Haryana

StateCommission

A/190/2015

LIFE INSURANCE CORP.OF INDIA - Complainant(s)

Versus

MADAN GOPAL - Opp.Party(s)

S.K.MAHAJAN

18 Sep 2015

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                 

First Appeal No  :      190 of 2015

Date of Institution:      02.03.2015

Date of Decision :       18.09.2015

 

1.     Life Insurance Corporation of India through its Senior Divisional Manager, Divisional Office, Sector 17, Chandigarh.

 

2.     Life Insurance Corporation of India, Divisional Office, near Jewel Chowk, Karnal.

                                     Appellants-Opposite Parties

Versus

 

Madan Gopal s/o Sh. Kotu Ram, Resident of Village and Post Office Pundri Via Gharaunda, District Karnal.

                                      Respondent-Complainant

 

CORAM:             Hon’ble Mr. Justice Nawab Singh, President.

                             Mr. B.M. Bedi, Judicial Member.

                                                                                                         

Present:              Shri Gurpreet Singh, Advocate appearing on behalf of Shri S.K. Mahajan, Advocate for appellants.

                             Shri Jatinder Nagpal, Advocate for respondent.

 

                                                   O R D E R

 

B.M. BEDI, JUDICIAL MEMBER

 

This Opposite Parties’ appeal is directed against the order dated January 19^th, 2015, passed by District Consumer Disputes Redressal Forum (for short ‘District Forum’), Karnal in Complaint No.283 of 2010.

2.          Madan Gopal-Complainant-respondent, purchased Life Insurance Medi-claim Policy (Annexure A-1), under Ashadeep Plan with profit without accident from Life Insurance Corporation of India (LIC). The policy commenced from March 28^th, 2004 and was valid upto March 28^th, 2024.  

3.      On April 13^th, 2008 the insured Madan Gopal felt chest pain and was admitted in Dr. Prem Hospital, Panipat, from where he was referred to Escorts Heart Institute and Research Centre Limited, New Delhi where he remained admitted from April 13^th, 2008 to April 18^th, 2008. He underwent angioplasty and PTCA + Stent, for his Coronary Artery Disease. He was discharged on April 18^th, 2008 (Exhibit C-12). According to the complainant, he spent Rs.2,24,482/- for his treatment.  Claim being filed, was repudiated by the LIC vide letter Annexure-5 stating therein as under:-

“With reference to your claim for contingent benefit “B” under the above Asha Deep Policy on your own life, we have to inform you that contingent benefit “B” is not payable as per the terms & conditions of the policy because the PTCA procedure is not covered under the policy conditions.”

4.      Aggrieved thereof, the complainant filed complaint under Section 12 of the Consumer Protection Act, 1986.

5.      The LIC-opposite parties, contested complaint by filing reply while reiterating the fact stated in the repudiation letter. It was stated that the operations like balloon angioplasty and thrombloysis by coronary artery catheterization were excluded as per ‘Exclusion Clause’.

6.      On appraisal of the pleadings of the parties and the evidence available on the record, the District Forum, vide impugned order allowed complaint issuing direction to the LIC as under:-

“…..we accept the present complaint and direct the OP to make the payment of the sum insured to the complaint along with interest @ 9% per annum from the date of filing of the present complaint i.e. 20.4.2010 till its actual realization. The complainant shall also be entitled for a sum of Rs.25000/- as compensation for the harassment caused to him alongwith a sum of Rs.2200/- towards legal fee and litigation expenses.”

7.      The solitary contention raised by the learned counsel for the appellants-LIC was that the complainant was not entitled for any compensation with respect to the treatment of angioplasty and PTCA +Stent, for Coronary Artery Disease. In support, reference was made to the terms and conditions of policy.

8.      The contention raised is not tenable. It is not disputable that angioplasty and PTCA + Stent, for Coronary Artery disease also require indoor admission and surgical procedure. It is for the doctors concerned treating the patient to see which best procedure is to be followed. From the evidence available on the record, it is established that the complainant suffered heart problem for which angioplasty and PTCA + Stent was done. The opposite parties-appellants do not deny having issued policy. They also do not deny complainant having suffered and undergone treatment or amount spent. Therefore, the LIC cannot escape from its liability to pay the benefits of insurance to the complainant.

9.      In view of the above, the appeal fails and is hereby dismissed.

10.    The statutory amount of Rs.25,000/- deposited at the time of filing the appeal be refunded to the complainant against proper receipt and identification in accordance with rules, after the expiry of period of appeal/revision, if any.

 

Announced: 18.09.2015

(B.M. Bedi) Judicial Member

(Nawab Singh) President

 

CL