DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BATHINDA CC.No.207 of 07-05-2010 Decided on 26-10-2010
Raj Kumar son of Sh. Babu Ram, resident of C/o Babu Ram & Sons, Commission Agents, Shop No.29B, Anaj Mandi, Rampura Phul, Tehsil Phul, Distt. Bathinda. .......Complainant Versus
Life Insurance Corporation of India, Divisional Office, Phase-I, Dugri, Ludhiana through its Divisional Manager. Life Insurance Corporation of India, Branch Office Near P.W.D. Office, Rampura Phul, Distt. Bathinda, through its Branch Manager.
......Opposite parties
Complaint under Section 12 of the Consumer Protection Act, 1986.
QUORUM
Smt. Vikramjit Kaur Soni, President. Dr. Phulinder Preet, Member. Sh. Amarjeet Paul, Member.
Present:- For the Complainant: Sh.Lalit Garg, counsel for the complainant. For Opposite parties: Sh.Sanjay Goyal, counsel for opposite parties.
ORDER
VIKRAMJIT KAUR SONI, PRESIDENT:-
1. In brief, the present complaint has been filed by the complainant under Section 12 of the Consumer Protection Act, 1986 (Here-in-after referred to as 'Act'). The complainant has filed the present complaint with allegations against the opposite parties that he purchased the Medical Insurance Policy for reimbursement of the medical claim in case of any illness vide policy No.300250930 dated 28.05.2003 under Table & Term of 121-20 for a sum assured of Rs.2 lacs from the opposite party No.2 and the annual premium of the said policy was payable of Rs.11,760/-. The complainant had heart problem and admitted in Fortis Hospital, Department of Cardiovasular and Thoracic Surgery on 01.07.2009 and undergone Surgery on 02.07.2009 and he remained admitted in the hospital till 10.07.2009 and spent approximately Rs.3.5 lacs on his treatment. The complainant has placed complete medical treatment referred on the file. The complainant applied for reimbursement of the said amount to the tune of Rs.2 lacs and furnished all the requisite formalities with opposite party No.2 including treatment record but the opposite parties repudiated the claim of the complainant vide letter dated 19.11.2009 on the ground that the disease for which the complainant took treatment, is not covered under the policy. The complainant alleged that the opposite parties never explained that the disease was not covered under the policy. Hence, the complainant has filed this complaint for medical claim of Rs.2 lacs, Rs.50,000/- as compensation and Rs.5,500/- as cost of litigation expenses. 2. The opposite parties have filed their joint written statement. The opposite parties have admitted that the complainant had purchased Medical Insurance Policy under Table 121 for the term of 20 years, subject to its terms and conditions. The disease of the complainant was not covered under the policy as per terms and conditions of the policy. As per discharge summary submitted by the complainant, he was admitted in Fortis Hospital on 01.07.2009 and had undergone surgery on 02.07.2009 for Aortic Valve Replacement and Mitral Valve Replacement and was discharged from the hospital on 10.07.2009. The disease suffered by the complainant was not covered as per terms and conditions. Hence, they have rightly repudiated the claim of the complainant. The opposite parties further pleaded that the complainant had purchased the policy after fully understanding and satisfying with the terms and conditions of the policy. 3. Parties have led their evidence in support of their respective pleadings. 4. Arguments heard. Record alongwith written submissions submitted by the parties perused. 5. Admittedly, the complainant purchased Mediclaim Insurance Policy No. 300250930 dated 28.05.2003 under Table & Term of 121-20 for a sum assured of Rs.2 lacs from the opposite party No.2, Ex.C-2 and the annual premium of the said policy was of Rs.11,760/-. The complainant fell ill and admitted in Fortis Hospital on 01.07.2009 and had undergone surgery on 02.07.2009 and remained admitted in the hospital till 10.07.2009 and expenses incurred on his treatment were to the tune of Rs.3.5 lacs. The complainant had applied for reimbursement of his claim of Rs.2 lacs but the claim of the complainant was repudiated by the opposite parties vide letter dated 19.11.2009 Ex.C-3 which is reproduced as under:- “With reference to the above policy number regarding the mediclaim under table 121. In this connection, we are sorry to inform you that the competent authority has rejected the claim amount, as the disease under which you have taken the treatment is not covered under the policy.” According to Ex.R-2, (2) (ii) type of complaints: Chest Pain & Dyspnoea (iii) Investigations undergone: Echo Cardiography (iv) Treatment Taken: Double Valve Replacement. It is particularly mentioned on Ex.R-3 Claim Form No.AD(CABG)-2 under column 4, wherethe query has been written that “When did the life assured have the first Date : symptoms/signs suggestive of Symptoms/Signs heart disease? Dyspnoea & Chest Pain For about 25 days. 5) Date of operation for Double Valve 2nd July, 2009 Replacement 6) Please state location(s) Location: Midline in the Chest Aortic only size & condition of Scar(s) Size: Condition: Healed. In Claim Form No.AD(CABG)-3 Ex.R-4 in column No.4(b), it has been written No. of grafts Double Valve Replacement Mitral Valve # 25mm ATS Aortic Valve # 20mm ATS A perusal of Ex.R-6 shows that the patient was Diagnosed as under: “Rheumatic Heart Disease Severe Aortic Stenosis Moderate Aortic Regurgitation Moderate Mitral Stenosis Severe Mitral Regugritation Operation: Aortic Valve Replacement With 25mm ATS Valve Sr.No.406469 Mitral Valve Replacement With 20mm ATS Valve Sr.No.395869 Resume of History: H/O Presenting complaints: Patient came with C/O Chest Pain and Dyspnoea since last 25 days. General examination No cyanosis, jaundice, clubbing. PR was 102/min; BP 130/90 mm/hg Chest clear; B/L.AEBE. Cardiovascular examination S1 & S2 normal CNS: normal, GCS 15, pulil B/L normal and reacting to light, plantars Normal Rest of the systemic examination was unremarkable.” In the clause 11(b)(i) of Life Insurance Policy under title of Conditions and Privileges, it has been mentioned vide Ex.C-2 as under:- “11(b) Benefit (B) of the Policy Schedule is applicable on the occurrence of any of the following contingencies:- (i) The Life Assured under goes open Heart By-Pass surgery performed on significantly narrowed/occluded coronary arteries to restore adequate blood supply to heart and the surgery must have been proved to be necessary be means of coronary angiography. All other operations (e.g. Angioplasty and Thrombulysis by Coronary Artery Catheterization) are specially excluded.” The record placed on the file shows that the complainant has undergone open Heart surgery as he has undergone operation for Aortic Valve Replacement With 25mm ATS Valve Sr.No.406469 and Mitral Valve Replacement With 20mm ATS Valve Sr.No.395869. Hence, the disease of the complainant is covered under the policy purchased by him. 6. In view of what has been discussed above, this Forum is of the considered view that there is deficiency in service and the disease of the complainant is covered under the policy and he has incurred Rs.3.5 lacs on his treatment but he has taken policy for Rs.2 lacs and insured for the sum of Rs.2 lacs only. In such circumstances, he is liable to get Rs.2 lacs for his treatment. Therefore, this complaint is accepted with Rs.10,000/- as cost and compensation and Rs.2 lacs for his treatment. Compliance of this order be made within 45 days from the date of receipt of copy of this order. If the opposite parties fail to comply this order within stipulated period, the interest @ 9% P.A. will yield till realization. 7. A copy of this order be sent to the parties concerned free of cost and file be consigned for record. '
Pronounced in open Forum (Vikramjit Kaur Soni) 26.10.2010 President
(Dr. Phulinder Preet) Member
(Amarjeet Paul) Member
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