Mch, consultant cardiothoracic surgeon. Now the question is whether this operation is excluded from the benefit (B) of the policy condition. Ex.B4 is the latter address to Dr.P.Bali Reddy, D.M.R for LIC seeking clarification on the applicability of the Asha Deep policy to the complainant operation on which the doctor endorsed as “Mitral Valve repair does not come under Asha Deep benefit”. In this context the counsel for the complainant relied on II (2009) CPJ 226 (NC), 2005 NCJ 280 (NC), 2010 CJ, 520 (Delhi) in which the Hon’ble Apex Court mentioned that the Values are the integral and internal parts of the heart. Values cannot be replaced without opening the heart. It is also stated that it is a settled law that where ever there is an ambiguity interms of the insurance policy, the benefit of interpretation should go to the insured and not to the insurer. In the present case through the surgery did not involve By-Passing of Coronary arteries, yet it was an open heart surgery, but it would not make difference in view of the main purpose rule of interpretation. In view of what is stated above the Forum holds that the contention of the opposite parties in rejecting the claim is not accepted and the benefit (B) under the policy is to be given to the complainant.
10. Point No.2:- The complainant claimed the assured amount and other benefits as mentioned in the policy. Looking in to the facts and circumstances of the case, the Benefit (B) under the policy conditions as given below is allowed.
Benefit (B) :- If any one of the contingencies given in Para–11 (b), subject however to the conditions mentioned in Para – 11 (a) and 11 (c) of the “conditions and privileges” within referred to occurs during the term of the policy, then the following benefits will be available.
- Immediate payment of 50% of the sum assured,
- 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 this death, if earlier,
- Payment of any amount equal to 10% of the sum assured, every year, commencing from the policy anniversary falling on or immediately after date of eligibility for benefit (B) and ending with the policy anniversary preceding the stipulated date of maturity or the date of death of life assured, which were is earlier.
11. In the result, the complaint is allowed directing the opposite parties to pay (1) the benefit (B) under the policy conditions, Rs.5,000/- for mental agony and Rs.1,000/- towards the cost of the case, payable within 6 weeks from the date of receipt of this order.
Dictated to the stenographer, transcribed by her, corrected and pronounced by us in the open bench on this the 14th day of February, 2011.
Sd/- Sd/-MALEMEMBER PRESIDENT
APPENDIX OF EVIDENCE
Witnesses Examined
For the complainant : Nil For the opposite parties : Nill
List of exhibits marked for the complainant:-
Ex.A1 Photo copy of policy NO.653387467 dt. 28-08-2004.
Ex.A2. Photo copy of Discharge summary card issued by Care Hospital, Hyderabad.
Ex.A3 Photo copy of Referral cared issued by Primary Health Center, Alamur bearing NO.2315.
Ex.A4 Refusal letter addressed to complainant by OP NO.2
dt.18-11-2009.
List of exhibits marked for the opposite parties:-
Ex.B1 Photo copy of policy NO.653387467 dt.28-08-2004.
Ex.B2 Photo copy of Addendum to proposal under Ashadeep plan (table 121) duly signed by the complainant.
Ex.B3 Photo copy of terms and conditions of the Ashadeep policy.
Ex.B4 Photo copy of Discharge summary card issued by Care Hospital, Hyderabad.
Ex.B5 Photo copy of Divisional Medical referries letter.
Sd/- Sd/-
MALE MEMBER PRESIDENT
// Certified free copy communicated under Rule 4 (10) of the
A.P.S.C.D.R.C. Rules, 1987//
Copy to:-
Complainant and Opposite parties :
Copy was made ready on :
Copy was dispatched on :
