BEFORE THE A.P STATE CONSUMER DISPUTES REDRESSAL COMMISSION AT  HYDERABAD.

FA  419 of 2009  against C.C. 15/2008,  Dist. Forum, Karimnagar  

Between:

The Manager,

LIC  Of India,

Karimnagar                                                ***                           Appellants/

          .                                                                                       Ops

                                                                   And

Avula Laxmaiah

Karimangar.                                                ***                         Respondent/

                                                                                                Complainant

Counsel for the Appellant:                          M/s. M. Venkataramana Reddy

Counsel for the Respondent:                       M/s. K. Visveshwara Rao                 

CORAM:

HON’BLE SRI JUSTICE D.APPA RAO, PRESIDENT.

&

                                  SMT. M. SHREESHA, MEMBER

WEDNESDAY, THIS THE  ELEVENTH DAY OF MAY TWO THOUSAND ELVEN

ORAL ORDER:  (Per Hon’ble Sri Justice D. Appa Rao, President)

***

1)                This is an appeal preferred by the insurance company against the order of the Dist. Forum directing it to pay Rs.  1 lakh covered under the policy together with Rs. 20,000/- every year till the maturity or death of the complainant  whichever is earlier  with interest @ 9% p.a., from the date of complaint and costs of Rs. 1,000/-.

2)                The case of the complainant in brief is that he has obtained Asha Deep-II Medical Insurnace policy commencing from   28.8.2004 for a sum of Rs. 2 lakhs on payment of yearly premium of Rs. 11,760/-for 20 years vide Ex. A3 policy.   He also underwent medical tests and after completion of the formalities the appellant insurance company issued the policy.    He had paid four instalments up to 9/2007.   When he felt chest pain he visited the local doctor and then went to Usha Mullapudi Cardiac Centre, Hyderabad.  After conducting TMT test he was admitted   as in-patient in the hospital on 1.3.2007 and Angiogram was done on the same day and was discharged on the next day i.e., on 2.3.2007.     Dr.  Narendranath Raj suggested stent.    On 23.3.2007   stent was applied and was discharged on 27.3.2007 vide Ex. A8.    He altogether spent Rs. 1, 64,928/- evidenced under Ex. A10.    When he submitted his claim it was repudiated on the ground that it comes under exclusion clause under ‘benefit-B’ vide Exs. B3 & B6.   Assailing the repudiation the complainant filed the complaint claiming the above said amounts. 

3)                The insurance company resisted the case.    While admitting issuance of policy for 20 years  commencing from 28.8.2004  it alleged that  assured having underwent  angioplasty  and stenting with  XIENCE-V stent  to LAD  on  23.3.2007 he was not entitled for the benefit  being not covered under benefit-B  as per the terms and conditions.    Repudiation was conveyed and for the notice issued it gave correct reply, and therefore it prayed for dismissal of the complaint with costs. 

4)                The complainant in proof of his case filed his affidavit evidence and got Exs. A1 to A15 and two CDs marked as MOs 1 & 2 while the insurance company filed the affidavit evidence of its Administrative Officer and got Exs. B1 to B8 marked. 

5)                The Dist. Forum after considering the evidence placed on record opined that the brochure issued under Ex. A2  wherein the amount spent towards  bypass surgery, coronary  artery disease  have been covered  directed the insurance company to pay the above amounts which we have earlier referred to. 

6)                Aggrieved by the said decision,   the opposite party insurance company preferred the appeal contending that the Dist. Forum did not appreciate either facts or law in correct perspective.    It did not consider the terms of the policy wherein the operation undergone by the complainant was not covered, and therefore prayed that the order be set-aside. 

7)                The point that arises for consideration is whether the order of the Dist. Forum is vitiated by mis-appreciation of fact or law?

8)                It is an undisputed fact that the complainant obtained Asha Deep-II policy with profits for sum assured of Rs. 2 lakhs commencing from 28.8.2004 for a period of 20 years.   When the complainant asserts that the policy was issued after medical examination the insurance company did not dispute the said fact.    Apart from it,  under the policy cancer, paralysis, failure of kidneys, bypass surgery, coronary artery disease  if the policy holder suffers from any of the above diseases  he will be paid 50% of the  sum assured viz.,  Rs. 1 lakh and 10% of the sum assured will be paid up till maturity or death.   In order to prove the said fact the complainant filed Ex. A2 pamphlet printed by the very insurance company which fact was not disputed.    While so, when he had chest pain he visited a local doctor and later to Usha Mullapudi Cardiac Centre, Hyderabad where angiogram was done with a suggestion to go for stenting.    Accordingly stenting was done.  He had spent Rs. 2, 02,930/-.    The complainant has submitted Ex. B7 claim form that was furnished to him wherein said facts were made a mention enclosing Medical attendant/Cardiologist report Ex. B8.     The insurance company repudiated the claim and relied on terms and conditions of the policy.    According to it angioplasty was not covered under benefit (b) for Ashadeedp-II policy.    Clause 11(b) reads as follows:

“Benefit (B) of the policy schedule shall be available or the occurrence of any of the following contingencies.” 

9)                The life assured undergoes 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 proven to be necessary by means of coronary angiography.   All other operations (e.g., angioplasty and thrombosis’s   by coronary artery catheterization) are specifically excluded.”     The same has been noted in the brochure.  Ex. A2.    Though the Dist. Forum stated that there discrepancy between   facts mentioned in Ex. A2 and that of Ex. B2 policy.    We do not see any discrepancy.    The same been translated in Telugu.    It is beneficial to note that Ex. B8  report of cardiologist  supplied by the complainant to the insurance company  it was mentioned  “Angioplasty and stenting  with  Xience V stent  to LAD  was done  on 23.3.2007”.  When the complainant got angioplasty which was one of the exclusions the complainant could not have claimed.    Had it been by-pass surgery undoubtedly he would get.    When his very doctor stated that it was of angioplasty, we cannot say that the operation underwent by the complainant does not attract exclusion.      In the circumstance, we are of the opinion that the insurance company has rightly repudiated the claim.    We do not subscribe to the opinion of the Dist. Forum. 

10)              In the result the appeal is allowed setting aside the order of the Dist. Forum.  Consequently the complaint is dismissed.   However, no costs. 

1)      _______________________________

PRESIDENT                 

2)      ________________________________

 MEMBER           

                                                                                      11/05/2011

*pnr