Date of filing : 12.04.2012
Date of order : 19.07.2022
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, VELLORE, AT VELLORE DISTRICT
PRESENT: THIRU. A. MEENAKSHI SUNDARAM, B.A.,B.L. PRESIDENT
THIRU. R. ASGHAR KHAN, B.SC, B.L. MEMBER- I
SELVI. I. MARIAN RAJAM ANUGRAHA, M.B.A., MEMBER -II
TUESDAY THE 19TH DAY OF JULY 2022
CONSUMER COMPLAINT NO: 27 /2012
R.S. Ashok Kummar,
S/o. J.M. Shanmugam,
No. 105, Chetty Street,
Tirupattur & Taluk,
Vellore District. …Complainant
-Vs-
1. The Branch Manager,
Life Insurance Corporation of India,
No. 86, Palanisamy Road,
Ganthipettai,
Tirupattur – 635 601,
Vellore district.
2. The Divisional Manager,
Life Insurance Corporation of India,
Divisional Office, Jeevan Prakash,
Arcot Road,
Vellore – 632 004.
3. The Zonal Manager,
LIC of India, Southern Zonal Office,
LIC Building,
No.102, Anna Salai,
Chennai – 600 002. …Opposite parties
Counsel for complainant : Thiru. M. Kulothungan
Counsel for opposite parties 1 to 3 : Thiru. K. Ravichandran
ORDER
THIRU.A.MEENAKSHI SUNDARAM, B.A.B.L., PRESIDENT
The complaint has been filed under section 12 of Consumer Protection Act 1986. The complainant has prayed to direct the opposite parties to pay a claim amount of Rs.1,76,840/- with interest at the rate of 12% p.a. from 04.08.2008 to till date, and to pay a sum of Rs.2,00,000/- towards the compensation for the mental shock and agony for the deficiency in service and also to pay the cost of the proceedings.
1. The case of the complaint is briefly as follows:
The complainant took a life insurance policy on 28.09.2002 from the opposite party. The name of the policy is Asha Deep. The assured value of the policy is Rs.1,00,000/-. In September 2008 the complainant had breathlessness, hypertension and fatiguability and was admitted at Narayana Hrudayalaya Hospital on 04.08.2008 and had undergone AORTIC VALVE REPLACEMENT WITH MEDTRONIC AORTIC VALVE PROSTHESIS (SIZE 25MM), on 06.08.2008. He had paid a sum of Rs.1,76,840/- towards medical expenses to the hospital. Under the Asha Deep policy, the complainant is entitled for reimbursement of entire medical expenses for the above said operation and the complainant made claim from the first opposite party on 01.09.2008. As there was no response from the first opposite party, the complainant issued a reminder on 26.09.2008. In turn the first opposite party by their letter dated 24.11.2008, directed the complainant to approach the Claims Review Committee, LIC of India Divisional Office, Vellore. Accordingly, the complainant on 11.12.2008, approached the Claims Review Committee. Though the said Committee received the claim of the complainant, there was no response from them as well. Hence the complainant issued a reminder on 21.02.2009 which was received by the second opposite party on 25.02.2009. On consideration that Claims Review Committee, declined to accept by their letter dated 05.03.2009, the claim of the complainant, is that the complainant is not eligible for the reimbursement, and also directed the complainant to file appeal before the third opposite party. In view of the above direction, the complainant preferred appeal before the third opposite party on 12.03.2009. On receipt of the above appeal, the Regional Manager, Claims Review Committee, had intimated the receipt of the said appeal and also informed that they are arranging to place the appeal, before the review committee for appropriate order. As there was no response from the Claims Review Committee of the Zonal Office, the complainant issued a reminder on 05.05.2009 and was received by them on 06.05.2009. Inspite of reminder letters, the Claims Review Committee, Zonal Office, kept quiet for about two years without any information. The complainant again wrote a reminder letter on 28.02.2011. After a long time, the third opposite party on 02.11.2011, repudiating the claim of the complainant, stated that Zonal Office had upheld the decision of second opposite party. The complainant was put to great shock and mental agony due to the deficiency in service of the respondent. As per the policy condition, the complainant is entitled to reimbursement of the medical expenses incurred. The opposite parties wantonly failed, to pay the complainant’s claim and repudiated the same after two years of the appeal filed by the complainant. Hence this complaint.
2.The written version filed by first opposite party and adopted the second and third opposite parties are as follows:
The complainant is not all entitled for reimbursement, for the surgery AORTIC VALVE REPLACEMENT WITH MEDTRONIC AORTIC VALVE PROSTHESIS (SIZE 25MM) which was carried out at Narayana Hrudayalaya Hospital on 04.08.2008,as this surgery was not covered under Asha Deep Benefit – B claim, under this life insurance policy. On 02.07.2008, as per the policy condition, life assured was covered for Open Heart By-pass surgery performed on, significantly narrowed / occulated coronary arterial to restore adequate blood supply to heart and surgery must have been proved to be necessary by means of coronary angiography. All other operations are specifically excluded from insurance cover. Whereas the complainant has stated that, he underwent open heart surgery on 06.08.2008. Ongoing through the discharge summary of the life assured, he was diagnosed to have suffered from severe Aortic Regurgitation Moderate Pulmonary Arterial Hypertension, Sinus Rhythm and was operated on 06.08.2008 for AORTIC VALVE REPLACEMENT WITH MEDTRONIC AORTIC VALVE PROSTHESIS.
This opposite party institution comes under Central Government undertaking. Hence, they have to follow the policy condition and pass order accordingly since the claim was not coming under the coverage of policy, this opposite party directed, the complainant to contact the Claims Review Committee, LIC of India, division of Vellore namely, second opposite party for proper adjudication. The Claims Review Committee, declined to accept the claim of the complainant, stating that the complainant is not eligible for reimbursement and suggested for an appeal before the Zonal Manager. After the appeal was filed, the Zonal Committee, under the medical referee has confirmed and upheld the decision of the second opposite party. The eligibility conditions are printed on the policy bond page 3 para 11(b) & (i) regarding coverage for Heart Operation. Since the surgery undergone by the complainant, is not covered under the policy for benefit. As per the policy condition. This opposite party was not able to consider the claim of the complainant. The complainant is not at all entitled for any compensation with cost, and interest for the simple reason that the claim is not at all coming under the preview of the policy condition. This complaint may be dismissed with cost.
3. Proof affidavit of complainant filed. Ex.A1 to Ex.A22 were marked. Proof affidavit of opposite parties filed. Ex.B1 marked. Written arguments of both sides filed.
4. THE POINTS THAT ARISES FOR CONSIDERATION ARE:
1. Whether there is any deficiency in service on the part of the opposite
parties?
2. Whether the complainant is entitled for relief as claimed in the complaint?
3. To what relief, the complainant is entitled to?
5. POINT NO.1&2: The complainant took a life insurance policy namely Asha Deep in 28.09.2002 for a sum of Rs.1,00,000/-. The said policy is coupled with medical claim also. On September 2008 the complainant was admitted at Narayana Hrudayalaya Hospital. On 04.08.2008, he had undergone AORTIC VALVE REPLACEMENT WITH MEDTRONIC AORTIC VALVE PROSTHESIS (SIZE 25MM). On 06.08.2008 and he was discharged from the hospital. On 15.08.2008, he has incurred a sum of Rs.1,76,840/- as medical expenses. He has paid the same to the hospital. There is no dispute with regard to above said facts. The only defence raised by the opposite party is that as per the policy condition, the said surgery is not covered. On going through the policy conditions, we find that the life assured undergoes Open Heart By-pass surgery on significantly narrowed / occulated coronary Artery to restore adequate blood supply to heart. On plain reading of the above said clause, we understand that the policy covered for any heart ailment including Open Heart By-pass surgery. Mearly because the surgery undergone by the complainant does not find place in the clause is not absolved from their obligation from honouring the claim of the complainant. Because the surgery done to the complainant also for the heart ailment. Further, the opposite party did not respond in a proper manner, while considering the claim of the complainant, on this ground as well, the opposite party has committed deficiency on their part by repudiating the claim of the complainant. Hence, these Point Nos. 1 and 2 are decided in favour of the complainant.
6. POINT NO.3: As we have decided in Point Nos.1 and 2 that there is a deficiency in service on the part of the opposite parties. The opposite parties are jointly or severally directed to reimburse Rs.1,76,840/- (Rupees One Lakh Seventy Six Thousand Eight Hundred and Forty only), the medical expenses incurred by the complainant with interest at the rate of 9% p.a. from 04.08.2008 to till the date of this order and also to pay a sum of Rs.1,00,000/- (Rupees One Lakh only) as compensation for deficiency in service and mental agony and also to pay a sum of Rs.5,000/- (Rupees Five Thousand only) towards cost to the complainant. This point No.3 is also answered accordingly.
7. In the result this complaint is partly allowed. The opposite parties are Jointly or severally directed to reimburse Rs.1,76,840/- (Rupees One Lakh Seventy Six Thousand and Eight Hundred and Forty only) the medical expenses incurred by the complainant with interest at the rate of 9% p.a. from 04.08.2008 to till the date of this order and also to pay a sum of Rs.1,00,000/- (Rupees One Lakh only) as compensation for deficiency in service and mental agony and also to pay a sum of Rs.5,000/- (Rupees Five Thousand only) towards cost to the complainant within one month from the date of receipt of this order, failing which the above amounts shall carry interest at the rate of 9% per annum from the date of this order to till the date of realization.
Dictated to the steno-typist transcribed and typed by her corrected and pronounced by us in the open Commission on this the 19th July, 2022.
Sd/- Sd/-/-Sd/- Sd/- VSd/ Sd/- Sd/-
MEMBER –I MEMBER – II PRESIDENT
LIST OF COMPLIANANT SIDE DOCUMENTS:
Ex.A1-19.07.2008 - Copy of LIC Renewal Premium Receipt
Ex.A2-31.09.2008 - Copy of the letter issued by the complainant in favour of the
Branch Manager, LIC of India, Tirupattur, Vellore District.
Ex.A3-26.09.2008 - Copy of the letter issued by the complainant in favour of the
Branch Manager, LIC of India, Tirupattur in favour of the
Complainant
Ex.A4-26.09.2008 - Copy of the courier receipt
Ex.A5-24.11.2008 - Copy of the letter issued by the life Insurance Corporation of India,
Branch Office, Tirupattur in favour of the complainant
Ex.A6-11.12.2008 - Copy of the letter issued by the complainant in favour of the claims
Review Committee, LIC of India, Divisional Office, Vellore
Ex.A7-15.12.2008 - Copy of the Acknowledgement Card signed by the claims Review
Committee, LIC of India, Divisional Office, Vellore
Ex.A8-21.02.2009 - Copy of the letter issued by the complainant in favour of the claims
Review committee, LIC of India, Divisional Office, Vellore.
Ex.A9-25.02.2009 - Copy of the acknowledgement card signed by the claims Review
Committee, LIC of India, Divisional Office, Vellore
Ex.A10-05.03.2009 – Copy of the letter issued by the LIC of India, Divisional Office,
Vellore-4, with specimen copy of policy
Ex.A11-12.03.2009 - Copy of the appeal filed to the Zonal Manager, LIC of India, Zonal
Office, Chennai-2
Ex.A12-14.03.2009 - Copy of the Postal Acknowledgement signed by the LIC of India,
Zonal Office, Chennai
Ex.A13-19.03.2009 - Copy of the letter of Acknowledgement issued by the Zonal Office,
Chennai-2
Ex.A14-05.05.2009 – Copy of the Reminder letter issued by the complainant to the Zonal
Manager, LIC of India, Chennai-2
Ex.A15-06.05.2009 – Copy of the Postal Acknowledgement signed by the Zonal Office,
Chennai-2.
Ex.A16-28.02.2011 - Copy of the Reminder letter issued by the complainant to the Zonal
Manager, LIC of India, Chennai-2
Ex.A17-01.03.2011 – Copy of the Postal acknowledgement signed by the Zonal Office,
Chennai
Ex.A18-02.11.2011 - Copy of the letter issued by the Divisional Manager, LIC of India,
Vellore-4
Ex.A19-15.08.2008 – Copy of the Discharge Summary
Ex.A20-15.08.2008 – Copy of the Receipt for the payment of Hospital bills
Ex.A21-24.09.2008 – Copy of the bill cum receipt
Ex.A22-17.02.2009 – Copy of the bill cum receipt
LIST OF OPPOSITE PARTIES SIDE DOCUMENTS:
Ex.B1 - Policy Copy
Sd/- Sd/- Sd/-
MEMBER – I MEMBER – II PRESIDENT
