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C.C. No. 14 of 2009th May 20092 and negligence on the part of the respondent. Thus the complaint was filed for Rs. 3,00,000/- together with interest @ 24% p.a. from the date of claim till realization and Rs. 50,000/- towards mental agony and Rs. 2,000/- towards costs. 3. The respondent filed a counter admitting the policy taken by the complainant. The premiums were paid upto August 2007 and subsequently the complainant was advised to continue further premiums. The complainant underwent an operation at NIMS, Hyderabad for Axillo Fumoral bypass which was a Pheriperal Vascular disease by synthetic graft. The complainant approached the respondent for sick benefit under the policy and the respondent examined the case with the reports and found that the complainant was a diabetic patient with Hypertension for the past five years. The complainant was under the use of OHA (Oral HypoGlacemic Agent) which was a Diabetic medicine since he was 20 years old. The complainant was a smoker and he did not reveal the same at the time of taking the policy and so he suppressed the material facts. Thus he was not entitled the claim. The operation undergone by the complainant was a Pheriperal Vascular disease which would not come under the schedule of benefit B. The operation was different from CABG. The reports were sent to Divisional Medical referee, who found that the operation was not under the purview of the policy. The corporation allowed the complainant to continue the insurance coverage and pay the premium keeping the policy in force by way of letter dt. 9-1-2008. Thus there were no merits in the complaint and the complaint may be dismissed with costs. 4. On the basis of the above pleadings the following points are settled for determination. i. Whether there is any negligence and deficiency of service on the part of the respondent? ii. Whether the complainant is entitled to the relief as prayed for? iii. To what relief? C.C. No. 14 of 20093 5. On behalf of the complainant Ex. A1 to A5 were marked and on behalf of the respondent Ex. B1 to B9 were marked. No written arguments were filed by both parties. 6. Point No. 1 & 2 It was not a dispute that the complainant as a conductor in APSRTC, Kadapa depot took one Ashadeep Insurance Policy bearing No. 652032717 on his life under salary savings scheme. Under the policy there was a sick benefit claim in case of hospitalization from the respondent. The complainant filed Ex. A1 a Xerox copy of receipt for payment of premium under salary savings scheme. He filed a Xerox copy of pamphlet of Ashadeep policy under Ex. A2. Under Ex. A2 it was mentioned that the Ashadeep policy was applicable to the diseases like cancer, Kidneys renal failure, Paralysis, and bypass surgery to heart. But in the same Ex. A2 under section B it was mentioned that the policy was not applicable Beloon Therapy or Laser catheter surgery. However, it was applicable to bypass surgery to heart and obstruction to blood vessels or blood circulation. 7. On 16-2-2007 the complainant underwent a bypass surgery at NIMS Hospital, Hyderabad and submitted all relevant documents including hospital documents, claim forms for medi claim to the respondent corporation that he incurred Rs. 3,00,000/- towards hospitalization and other expenses. The Xerox copy of the letter sent to the respondent was Ex. A3. Ex. A4 was Xerox copy of cash receipt issued by NIMS Hyderabad in the name of the complainant. While so the respondent corporation repudiated the claim by way of letter dt. 9-1-2008 that the disease of the complainant was not under the conditions of Ashadeep sick benefit insurance policy. The Xerox copy of repudiation letter was Ex. A5. The respondent corporation filed Ex. B1 a copy of insurance policy in the name of the complainant. The respondent filed Ex. B2 a Xerox copy of proposal form submitted by the complainant at the time of taking the policy in which his general heath under question No. 11 was good. There were no ailments including hypertension and C.C. No. 14 of 20094 diabetes. Ex. B3 was Xerox copy of medical attendant / cardiologist’s report issued by NIMS Hospital, Hyderabad. Ex. B4 was Xerox copy of operating surgeon report from NIMS Hyderabad. It was mentioned in Ex. B4 that the operation was for Axillo Fumoral bypass by synthetic graft which was a pheriperal Vascular disease. The diagnosis was for pheriperal Vascular disease (PVD). Ex. B5 was medical certificate issued to the complainant by NIMS, Hyderabad for the said operation. Ex. B6 was Xerox copy of discharge summary issued by NIMS Hyderabad. Ex. B7 was Xerox copy of repudiation letter. The complainant’s records were referred to the Divisional medical referring doctor, who opined that the ailment of the complainant would not come under the purview of Ashadeep policy benefit. The letter was Ex. B8. Ex. B9 was another letter issued by the same doctor namely Dr. P. Bali Reddy. But in Ex. A2 a Xerox copy of Ashadeep (II) pamphlet it was mentioned that the policy would cover to heart and bypass surgery. The ailment was not Beloon therapy o r Laser catheter surgery as mentioned in Ex. A2. It was not mentioned in Ex. A2 that the ailment of the complainant would not cover under the policy. Simultaneously the complainant failed to produce the bills and prescriptions given by the NIMS hospital, Hyderabad that the complainant incurred Rs. 3,00,000/- towards hospitalization and other expenses. The burden was on the complainant to prove that he incurred Rs. 3,00,000/- t owards hospitalization and other expenses. No doubt that the respondent corporation admitted the policy taken by the complainant and Xerox copy of the policy was filed under Ex. B1 for a premium amount of Rs. 50,000/-. Hence, in these circumstances the complaint is allowed. The points are answered accordingly. 8. Point No. 3 In the result, the complaint is allowed, directing the respondent to pay Rs. 50,000/- (Rupees fifty thousand only) towards hospitalization charges under the policy along with Rs. 10,000/- (Rupees ten thousand only) towards mental agony and Rs. 1,000/- (Rupees one thousand only) towards costs, C.C. No. 14 of 20095 payable within 45 days from the date of receipt of the order, failing which the complainant is entitled interest @ 9% p.a. on the amount of Rs. 50,000/- from the date of claim till date of realization. Dictated to the Stenographer, transcribed by him, corrected and pronounced by us in the open forum, this the 4 MEMBER MEMBER PRESIDENT APPENDIX OF EVIDENCE Witnesses examined. For Complainant : NIL For Respondent : NIL Exhibits marked for Complainant : - Ex. A1 X/c of premium receipt issued by respondent, dt. 26-7-2008. Ex. A2 X/c of Ashadeep (II) pamphlet issued by respondent. Ex. A3 X/c of letter from complainant to respondent dt. 13-7-2007. Ex. A4 X/c of cash receipt issued by NIMS, Hyderabad dt. 26-6-2007. Ex. A5 X/c of letter from respondent to complainant, dt. 9-1-2008. Exhibits marked for Respondents: - Ex. B1 X/c of policy issued by respondent in favour of complainant. Ex. B2 X/c of proposal form submitted by the complainant. Ex. B3 X/c of Medical attendant / Cardiologist’s report issue by NIMS, Hyd. Ex. B4 X/c of Operating surgeon’s report issued by NIMS, Hyderabad. Ex. B5 X/c of medical certificate issued by NIMS, Hyderabad, dt. 17-3-2007. Ex. B6 X/c of Department of Vascular surgery, NIMS, Hyderabad. Ex. B7 X/c of letter from respondent to complainant, dt. 9-1-2008. Ex. B8 Doctor report issued by Dr. Bali Reddy, M.D., dt. 6-11-2007. Ex. B9 Report issued by Dr. P. Bali Reddy, dt. 22-5-2009. MEMBER MEMBER PRESIDENT Copy to :- 1) Sri T. Nagaraju and G. Trivikram Singh, Advocated. 2) Sri T.V.S.S. Murthy, Advocate. 1) Copy was made ready on : 2) Copy was dispatched on : 3) Copy of delivered to parties : B.V.P. - - - C.C. No. 14 of 2009th May 2009 DISTRICT FORUM :: KADAPA PRESENT SRI P.V. NAGESWARA RAO, M.A., LL.M., PRESIDENT SRI S. ABDUL KHADER BASHA, B.Sc., MEMBER Thursday, 4 CONSUMER COMPLAINT No. 14 / 2009 Syed Naster, S/o Abdul Sattar, aged about 46 years, Muslim, R/at.D.No. 6745-2, Ganjikunta Colony, Kadapa, Kadapa district. ….. Complainant. Vs. Life Insurance Corporation of India, Rep. by its Branch manager, Branch Office, Nagarajupet, Kadapa – 516 001 (AP) ….. Respondent. This complaint coming on this day for final hearing on 28-5-2009 in the presence of Sri T. Nagaraju and Sri G. Trivikram Singh, Advocates, for complainant and Sri T.V.S.S. Murthy, Advocate for respondent and upon perusing the material papers on record, the Forum made the following:- O R D E R (Per Sri P.V. Nageswara Rao, President), 1. Complaint filed under section 12 of the Consumer Protection Act 1986. 2. The brief facts of the complaint is as follows:- The complainant was working as conductor in APSRTC Kadapa depot and took one Ashadeep insurance policy bearing No. 652032717 on his life under salary savings scheme from the respondent. The premium amount was deducted from his salary and remitted to the respondent. Under the policy there was a sick benefit claim and in case of hospitalization the insured would claim for the same from the respondent. On 16-2-2007 the complainant underwent bypass surgery at NIMS hospital, Hyderabad and spent Rs. 3,00,000/- towards hospitalization and expenses. The complainant made a claim to the respondent under the policy by submitting all relevant documents. On 19-1-2008 the complainant received a letter from the respondent repudiating the claim on the ground that the disease did not come under the purview of the policy. The policy covered to serious diseases like cancer, Kidneys renal failure, Paralysis, and bypass surgery. It was mentioned in the pamphlets distributed by the respondent company. Therefore, there was deficiency of service
......................Sri P.V. Nageswara Rao
......................Sri.S.A.Khader Basha | |
