Orissa

StateCommission

A/59/2015

Manager, Life Insurance Corporation of India - Complainant(s)

Versus

Shri Karunakar Sahu - Opp.Party(s)

M/s. S. Swarn & Assoc.

15 Sep 2022

ORDER

                 Heard the learned counsel for  the appellant. None appears for respondent.

2.              This   appeal is   filed  U/S-15 of erstwhile  Consumer Protection Act,1986(herein-after called the Act). Hereinafter, the parties to this appeal shall be referred to  with reference to their respective status before the learned District Forum.

3.                  The case    of the complainant, in nutshell  is that  the complainant   had purchased  policy No.593847592 dtd.27.02.2010 covering the period from 27.02.2010 to 27.10.2028. It is alleged inter-alia that the complainant got pain in  Spinal Cord  and he underwent  operation   of the spinal cord in the month of November,2010 at Kalinga Hospital,Bhubaneswar that he has spent Rs.80, 340/-  as medical expenses.The matter was informed to the  insurer for reimbursement but it was repudiated on the ground that the disease is not covered within the policy condition. Also OP alleged  that complainant had  got Stenosis + Disc as pre-existing illness which he has not disclosed in the proposal form. Challenging such ground of repudiation as deficiency in service on the part of the Op, the complaint was filed.

4.              The OP  filed written version stating  that they have allegedly  gathered by investigation that the complainant has got pre-existing illness but it was not disclosed in the proposal form. Moreover, the surgery was done by the complainant  is not covered by the policy. Therefore, they have no deficiency in service on their part by repudiating  claim.

5.                       After hearing both the parties, learned District Forum  passed the following order:-

                       Xxxxxxxx      xxxxx               xxxxxxxxx

                    “ The OP No.1 is liable to pay the complainant an amount of Rs.1,02,000/-(Rupees one lakh and two thousand) towards surgical benefit, Rs.30,000/- (Rupees thirty thousand towards compensation for mental agony and harassment and Rs.10,000/- (Rupees ten thousand) towards cost of litigation to the complainant within 45 days of pronouncement of this order failing which OP in addition to the amounts as above shall have to pay interest @ 12 % on it till the date, the amount is actually paid.”

  6.               Learned counsel for the appellant submitted that  learned District Forum has committed error in law by not awarding the compensation  more than  the relief  claimed by the complainant. According to him the complainant  has undertaken operation  of spinal cord for the disease of  Stenosis + Disc and provision at 24 & 25  and Discectomy was performed which  was not covered under the list of diseases under policy purchased. He also submitted that complainant  was having such pre-exiting disease but he has not disclosed same in the proposal form. Learned  District Forum ought to have considered  all these facts and law. Therefore, he submitted to set-aside the impugned order by allowing the appeal.

7.               Considered the submission of learned counsel for the  appellant,  perused the DFR and impugned order .

8.                It is admitted fact that the complainant had undertaken  surgical operation of his  spinal cord at Kalinga Hospital during currency of the policy and spent Rs.80,340/-. It is also not in dispute that the complainant has to prove his case but when the OP has alleged  about  pre-existing  disease suffered   by complainant, the onus lies on Op to prove it. The OP has not filed any document   of medical treatment to prove pre-existing disease  earlier to the proposal form filled up by the complainant. The OP has also alleged that the  diseases for which surgery was conducted is not included in the list. Learned District Forum has discovered material and came to the conclusion  that such diseases is covered by the policy. We have gone through the  list  of the diseases  under the heading Nervous system where found such surgery, it is for repairing spinal Arteno-venous malformations is covered under the policy. Now the doctor’s report shows that the complainant underwent  operation  due to  problem in canal Stenosis + Disc  and he performed  Discectomy on spinal cord of complainant.  In fact the discussion on the report of the medical as made by the learned District Forum is quite appropriate. On the otherhand  the disease for which the complainant was diagnosed  is fully covered  by the list of the diseases in the policy. Since, the OP has not been  paid  any amount so far, the deficiency in service on the part of the OP is proved. It is revealed from the complaint that the complainant has spent Rs.80,340/- towards  medical expenses and same should be payable by the OP. Since, complainant has been harassed being not paid with reimbursement cost by OP, he is entitled to compensation and cost of litigation.

9.                In view of aforesaid discussion while confirming finding of learned District Forum we modify  the impugned order by directing OP No.2 to pay medical expenses of  Rs.80,340/-  with compensation of  Rs.20,000/-  for mental agony and harassment and Rs.10,000/- towards cost  to the complainant  within 60 days from the date of this  order, failing which it will carry interest @ 12 % per annum from the date of impugned order till date of payment.

                    The appeal is disposed of accordingly.

                   Free copy of the order be supplied to the respective parties or they may download same from the confonet  or webtsite of this  Commission to treat same as copy of order received from this Commission.   

                     DFR be sent back forthwith.