BEFORE THE DISTRICT FORUM: KURNOOL

Present: Sri. T. Sundara Ramaiah , B.Com B.L., President

And

Sri. M.Krishna Reddy, M.Sc., M.Phil., Male Member

Monday the 22^nd day of November , 2010

C.C.No 108/10

Between:

Kosuru Umadevi alias C.Umadevi, W/o. C.V.Subba Rao,

H.No. 6-6-489A, Upstairs, Irlanagar, Tirupati,  Chittoor District.         

                …..…Complainant

-Vs-

1. The Branch Manager,Life Insurance Corporation of India,

    Holding its office at Railway Station Road, Nandyal, Kurnool District.       

2. The Divisional Manager,Life Insurance Corporation of India,   Divisional Office,

    Kadapa.                                           ….…Opposite  Parties

                              This complaint is coming on this day for orders in the presence of Sri. C. Raghava Reddy, Advocate, for complainant, and Sri. G.Md. Habeebur Rahiman, Advocate for opposite parties and upon perusing the material papers on record, the Forum made the following.

ORDER

(As per Sri. T.Sundara Ramaiah, President)

C.C. No.108/10

1. This complaint is filed under section 12 & 14 of C. P. Act, 1986 praying to direct the OPs

1.   1 & 2 to pay a sum of Rs.1,00,000/ towards assured amount

          along with interests @ 12% p.a for the late payment.

(b)          to pay a sum of Rs.25,000/- towards damages, mental

              agony expenses of the complainant ,

(c )         directing the Ops to pay a sum of Rs.2,500/- towards the costs of this complaint, and   

(d)          pass such other  and further orders as this Hon’ble Forum

may deem fit and proper in the circumstances of the case.

(2)   The case of the complainants is as under :- The complainant took the LIC policy from OP.No.1 on 28-10-2004. The period of policy is 20 years. The complainant nominated her husband as nominee in the policy. Under the policy the OPs have assured an amount equal to 100% of the sum assured subject to maximum of Rs.2,00,000/- . The amount is payable on the diagnosis of invasive cancers manifest on the following organs: Breast, Cervix Uteri, Corpus Uteri, Ovaries, Fellopain tubes, Vagina/Vulva. The complainant suffered ill health and took treatment at Sri Venkateswara Nursing Home, Nandyal from     22-11-2006 to 14-05-2007. The doctor by name Dr.K. Chandrakala Reddy has diagnosised that the complainant suffered from bleeding disorder of Uterus and it comes under the preview of Cervix Uteri. The complainant was referred to Aswani Nursing Home, Kurnool. In the said hospital the complainant underwent surgery on 18-06-2007 got removed her cervix uteri. After operation the removal part was sent to Biopsy to the Gowri Gopal Hospital Pvt Ltd, Kurnool. The said hospital report dated 23-06-2007 revealed that the complainant  suffered with Chronic Cervicities and Leiomyoma ( Uterus). The complainant has spent more than Rs.45,000/- towards medical expenses, surgical charges and diagnosis . The complainant submitted claim forms to the OPs. The OP.No.1 wrongly repudiated the claim stating that the surgery underwent by the complainant was not covered under the critical illness. On account of the repudiation of the claim the complainant suffered mental agony. There is deficiency of service on the part of the OPs. Hence the complaint.   

3.     OP.No.2 filed written version and the same is adopted by OP.No.1. It is averred in the written version of OP.No.2 that the complaint is not maintainable. As per the terms and conditions of the policy the diagnosis of invasive cancer manifest in the organs like Breast , Cervix, Uteri, Ovaries, Fallopian Tubes, Vaginal Vulva are covered . As per the discharge summary issued by Sri. Aswani Hospital , Kurnool the complainant has suffered from sever bleeding from uterus . The said deceased was not covered under critical illness benefits.  Hence the claim of the complainant was repudiated as per polices condition No.14 - A .  There is no deficiency of service on the part of OPs. The surgery underwent by the complainant is not covered under the critical illness benefits as per the policy conditions. The  complainant  is liable to be dismissed.            

  4.   On behalf of the complainants Ex.A1 to A5 are marked and the sworn affidavit of the complainant is filed.  On behalf of the opposite parties Ex.B1 to B10 are marked and the sworn affidavit of OP.No.2 is filed.

5.     Both sides filed written arguments.

6.     The points that arise for consideration are     

(i)     whether there is deficiency of service on the part of the OPs ?

(ii)    whether the  complainant is  entitled to the reliefs as prayed for?

(iii)    To what relief?

7. Point No.1 & 2:  Admittedly the complainant obtained Ex.A1 policy bearing No. 653608002 dated 28-11-2004. As per the said policy an amount equal to 100% of the sum assured subject to a maximum of Rs.2,00,000/- is payable on the diagnosis of invasive cancer manifest in Breast , Cervix, Uteri, Ovaries, Fallopian Tubes, Vaginal Vulva. It is the case of the complainant that she took treatment in Sri. Venkateswara Nursing Home, Nandyal from 22-11-2006 to              14-05-2007 and that the Dr. K. Chandrakala Reddy issued Ex.A4 certificate. It is mentioned in Ex.A4 certificate dated 25-09-2007 that the complainant suffered from bleeding disorder of uterus and it comes under the category of cervix uteri and that the complainant was referred to Sri. Aswani Nursing Hospital, Kurnool for Laparoscopy hysterectomy. The complainant filed Ex.A5 bunch of medical prescriptions to show that the complainant took treatment in Aswani Hospital. Ex.B3 is the discharge summary of the complainant maintained by Sri. Aswani Hospital. It is mentioned in Ex.B3 that cervix uteri of the complainant was removed on 18-06-2007. Ex.B9 is the Biopsy report dated 23-06-2007 issued by Gowri Gopal Hospital, Kurnool. In Ex.B9 it is mentioned that Histological picture is suggestive of (1) Chronic Cervicitis , (2) Leiomyoma (Uterus) .     

8.     The OPs repudiated the claim of the complainant stating that the surgery underwent by the complainant is not cover under the critical illness benefits as per condition No. 14 of the policy. As per the terms and conditions of the policy the complainant is entitled to the sum assured if she is suffering from  invasive cancer on cervix uteri etc., No doubt in the present case there is evidence on record to show that the complainant underwent operation and her organ cervix uteri was removed. The complainant did not place any evidence to show that she suffered from cancer. The various documents filed by the both parties do not suggest that the complainant  suffered from cancer to uterus . The complainant did not choose to examine Dr. K.Chandrakala Reddy who issued Ex.A4 certificate to show that the complainant suffered from cancer to uterus. Mere bleeding from uterus does not amount to cancer. There is no medical evidence to come to the conclusion that the complainant suffered from cancer to uterus. Merely because some fibroied is found on the uterus of the complainant and the same was removed by conducting surgery it can not be said that the complainant suffered from cancer to her uterus. The biopsy report Ex.B9 also does not reveal that the complainant suffered from cancer to her uterus. As already stated as per the conditions of the policy the complainant is entitled to the assured amount if she suffered from cancer to uterus etc., The mere removal of uterus does not cover critical illness benefits as mentioned in the policy. The OPs rightly repudiated the claim of the complainant stating that surgery underwent by the complainant is not covered under the critical illness benefits as per the policy conditions. There is no deficiency of service on the part of the OPs. The complainant is not entitled to the reliefs as prayed for.

9.Point No3:   In the result the complaint is dismissed . In the circumstances no costs.

Dictated to the stenographer, transcribed by her, corrected and pronounced by us in the open bench on this the 22^nd day of November, 2010.

          Sd/-                                                                Sd/-

     MALE MEMBER                                                  PRESIDENT

APPENDIX OF EVIDENCE

Witnesses Examined

For the complainant : Nil            For the opposite parties : Nil

List of exhibits marked for the complainant:-

List of exhibits marked for the opposite parties:

                   Sd/-                                                                           Sd/-

         MALE MEMBER                                                                     PRESIDENT

// Certified free copy communicated under Rule 4 (10) of the

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