BEFORE THE DISTRICT CONSUMER’S FORUM: KURNOOL

Present: Sri.Y.Reddappa Reddy, M.A., L.L.M., President,

And

Smt. S.Nazeerunnisa, B.A., B.L., Lady Member

Friday the 8^th day of May, 2015

C.C.No.117/2013

Between:

Dr.Y.Muralidhar Reddy,

H/o Y.Manjula,

Aged 54, Years,

Flot No.301, Dheeraj Enclave,

Sapthagiri Nagar,

Kurnool District-518 002.                                           …Complainant

                                                        -Vs-

1. Life Insurance Corporation of India Limited,

    Represented by its Branch Manager,

    River View Colony,

    Kurnool-518 002.

2. The Senior Divisional Manager, (Health Insurance)

    Life Insurance Corporation of India Limited,

    Divisional Office, Post Box No.10,

    College Road, Kadapa-516 004.

3. Family Health Insurance Plan Limited,

    Represented by its Authorized Signatory,

    Srinilaya-Cyber Spazio, Suite 1-1, 1-2, 109,

    Ground Floor, Road No.2

    Banzara Hills,

    Hyderabad-500 034.                                …OPPOSITE PARTIES

This complaint is coming on this day for orders in the presence of Sri.P.Siva Sudarshan, Advocate for complainant and Sri.L.Hari Hara Natha Reddy, Advocate for opposite parties 1 and 2 and opposite party No.3 called absent and set exparte and upon perusing the material papers on record, the Forum made the following.                                          

   ORDER

(As per Smt. S.Nazeerunnisa, Lady Member)

  C.C. No.117/2013

1.      This complaint is filed under section 11 and 12 of Consumer Protection Act, 1986 praying:-

1. To direct the opposite parties to pay the policy amount a sum of Rs.2,00,000/- to the complainant with interest at 24% per annum from the date of operation i.e., 24.04.2013 to till the date of realization.

2. To direct the opposite parties to pay a sum of Rs.30,000/- towards mental agony.

3. To direct the opposite parties to pay a sum of Rs.10,000/- towards costs of the complaint.
4.  
4.  To grant any other relief as the Honourable Forum deems fit and proper in the circumstances of the case.

2.    The case of the complaint in brief runs as follows:- The complainant took the LIC Health plan policy bearing No.654882034 dated 17-06-2008 from opposite parties for the period from 08.03.2008 to 08.03.2024.  The complainant wife Y.Manjula and his two children also covered under the policy.  The complainant’s wife suffering with “Gastric and liver” problem she admitted in Global Hospital Hyderabad as inpatient for the period of 23.04.2013 to 30.04.2013 and LAPAROSCOPIC SUIS SLEEVE GASTGRICTOMY surgical operation was conducted to her in that hospital.  The complainant incurred Rs.2,90,646/- towards treatment charges.  The complianant submitted claim form to opposite party No.3 along with relevant documents for reimbursement of medical expenses.  The opposite parties repudiated the claim on 31.05.2013 on the ground that circumcision, cosmetic or aesthetic treatment of any description change of gender surgery, plastic surgery, dental surgery unless it is a part of treatment of illness or accidental injury within 6 months (MO7).  Opposite party No.2 also repudiated the claim on the above said grounds on 04.07.2013.  The laparoscopic sius sleeve gastrictomy is not a cosmetic surgery.  The complainant regularly paying the policy amount since five years as per the policy “Resection and Anastomosis of any part digestive tract”, the policy holder is entitled for 60% of the assured amount.  The opposite parties without any reasonable cause repudiated the claim of the complainant.  There is deficiency of service on the part of opposite parties and caused mental agony to the complainant.  Hence this complaint.

3.      Opposite party No.2 filed written version and the same is adopted by opposite party No.1.  Opposite party No.2 filed written version stating that the complaint is not maintainable either in law or on facts of the case.  It is admitted that opposite party No.1 issued policy bearing No.654882034 with annual premium of Rs.15,000/- its covers the risk of complainant along his wife and two children.  It provides for payment of hospital benefits (HCB) and major surgical benefits according to the terms and conditions of policy.  The complainant made a claim form for claiming HCB/MSB/OSB/DCB, along with hospital treatment.  After scrutiny of the claim and hospital record stated that the wife of complainant had history of excessive weight gained for last ten years and history of OSA is present for which she is receiving CPAP and she had under gone Hysterectomy six years back and LSCS done in 2002, which were not disclosed in the proposal form at the time of taking policy.  Hence the claim is rejected under exclusion and she is a patient diagnosis “Morbid Obesity” comes under exclusions 6 I VII and also non disclosure of material facts regarding pre-existing disease and treatment particulars.  The principal diagnosis “Morbid Obesity” and the surgery was done to reduce the weight of Smt.G.manjula it comes under the exclusions.  Hence she is not entitled for that amount as per the conditions and privileges under the policy.  There is no deficiency of service on the part of opposite party No.2.  The complaint is liable to be dismissed.

Opposite party No.3 called absent and set exparte. 

4.      On behalf of the complainant Ex.A1 to Ex.A11 are marked and sworn affidavit of the complainant is filed. On behalf of the opposite parties Ex.B1 to Ex.B10 are marked and sworn affidavit of opposite parties are filed.

5.      Both sides filed Written Argument.

6.      Now the points that arise for consideration are:

1. Whether there is deficiency of service on the part of opposite parties?

2. Whether the complainant is entitled for the reliefs as

Prayed for?

3. To what relief?

7.     POINTS i and ii:  Admittedly the complainant obtained LIC Health Plus Plan Policy bearing No.654882034 with its annual premium of Rs.15,000/- with its date of commencement 08.03.2008.  Ex.B1=Ex.A1 is the policy documents, Ex.B2 is the proposal form.  The said policy covers the risk of the complain ant along with his wife and two children.  The complainant wife G.Manjula was suffering from “Gastric and liver” problem.  She admitted in Global Hospital, Hyderabad as inpatient from 23.04.2013 to 30.04.2013 and on 24.04.2013 “LAPAROSCOPIC SIUS SLEEVE GASTRICTOMY” surgical operation was conducted to her in the said hospital.  Ex.A5 to Ex.A8 are photo copy of Global Hospital, cash bills receipts dated 22.04.2013 to 30.04.2013 and photo copy of endoscopy report is marked as Ex.A9 dated 22.04.2013 the photo copy of Hospital Treatment form and discharge summary of Global Hospital, Hyderabad are marked as Ex.B6 and Ex.B7. The complainant paid Rs.2,90,646/- to the Hospital towards medical expenses and he submitted claim form to the opposite parties.  Ex.B4 is the photo copy of the claim intimation form dated 24.04.2013.  The photo copy of claim form along with hospital treatment is marked as Ex.B6.  The photo Identity Card issued by the opposite parties is marked as Ex.A11.  The photo copy of the claim form under health insurance policy is marked as Ex.B5=Ex.A2 the claim of the complainant is repudiated by the opposite parties 2 and 3 under Ex.A3=Ex.B9 and Ex.A4=Ex.B10 on the ground that Ex.A3 circumcision, cosmetic or aesthetic treatment of any description change of gender surgery, plastic surgery, dental surgery.

It is the case of the complainant that “LAPAROSCOPIC SIUS SLEEVE GASTRICTOMY” Surgery is not a cosmetic surgery and policy holder is entitled for 60% of insured amount.  It is the case of the opposite party No.2 that the wife of complainant had a history of excessive weight gained for last ten years and OSA for which she is receiving CPAP and patient of HNT and she had undergone Hysterectomy operation and LSCS done in 2002 and she was diagnosis “Morbid Obesity” and the surgery was conducted to reduce the weight of his wife it comes under the exclusions, the said material fact was not disclose at the time of obtaining the policy. Hence the opposite parties acted as per the conditions of the policy.  The photo copy of policy conditions is marked as Ex.A10=Ex.B3.  The learned counsel appearing for the complainant contended that if “LAPAROSCOPIC SIUS SLEEVE GASTRICTOMY” operation was not conducted to the wife of complainant she will die due to respiratory and cardiac arrest.  The complainant is entitled to receive claim amount from the opposite parties.  The learned counsel appearing for the opposite parties 1 and 2 argued that the principal diagnosis was “Morbid Obesity” it comes under exclusion 6 I VII (Exclusions application to hospital cash benefit) of the policy conditions.  The doctor was examined by commissioner as per order in IA No.61/2014.  The concerned doctor (Lakshmi) working in “LAPAROSCOPIC Bariatic Sciance” since 1998 at Global Hospital, Hyderabad is examined on behalf of complainant.  She deposed that “LAPAROSCOPIC SIUS SLEEVE GASTRICTOMY” is not cosmetic surgery.  It is done to prevent further deterition patient health and some time death also.

          There is no dispute with regard to issuance of LIC Health Plus policy in favour of complainant and it covers the risk of complainant along with his wife and children.  Admittedly the complainant made a claim to opposite parties and the opposite parties repudiated the same.  As seen from Ex.A5 to Ex.A9 and Ex.B7 and Ex.B9 it is very clear that the wife of complainant was admitted in Global Hospital on 23.04.2013 and operation was conducted on 24.04.2013 and she was discharged on 30.04.2013 the complainant paid Rs.2,71,666/- to the Hospital under Ex.A7 and Ex.A8 apart from endoscopy report (Ex.A9).  As per the terms and conditions of policy, the policy holder is entitled for 60% of insured amount.  We consider all the material available on record, we hold the opinion that there is deficiency of service on the part of opposite parties for not settling the claim of complainant and caused mental agony.

8.      POINTS iii:  The complainant prayed that to direct to pay policy amount a sum of Rs.2,00,000/- with interest at 24% from the date of operation till the date of realization and further prayed to direct to pay Rs.30,000/- towards mental agony .  Basing on the material placed on record, facts and circumstance of the case we are in a view that the complainant is entitled for 60% of insured amount i.e., Rs.1,34,000/- with interest at 9% per annum from the date of complaint i.e., on 20.11.2013 till the date of payment and further entitled for compensation of Rs.5,000/-towards mental agony.    

9.      In the result, the complaint is partly allowed directing the opposite parties jointly and severally liable to pay an amount of Rs.1,34,000/- with interest 9% per annum from the date of complaint i.e., on 20.11.2013 till the date of realization and further direct to pay compensation of Rs.5,000/- towards mental agony and Rs.1,000/-as costs of the case.  Time for compliance is one month 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 8^th day of May, 2015.

        Sd/-                                                                          Sd/-

LADY MEMBER                                                            RESIDENT

APPENDIX OF EVIDENCE 

   Witnesses Examined

For the complainant: Nil                   For the opposite parties: Nil

List of exhibits marked for the complainant:-

Ex.A1         Photo copy of LIC’s Health Plus Plan Policy bearing                     No.654882034.

Ex.A2         Photo copy of Claim Application along with Hospital Treatment form 30.04.2013.

Ex.A3         Photo copy of Claim Rejection Letter dated 31.05.2013 by TPA.

Ex.A4         Claim Repudiation Letter of opposite party No.2 dated 04.07.2013.

Ex.A5         Photo copy of Out Patient Cash Bill Receipt of the Global Hospital, Hyderabad dated 22.04.2013.

Ex.A6         Photo copy of In-Patient Receipts of the Global Hospital, Hyderabad dated 23.04.2013.

Ex.A7         Photo copy of In-Patient Receipts of the Global Hospital, Hyderabad dated 30.04.2013.

Ex.A8         Photo copy of In-Patient Cash Bill Receipt of the Global Hospital, Hyderabad dated 30.04.2013.

Ex.A9         Photo copy of Endoscopy Report of Global Hospital, Hyderabad dated 22.04.2013.

Ex.A10       Photo copy of Conditions and privileges referred to in the policy documents.         

Ex.A11       Photo copy of Identity Card (LIC Health Plus Cards) issued by the opposite parties to the complainant and her wife.

List of exhibits marked for the opposite parties:-

Ex.B1         Office copy of LIC’s Health Plus Plan Policy bearing No.654882034.

Ex.B2         Proposal Form submitted at the time of taking the Health Insurance Policy

Ex.B3         Policy Conditions and Privileges Booklet.

Ex.B4         Claim Intimation Form, dated 24.04.2013.

Ex.B5         Form for claiming, DCB/MSB/OSB/Day Care benefits under the Health Insurance Policy.

Ex.B6         Hospital Treatment Form dated 30.04.2013, for Health Policies duly signed by the Hospital Authorities.

Ex.B7         Discharge Summary of Global Hospital, Hyderabad dated 30.04.2013.

Ex.B8         Investigation Report by TPA i.e., Family Health Plan Limited, Hyderabad.

Ex.B9         Claim Rejection Letter dated 31.05.2013 by TPA.

Ex.B10       Office copy of Claim Repudiation Letter dated 04.07.2013 by the Divisional Health Unit, Divisional Office, Kadapa.

        Sd/-                                                                          Sd/-

LADY MEMBER                                                            RESIDENT

    // 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                 :