BEFORE THE DISTRICT CONSUMER FORUM AT NALGONDA

       PRESENT:  SRI MAMIDI CHRISTOPHER,

                      PRESIDENT.

                      SMT.S.SANDHYA RANI,

                      FEMALE MEMBER.

. . .

MONDAY, THE THIRTIETH DAY OF DECEMBER, 2019

CONSUMER COMPLAINT No. 42  OF 2014

Between:

Kancharla Madhusudham Reddy S/o Ram Reddy, Aged: 45 years,

Occ: Asst.Professor (contract) in Mahathma Gandhi University, Nalgonda. R/o Plot No.2, Sri Sai Dwarakapuri, Hyderabad Road, Cherlapally, Nalgonda Town and District.

                                                                       …COMPLAINANT.

]

                                            AND

1.Life Insurance Corporation of India, Branch Office-I, Nalgonda Town and District. Represented by its Branch Manager.

2.Life Insurance Corporation of India, Divisional Office, Jeevan Sagar, Near Indira Park, Behind NTR Stadium, Hyderabad.

Represented by its Manager (Health Insurance).     

                                                              …OPPOSITE PARTIES.

        This complaint  coming on before us for final hearing, in the presence of Sri G.Venkat Ramana Reddy, Advocate for the Complainant, and Sri K.Anantha Reddy, Advocate for the Opposite Parties No.1 and No.2, and on perusing the material papers on record, and having stood over for consideration till this day,  the Forum passed the following:

ORDER OF THE FORUM DELIVERED

BY SRI MAMIDI CHRISTOPHER, PRESIDENT

1.     The  Complainant  filed  this   complaint   Under  Section 12 of Consumer Protection Act, 1986 to direct the Opposite Parties to pay a sum of Rs.1,05,000/- towards the Policy amount, Rs.25,000/- towards mental agony and deficiency of services and Rs.10,000/- towards legal expenses and interest @ 18% p.a. on the sum assured.

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2.     The facts leading to the filing of this complaint as follows:

        The Complainant obtained health insurance policy from the Opposite Parties, vide Policy No.605624750, valid from 19/11/2012 to 19/11/2047 and the said policy being renewed year to year since last two years and the sum assured is Rs.1,00,000/- for one year and Rs.1,05,000/- for second year onwards and the highest sum assured is Rs.12,00,000/-.  The Complainant has been paying the required premium amount of Rs.3,165/-.  On 09/01/2014 in the night hours, the Complainant suddenly suffered chest pain and was shifted to Sunshine Heart Institute, Hyderabad for treatment.  After conducting tests, the doctors diagnosed that the Complainant has been suffering from IHD ACUTE STEMI MILD LV DYSFUNCTION CAG-DOUBLE VESSET DISEASE.  The Complainant was admitted in the hospital, vide Admission No.SH14000211, dated 10/01/2014 under the medical supervision of Dr.P.Sridhar, Cardiologist.  The Complainant underwent surgery for his heart first RAC Vessel PTCA + Stent to RAC was done on the same day and he was discharged on 13/01/2014.  The Complainant was again admitted in the hospital on 05/02/2014, where he underwent surgery for second time to LAD Vessel successfully staged PTCA +Stent to LAD and he was discharged on 08/02/2014.  The Complainant spent an amount of Rs.4,80,000/- towards two surgeries and medical expenses in the hospital.  The Complainant is entitled for Rs.1,05,000/- from the Opposite Parties towards major surgical benefit under the above said policy.  The Complainant submitted claim form along with other required documents to the Opposite Parties to settle the claim, vide ID.No.11848.  The Complainant received a mail from the Opposite Parties on 25/06/2014

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repudiating the claim on the ground that the Complainant was known case of DM since 10 years and the same was not disclosed during the policy inception.  Hence, the claim was rejected under PED.  The Complainant submitted that he was healthy and in good condition and he was not having any disease as mentioned in the repudiation letter and there is no misrepresentation about the health condition or any suppression of fact.  The Opposite Parties are trying to evade the payment of medical bills duly spent by the Complainant, in fact the Opposite Parties are liable to pay the same according to the policy conditions.  Hence, the Complainant filed this complaint.

3.     The Opposite Parties No.1 and 2 filed written version, stating that the Complainant was a policy holder, vide Policy No.605624750 for assured sum of Rs.1,00,000/- and he underwent surgery for primary PTCA + stent to LAD was performed on 05/02/2014.  As per the plan conditions, under major surgical benefits annexure, Sl.No.12, for coronary angioplasty with stent implantation (two or more coronary arteries must be stented), 40% of major surgical benefit sum assured is payable.  In the instant case, only single stent to LAD done on 05/02/2014, as such as per the plan features of Jeevan Arogya, major surgical benefit is not payable.  As per the conditions and privileges No.7, which is exclusion clause of Jeevan Arogya, no benefits are available hereunder and no payment will be made by Corporation for any claim under thispolicy on account of hospitalization or surgery directly or indirectly caused by, based on, arising out of or how so ever attributable to any of the following, i.e. any pre-existing condition unless disclosed to and accepted by the Corporation prior to the date of cover commencement or the date of revival.  As per the progress

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records of the hospital, it is evident that Complainant was a DM case for past 10 years and the Discharge Summary reveals that the Complainant was hospitalization from 05/02/2014 to 08/02/2014, wherein surgery for PTCA + stent to LAD was performed on the Complainant on 05/02/2014.  The risk factor was given as type 2 DM.  as such, the claim was rejected according to the terms and conditions of the policy.  Therefore, the Complainant is not entitled to claim expenses of Rs.1,05,000/- which was incurred for implantation of single stent to LAD done on 05/02/2014 and no amount is payable under the policy.  The Opposite Parties prayed for the dismissal of the complaint. 

4.     The Complainant filed his proof affidavit and marked Exs.A-1 to A-5.  Sri V.Vijaya Saradhi, Manager (L&H.P.F.), LIC of India, Secunderabad Divisional Office filed his proof affidavit on behalf of Opposite Parties and marked Exs.B-1 to B-6.

5.      The points for consideration are:

1) Whether there was deficiency in service on the part of the

            Opposite Parties No.1 and 2?

        2) Whether the Complainant is entitled for the claims

            as prayed for?

        3) If so, to what extent?

6.     POINT No.1:

It is not in dispute that the Complainant obtained health insurance policy under LIC’s Jeevan Arogya (Table 903) from the Opposite Parties, vide Policy No.605624750, valid from 19/11/2012 to 19/11/2047 and the said policy being renewed year to year since last two years and the sum assured is Rs.1,00,000/- for one year and Rs.1,05,000/- for second year onwards and the highest sum assured is

Rs.12,00,000/-.  The Complainant has been paying the required

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premium amount of Rs.3,165/-.  According to the Complainant, on 09/01/2014 in the night hours, the Complainant suddenly suffered chest pain and was shifted to Sunshine Heart Institute, Hyderabad for treatment.  After conducting tests, the doctors diagnosed that the Complainant has been suffering from IHD ACUTE STEMI MILD LV DYSFUNCTION CAG-DOUBLE VESSET DISEASE.  The Complainant was admitted in the hospital, vide Admission No.SH14000211, dated 10/01/2014 under the medical supervision of Dr.P.Sridhar, Cardiologist.  The Complainant underwent surgery for his heart first RAC Vessel PTCA + Stent to RAC was done on the same day and he was discharged on 13/01/2014.  The Complainant was again admitted in the hospital on 05/02/2014, where he underwent surgery for second time to LAD Vessel successfully staged PTCA +Stent to LAD and he was discharged on 08/02/2014.  The Complainant spent an amount of Rs.4,80,000/- towards two surgeries and medical expenses in the hospital.  The Complainant is entitled for Rs.1,05,000/- from the Opposite Parties towards major surgical benefit under the above said policy.  The Complainant submitted claim form along with other required documents to the Opposite Parties to settle the claim, but  the Opposite Parties repudiating the claim on 25/06/2014  on the ground that the Complainant was known case of DM since 10 years and the same was not disclosed during the policy inception.  Hence, the claim was rejected under PED.  The Complainant was healthy and in good condition and he was not having any disease as mentioned in the repudiation letter and there is no misrepresentation about the health condition or any suppression of fact.  Hence, the Opposite Parties are liable to pay the medical bills duly spent by the Complainant for two surgeries, according to the policy conditions.

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