OF 2008 AGAINST C.C.NO.200 OF 2007 DISTRICT CONSUMER FORUM WEST GODAVARI AT ELURU

Between

Sri Bongu Atchuta Rao S/o China Appalaswamy
Hindu, Male aged 48 years, Advocate Ex.Asst.GP(LRAT)
Koteswara Durapuram Eluru Rural Mandal, W.G.Dist.

                                                                Appellant/complainant

        A N D

1.     The Divisional Manager
        LIC of India, Tadithota
        Rajahmundry E.G.Dist.
2.     The Branch Manager
        LIC of India Canal Road
        Eluru W.G.Dist.

                                                                Respondents/opposite parties

Counsel for the Appellant             Sri M.Ram Gopal Reddy

Counsel for the Respondents        Sri N.Mohan Krishna

 QUORUM:                  SRI SYED ABDULLAH, HON’BLE MEMBER

      &

                            SRI R.LAKSHMINARSIMHA RAO, HON’BLE MEMBER

                               TUESDAY THE NINETEENTH DAY OF OCTOBER

                                            TWO THOUSAND TEN

Oral Order ( As per R.Lakshminarsimha Rao, Member)
           ***

        The unsuccessful complainant is the appellant.  The facts leading to filing of the appeal are that the appellant obtained insurance policy having gone through the advertisement in Eenadu daily newspaper rendered by the respondent insurance company that it would pay 50% of the amount out of the sum assured to the insured and 10% out of the sum assured every year to him till completion of the table and term under the insurance policy in case the insured  suffered from cancer, bypass surgery and other heart diseases, paralysis and failure of kidneys after obtaining the insurance policy and it was also provided that thereafter the insured need not pay any further premium under the insurance policy. The appellant obtained insurance policy bearing no.802202599 on 22.6.2001 for a sum assured of `one lakh under the name and style of Ashadeep and the table and term 121-20.  The respondent no.2 issued another insurance policy bearing no.802252518 dated 28.7.2004 for a sum assured of Rs.one lakh.  The appellant had paid the premiums regularly.  Before issuing the insurance policies, the respondent subjected the appellant for medical examination.  The appellant had undergone angiogram in Care Hospitals Hyderabad and on 23.3.2006 he had undergone the treatment and on 26.3.2006 he was discharged from the hospital.  The appellant had incurred expenditure of Rs.2,50,284/- towards medical expenses and treatment charges.  The respondents had not settled the claim of the appellant whereby the appellant had got issued the notice dated 23.6.2007 claiming 50% of the sum assured towards medical expenditure incurred by him for the treatment for his heart ailment as also waiver of the future premium under the two insurance policies. 

        The respondents contested the claim on the ground that they came to know about the claim only on receipt of the notice from the District Forum.  It was submitted that as per the certificate issued by the Care Hospital the appellant had undergone PTCA/Stent operation but not open heart surgery.  Further, it was stated that as per the terms and conditions of Asha Deep Policy, PTCA/Stent operation is not covered under the provisions of benefit “B”.  It was stated that had they informed earlier, the position would be not different from the one that the appellant is not entitled to the benefits of the insurance. 

        The appellant had filed his affidavit. Exs.A1 to A11 were marked on his behalf.

        On behalf of the respondent insurance corporation, the Administrative Office of the respondent no.1 corporation has filed his affidavit and got marked Exs.B1 to B6.

        The District Forum has dismissed the complaint having come to the conclusion that the appellant had not undergone open heart surgery so as to be covered by the terms of the insurance policy. 

        The point for consideration are :

1)                Whether the PTCA/Stent operation that the appellant had undergone is covered by the terms and condition of the paper publication and the insurance policy?

2)                Whether the appellant is entitled to the relief sought for?

3)                Whether there was deficiency in service on the part of the respondent insurance corporation?

4)                To what relief?

POINTS NO.1 AND 2  The issuance of two insurance policies bearing No.802202599 and no.802252518 in favour of the appellant and his undergoing percutaneous coronary intervention on 23.6.2006 during the period the insurance policies were in force are not disputed.  The appellant had submitted that his claim for reimbursement of an amount of Rs.2,50,284/- was not settled by the respondent compelling him to get issued notice dated 23.6.2007 for which no reply stated to have been given by the respondent.  The respondents in their counter had taken a specific plea that the appellant had not lodged any claim and without filing any claim the appellant could not have attributed  deficiency in service to them.

  The appellant had relied up on the advertisement of Asha Deep Insurance Policy in Eenadu Daily News paper where as the respondent had relied up on the terms and conditions of the insurance policy.  The advertisement issued by the respondent has to be given due importance on par with the terms and conditions of the insurance policy.  The contention of the respondent that there was no claim lodged by the appellant is to be given consideration in the absence of any denial thereof by the appellant.  It is beyond the scope of any person’s imagination as to straight away proceed with the application of certain clause of the insurance policy or a particular aspect of the advertisement tendered by the respondents without there being filed any claim.  The District Forum ought to have directed the appellant to lodge his claim with the respondents and then the respondents to proceed with the claim. 

In the result, the appeal is allowed.  The order dated 30.7.2008 of the District Forum is set aside.  The appellant/complainant directed to lodge claim with the respondents and on receipt of the claim the respondents shall proceed to settle the claim in accordance with law.  No costs.

                                                                MEMBER

                                                                MEMBER

                                                           Dt.19.10.2010

KMK*