Haryana

Ambala

CC/153/2014

ARUN GUPTA S/O R.K.GUPTA - Complainant(s)

Versus

LIFE INSURNACE CORPORATION OF INDIA - Opp.Party(s)

ASHUTOSH AGGARWAL

20 Jun 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMBALA.

 

Complaint Case No.    : 153 of 2014

Date of Institution       : 11.06.2014

Date of Decision         : 20.06.2017

 

Arun Gupta son of Late Sh. R.K. Gupta, R/o H. No. 5418, Punjabi Mohalla, Ambala Cantt.                                                                                              

……Complainant.

 

Versus

 

1. The Life Insurance Corporation of India Branch Office at Jeevan Jyoti Building, Jawahar Lal Nehru Marg, Ambala Cantt through its Manager.
2. Life Insurance Corporation of India, Divisional office at P.O. Box No. 106, Jeevan Parkash 489, Model Town, Karnal through its Manager.
3. Insurance Regulatory and Development Authority, Delhi Office – Gate No. 3 Jeevan Tara Building, First Floor, Sansad Marg, New Delhi 110001 through its Chairman.

 

                                                                                                ……Opposite Parties.

 

Complaint Under Section 12 of the Consumer Protection Act

 

 

BEFORE:       SH. D.N. ARORA,  PRESIDENT.

                        SH. PUSHPENDER KUMAR, MEMBER.

                        MS. ANAMIKA GUPTA, MEMBER.

                       

Present:          Sh. Ashutosh Aggarwal, Counsel for complainant.

                        Sh. R.K. Jindal, counsel for the OPs.

                         

ORDER.

 

                        In nutshell, brief facts of the complaint are that the representatives of the OP No. 1 and 2 approached the complainant for ‘Asha Deep Policy’ being very useful and provides risk cover in case of death as well as medical problems viz., Cancer, Paralytic stroke, Failure of both kidneys and Heart disease. It is further assured that in case of above mentioned medical problems, on production of satisfactory medical certificate, the complainant is paid as following –

1. 50% of the sum assured is immediately paid.
2. Balance of 50% of sum assured is paid on maturity or the death of the policy holder. Even if 50% of sum is paid, the bonus is paid for full amount of policy.
3. An annual payment of 10% of sum assured shall be paid which start from the date of getting disease or from the next policy commencement date. Such 10% shall be continued upto the death or the maturity date of policy (whichever is earlier)
4. From the date of qualifying the payments, the future payments of premium are waived from next policy birth date.

                        On persuasion, the complainant signed proposal form given by respondent No. 1 and 2 for obtaining the said policy with the said proposal benefits. After couple of days, the complainant was issued policy named as ‘Asha Deep Policy’ bearing No. 174220778, date of commencement 19-07-2004. Since then complainant has been paying regular yearly premium @ Rs. 13,290/- till today in time. During the endurance of the policy, the complainant suffered chest pain on 20-02-2013 and when the complainant approached Shri Balaji Action Medical Institute, New Delhi for check up, he was referred for Percutaneous Transluminal Coronary Angioplasty. When the complainant consulted the OP No. 1 and 2 telephonically and detailed about his illness and the medical procedure to be opted, the complainant was told to undergo for the best medical facility available first, save life and then to file claim for benefits available with the policy in question with the OP No. 1 and 2. The surgery- Percutaneous Transluminal Coronary Angioplasty was successfully done on 20-02-2013 and claim form duly attested by the operating doctor was submitted to OP No. 1.But the OP No. 1 has repudiated the claim of the complainant vide letter dated     10-07-2013. The complainant has also received letter dated 19-07-2013 from the OP No. 2 wherein the complainant was detailed that ‘treatment taken is not covered under terms and conditions as per clause 11 (a)(i). The Ops knowingly and illegally paste unreasonable and unwarranted clauses while making insurance policies and such clauses are not detailed/briefed to the consumers in time. As such, there is deficiency in service, unfair trade practice and monopolistic restrictive trade practice and thus prayed that the OPs may kindly be directed to pay 50% of the sum assured, bonus for full amount policy, annual payment of 10% of sum assured which starts from the date of getting disease or from the next policy commencement date and further to pay 10% up to the death or the maturity date of policy, whichever is earlier, to waive the future payments of premium from next policy birth date from the date of qualifying the payments, to pay Rs. 20,000/- as deficiency in service, Rs. 20,000/- on account of unfair trade practice, Rs. 20,000/- for monopolistic restrictive trade practice, Rs. 20,000/- as compensation for mental agony, Rs. 20,000/- as compensation for loss of reputation and Rs. 21,000/- as litigation expenses, to the complainant.

2.                     Upon notice, OPs appeared through counsel and filed reply raising preliminary objections qua non-maintainability of complaint. On merits, it is submitted that as per the condition 11 (b) (1) mention in the policy bond of insurance that the Percutaneous Transluminal Coronary Angioplasty done on 20-02-2013 upon the complainant, is not covered. As per the condition 11 (b) (1) of policy, only hear by-pass surgery is covered under benefit of the policy and all other operation e.g. angioplasty and thrombulysis are specifically excluded. Rest of the averments made by the complainants are wrong and denied.  Hence, the OPs prayed that the present complain may kindly be dismissed with costs.

3.                     To prove his version, counsel for the complainant tendered affidavit Annexure CX alongwith documents as Annexure C-1 to C-10 and closed the evidence. On the other hand, counsel for OPs tendered affidavit annexure RX alongwith documents as annexure R-1 and R-5 and closed the evidence on behalf of the OPs.

4.                     We have heard learned counsel for complainant and gone through the case file very carefully. It is not disputed that the complainant obtained policy bearing No.174220778 as per annexure C1 and he paid regular premium towards the policy in question. It is also not disputed that the complainant had under gone the surgery- Percutaneous Transluminal Coronary Angioplasty on 20-02-2013 and claim form duly attested by the operating doctor was submitted to OP No. 1 but the OP No. 1 has repudiated the claim of the complainant vide letter dated 10-07-2013 and another letter dated 19-07-2013 sent by the OP No. 2 to the complainant wherein it is stated that ‘treatment taken is not covered under terms and conditions as per clause 11 (a&b)(i) of the policy. Counsel for the complainant has argued that the OPs knowingly and illegally paste unreasonable and unwarranted clauses while making insurance policies and such clauses are not detailed/briefed to the consumers in time. Counsel for the complainant has also placed on record the document annexure C8 i.e. literature definition of surgery as well as difference between angioplasty and by-pass surgery. It is mentioned in the literature in column of (Deciding between angioplasty and by-pass surgery) that the choice of angioplasty or by-pass surgery is based on physician and patient preference, as well as patient-specific characteristics, such as diabetes or heart failure, which may favor one strategy over another, Angioplasty should be considered when one, two, or even three arteries have become narrowed, provided that the arteries are suitable for angioplasty. When there is significant narrowing of left main coronary artery or of all three major coronary arteries, CABG should the left main coronary artery or of all three major coronary arteries, CABG should be considered. CABG is preferable in the presence of diabetes and/or heart failure when two or three coronary arteries are narrowed. If revascularization is feasible, either angioplasty or CABG is indicated when medical treatment has failed to relieve angina. He further draws our attention towards the literature that one of most frequent concerns of patients following coronary artery by-pass surgery is the leg incisions from where the vessels were “harvested” for the bypass. It should be noted that it may take several months for these leg wounds to fully heal and the patient should be given written instructions from either the physician or “cardiac rehab team” as to how to manage to the leg incision. Another common concern is pain control. Due to the nature of the surgery, itself, most patients experience more pain after bypass surgery than those who have undergone a general surgical procedure. The patient should clearly understand how to differentiate between pain from the incision and possible pain coming from low blood supply to the heart muscle following bypass. If there is any concern, the patient should contact the physician’s office.   

                        It is true that angioplasty procedure is also a surgical procedure but this Forum cannot go beyond the terms and conditions of the policy placed on the file.

                        On the other hand counsel for the opposite parties has argued that as per the condition 11 (a&b) (1) mentioned in the policy bond of insurance that the Percutaneous Transluminal Coronary Angioplasty is not covered and only heart by-pass surgery is covered under benefit of the policy and all other operation e.g. angioplasty and thrombulysis are specifically excluded as per annexure R1/C1.

                        Clause 11 (a&b) of the Insurance Policy taken by the complainant, to the extent it is relevant, reads as under: -

                        11. (A) Benefit (B) of the Policy schedule is not applicable if any of the contingencies mentioned in Paras 11 (b) occurs (i) at any time on or after the date on which the risk under this policy is commenced but before the expiry of one year reckoned from the date of Policy or (ii) within one year from the date of revival.

                        (B) Benefit (B) of the Policy Schedule is applicable on the occurrence of any of the following contingencies.

                        (i) The Life Assured undergoes open Hear By-Pass Surgery performed on significantly narrowed/occluded coronary arteries to restore adequate blood supply to heart and the surgery must have been proven to be necessary be means of coronary angiography. All other operations (e.g. angioplasty and Thrombolysis by Coronary Arteries Catheterization) are specifically excluded.”

                        Counsel for the opposite parties has further relied upon the revision petition No. 2333 of 2012 titled as LIC of India v. Niwas Bansal decided on 12-04-2013 passed by National Consumer disputes Redressal Commission and in revision petition No. 167 of 2016 titled as Life Insurance Corporation of India v. Madan Gopal decided on 18-03-2016, whereby National Consumer disputes Redressal Commission has held that the “Head note: The complainant took a Medicalaim policy called Asha Deep. He suffered angina pain and underwent angioplasty. He applied to the petitioner claim reimbursement in terms of the policy taken by him. Held: the complainant’s claim was rejected on the ground that the medicalaim treatment undergone by him was not covered under the policy taken by him. The said procedure was among the exclusions for the purpose of the reimbursement under the policy, hence was not payable to him”.                  

5.                     In view of the laws placed on the file by the counsel for the opposite parties, which are squarely covered the facts of the present case and we are of the considered view that the Percutaneous Transluminal Coronary Angioplasty was done upon the complainant is not covered under the policy in question as per the condition 11 (a&b) (1).  Accordingly, the complainant is not entitled to get any relief qua the policy in question towards the present claim and the complaint is dismissed with no order as to costs.  Copies of the order be sent to the parties concerned, free of costs, as per rules. File after due compliance be consigned to record room. 

 

Announced on: 20.06.2017                             

                                                                   (D.N. ARORA)                                                                                                                   

                                                                       PRESIDENT

 

 

                                                                           (PUSHPENDER KUMAR)                                                                                                                                                                                        MEMBER

 

                                                                       

                                                                                                (ANAMIKA GUPTA)

                                                                                                            MEMBER