DATE OF FILING: 04.01.2011

BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, IDUKKI

Dated this the 29th day of August, 2011

Present:

SRI.LAIJU RAMAKRISHNAN PRESIDENT

SMT.BINDU SOMAN MEMBER

C.C No. 6/2011

Between

Complainant : E.A.Rahim,

Ekkarakudiyil House,

Adimali P.O, Adimali,

Idukki District.

(By Adv: Shiji Joseph)

And

Opposite Parties : 1. The Branch Manager,

Life Insurance Corporation of India, Adimali.

2. The Divisional Manager,

Life Insurance Corporation of India, Kottayam.

(Both by Advs: C.M.Tomy & V.C.Sebastian)

SRI.LAIJU RAMAKRISHNAN(PRESIDENT)

The complainant availed a Jeevan Anand insurance policy from the opposite parties on 23.08.2005 as No.392985792. The sum assured was Rs.5 lakhs and the premium payable was Rs.24,088/-, which was a half yearly one. The policy was also having a critical illness coverage of Rs.5 lakhs. For the critical illness and premium waiver benefit fund Rider, a premium of Rs.3,162/- was also paid by the complainant. The complainant was paying the premium without any default. As per the Critical illness benefit scheme of the policy, in addition to the policy benefit, the complainant would get the benefits of the policy if any one of the illness covered by the policy including Heart attack. On 18.05.2010 the complainant suffered acute interior wall ST elevation Myocardial Infarction. He was admitted in Morning Star Hospital, Adimali and then he was referred to Lissie Hospital, Ernakulam and was treated with Coronary Angioplasty. After discharging from the hospital, the complainant claimed the critical illness benefit of the policy and all the treatment records including ECG, Angiogram, Lab report etc. were also produced. But the opposite party repudiated the claim on 30.08.2010 stating that the contingency is not covered as per the policy condition. The repudiation of the claim of the opposite party is totally against the policy conditions and hence there is deficiency in the service of the opposite parties. The opposite party repudiated the claim on the ground that angioplasty is not covered under the policy. So this petition is filed for getting the policy benefits of critical illness coverage of Rs.5 lakhs and also for compensation.
 

2. As per the written version filed by the opposite parties, it is admitted that the complainant availed an insurance policy as No.392985792 for a sum assured of Rs.5 lakhs with date of commencement 23.08.2005 and the premium for the same was Rs.24,088/-. There is a provision of Rs.5,00,000/- as critical illness benefit, covered in the event of contingencies occurred, which is described and detailed in the policy subject to the conditions and exclusions. It is admitted that the complainant was admitted in hospital on 18.05.2010, diagnosed to have been suffering from coronary artery disease. Thereafter he underwent percutaneous transluminal coronary angioplasty to mid-right coronary artery and left circumflex and stent was implanted. As per the policy conditions, the exclusion clause under the head of (D) Sub clause (9) under Aorta Graft surgery, stent grafting is excluded and surgery on the branches of the aorta is not covered. Under coronary artery bypass surgery, the non-surgical techniques such as balloon angioplasty and all other intra arteria, catheter based techniques or laser procedure treatments are excluded. So the claim in the petition is not at all covered by the above policy which were specifically excluded. So the LIC is not bound to pay anything more than that of contractual obligations. Hence the petition is liable to be dismissed.

3. The point for consideration is whether there was any deficiency in service on the part of the opposite parties, and if so, for what relief the complainant is entitled to ?

4. The evidence consists of the oral testimony of PW1 and Exts.P1 to P4 marked on the side of the complainant and the oral testimony of DW1.

5. The POINT :- The complainant filed affidavit and deposed as PW1. The copy of the insurance policy availed by the complainant is produced and marked as Ext.P1, which is of Critical Illness and Premium Waiver Benefit Rider. The critical illness sum assured is Rs.5,00,000/- and its premium is Rs.2,116/-. The premium waiver benefit rider premium is Rs.1,046/- and the policy is covered upto 23.08.2020. The complainant was admitted in Lissie Hospital on 18.05.2010 for the treatment of Myocardial Infarction and the treatment records issued from the Lissie Hospital, Ernakulam is marked as Ext.P2. He was admitted in Morning Star Hospital, Adimali and from there he was referred to Lissie Hospital, Ernakulam and was treated there with coronary angioplasty. Ext.P2 shows the same. As per the critical illness and premium waiver benefit rider, which is Ext.P1, the complainant is entitled to get an amount of Rs.5 lakhs from the opposite party. So a claim was filed by the complainant. But it was repudiated by the opposite party by a letter dated 30.08.2010 which is marked as Ext.P3. The copy of the claim form filed by the complainant is marked as Ext.P4. On cross examination of the learned counsel for the opposite party, the complainant admitted that stent was implanted and angioplasty was done on him. PW2, who is a doctor working in the Department of Cardiology at Lissie Hospital, Ernakulam. The treatment records of the patient at Lissie Hospital, Ernakulam is produced and marked as Ext.X1(series). PW2 deposed that the patient was suffering from chest pain. The actual disease was coronary artery disease, it can be called as Myocardial infarction as per diagnosis, with double vessel disease. We have done angiogram and found that two vessels were effected. In myocardial infarction, the SGOT level(Enzyme) increased. It is also deposed by PW2 that this is a critical illness which results the death of the patient, even cannot reach the patient to the hospital. The treatment for myocardial infarction are medical and surgical. Medical treatment is in which medicines alone is giving. Medicine is only a temporary relief and the surgical proceedings is the actual treatment to improve the physical condition and prevents future complications. Two types of major surgical procedures are available. One is open heart by pass surgery and the other is Angioplasty. In bypass surgery the occluded vessel is bypassed with graft. In angioplasty the effected nerve vessel is inflated with a balloon and a stent is placed at the cite of occlusion to prevent the collapse. If the patient needs bypass surgery or angioplasty depends upon the angiogram report and it is decided by the treating doctor depend upon the conditions of the vessel. Angioplasty became popular only in 2000 in Kerala. Before that these conditions were treated by bypass surgery. DW1 is the Manager of the opposite party. The treatment is having coverage as per the policy. As per exclusion clause (D) 9 the claim was rejected. The critical illness policy is an additional policy. As per the additional conditions, treatment expenses of some diseases will be given. In case of death, the benefits of basic policy will be given.

As per the complainant, Ext.P1 Critical Illness and Premium Waiver Benefit Rider policy covers critical illness and in definitions of conditions “(B)1, myocardial infarction is included as a critical illness” and the complainant is liable to get the claim amount. As per the opposite party, the exclusions of policy condition “(D)9 clearly states that stent grafting is excluded and surgery on the branches of the aorta is not covered”. As per “(D)10, under coronary artery bypass surgery, the non-surgical techniques such as balloon angioplasty and all other intra arteria, catheter based techniques or laser procedure treatments are excluded”. So as per the opposite party, certain type of surgeries are excluded in the policy conditions. Even open heart surgery is included the angiogram or stent is excluded and the complainant is not at all liable to get the claim amount.

But we think that the Critical Illness and Premium Waiver Benefit Rider is an additional policy availed by the complainant for critical illness only and a specific premium was also paid other than the basic policy by the complainant. As per the definitions of conditions 2(B), the benefit of the policy schedule will be available on the occurrence of any of the following contingencies :-

(1)Heart Attack(Myocardial Infarction) - The first occurrence of heart attack or myocardial infarction which means the death of portion of the heart muscle, as a result of an acute interruption of blood supply to myocardium (2) stroke etc. which is included in the critical illness coverage.

As per the decision of the Hon'ble National Commission reported in 2011 CTJ 22(CP)(NCDRC), Mahesh Chand Ghiya Versus New India Assurance Company Limited, Hon'ble Justice B.N.P.Singh, President and Mr.Suresh Chandra, Member in Appeals No.130 of 2004 and 113 of 2004, Insurance – Mediclaim – Consumer Protection Act, 1986 –

Deficiency in service – Section 2(1)(g) – Section (2)(1)(o) – Policy taken in the year 1997 renewed from year to year, the latest being from 22.01.2001 to 21.01.2002 – Petitioner hospitalised when he suffered from heart ailment – His claim of Rs.2,01,021.06 restricted for payment to Rs.85,000/- by the respondent citing Exclusion clause of the policy – Held, petitioner being conscious and aware of the restrictions imposed by the insurer in renewing the policy from 22.01.2001 to 21.01.2002, he is estopped from challenging the Exclusion clause incorporated in it – Revision by the petitioner – Terms and conditions apparently unilaterally imposed by the insurer at the time of renewing the policy.

So we think that the exclusion clause incorporated in the conditions of the policy are not at all signed or accepted by the petitioner and they are unilaterally made by the opposite party. The complainant himself made an additional premium for critical illness and when the claim arised the opposite party deliberately avoided the claim striking on the conditions of the exclusion clause and it is not at all proper. It is a gross deficiency from the part of the opposite party. Here the sum assured is Rs.5 lakhs and the complainant is claimed Rs.5 lakhs. But we think that the complainant can claim for the treatment expenses for the disease and the opposite party is entitled to pay the same. There is no dispute regarding the policy and the premium paid by the complainant.

Hence the petition allowed. The opposite parties are directed to settle the claim of the complainant for the treatment expenses of Myocardial Infarction occurred on 18.05.2010, with 12% interest from the date of this petition as per Ext.X1(series) and Ext.P2 treatment records produced by the complainant. The opposite parties are also directed to pay Rs.2,000/- as cost of this petition to the complainant within 30 days of receipt of a copy of this order, failing which the outstanding amount shall carry further interest at 12% per annum from the date of default.

Pronounced in the Open Forum on this the 29th day of August, 2011

Sd/-

SRI. LAIJU RAMAKRISHNAN(PRESIDENT)

Sd/-

SMT.BINDU SOMAN(MEMBER
APPENDIX) 

Depositions :

On the side of Complainant :

PW1 - E.A.Rahim

PW2 - Dr.Nidhin Parrit

On the side of Opposite Parties :

DW1 - P.T.Jose

Exhibits:

On the side of Complainant:

Ext.P1 - Photocopy of Critical Illness and Premium Waiver Benefit Rider policy

Ext.P2 - Photocopy of treatment records issued from Lissie Hospital, Ernakulam

Ext.P3 - Repudiation letter dated 30.08.2010 issued by the opposite party

Ext.P4 - Photocopy of Claim Form filed by the complainant

Ext.X1(series) - Treatment Records of the complainant at Lissie Hospital, Ernakulam

On the side of Opposite Parties:

Nil