The Divisional Manager, LIC of India, Raichur V/S Smt. Jayashree W/o. U.D Javalagi, Raichur - Consumer Court Case

Karnataka

Raichur

CC/10/40

Smt. Jayashree W/o. U.D Javalagi, Raichur - Complainant(s)

Versus

The Divisional Manager, LIC of India, Raichur - Opp.Party(s)

Sri. S.K. Purohit

29 Nov 2010

ORDER

Dist. Consumer Disputes Redressal Forum, Sath Kacheri, Raichur.
Dist. Consumer Disputes Redressal Forum, Sath Kacheri, Raichur.
consumer case(CC) No. CC/10/40

Smt. Jayashree W/o. U.D Javalagi, Raichur UD Javalagi S/o. Daulat Rao, Raichur						...........Appellant(s)
Vs.
The Divisional Manager, LIC of India, Raichur The Zonal Manager, LIC of India, Hyderabad.						...........Respondent(s)

BEFORE:

Complainant(s)/Appellant(s):

OppositeParty/Respondent(s):

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ORDER

JUDGEMENT By Sri. Pampapathi President:- This is a complaint filed by complainant Nos. 1 & 2 against the opposite LIC of India U/sec. 12 of Consumer Protection Act for to direct it to pay a sum of Rs. 1,13,370/- with 10,000/-, another 10,000/- and Rs. 35,000/- with cost and other reliefs as deems fit to the circumstances of this case. 2. The brief facts of the complainants case are that, complainant No-1 being the wife of complainant No-2 purchased jointly LIC Health Plus Insurance Policy dt. 15-05-2008 from the opposite Insurance Company Ltd., The said policy covering their health problems and accordingly in the month of December 2008, the complainant started suffering severe cough problems, she got treated in Rajiv Gandhi Super Specialty Hospital, Raichur. The Cardiologist Dr. Suresh Sagarad advised her to go for C.T Scanning and other tests, thereafter he advised her to take treatment in Apollo Hospital Bangalore, accordingly she took treatment in the Apollo Hospital, Bangalore wherein her decease was diagnosed as chronic constructive Pericarditis, Periacardectomy, she undergone operation by admitting as an inpatient. She was kept 4 days in ICU, totally she was in patient for (9) days in the hospital. She incurred heavy medical expenditure, she filed claim petition before the opposite but opposite sent only an amount of Rs. 2,800/- and Rs. 4,200/- in respect of the said two policies, therefore they approached opposite LIC for to settle her full claim, as per the medical bills submitted but opposite shown its negligence in settling her claim by giving untenable grounds and thereby it refused to consider their requests, as such complainant Nos-1 & 2 have filed this complaint for the reliefs as prayed in it. 3. The opposite LIC of India appeared in this case through their Advocate, filed their written version, admitted regarding the subscribing the policy by complainant Nos- 1 & 2 and payment of regular premiums vide policy. It is contended in Para-6 of its written version that, the decease suffered by the complainant No-1 as per the summary report dt. 29-12-08 is Mediastinal mass S/p Excision of mass with Pericardectomy which is a different decease from the Periacardectomy. The said decease is not listed in the list of deceases annexed to this policy, as such the complainants and not entitled for any kind of reliefs as prayed in the complainant and prayed for to dismiss their complaint among other grounds. 4. In-view of the pleadings of the parties. Now the points that arise for our consideration and determination are that: 1. Whether the complainant Nos-1 & 2 proves that, both of them have subscribed LIC Health Plus Insurance Policy in the name of complainant No-2 from the opposite thereafter complainant No-1 suffered chest problems consulted doctors in Rajiv Gandhi Super Specialty Hospital, Raichur and as per the medical advise, she admitted in Apollo Hospital, Bangalore wherein an operation conducted for periacarditis pericardectomy she admitted in the hospital as an inpatient and incurred medical expenditure to the extent of Rs. 1,13,370/-. Prior to it she incurred expenditure of Rs. 10,000/- for getting treatment in Rajiv Gandhi Super Specialty Hospital, she filed claim petition before the LIC of India for to reimbursement of medical expenditure but opposite not considered their requests they have refunded only to the extent of Rs. 2800/- on 15-05-09 and Rs. 4200/- on 23-06-09, they shown negligence in settling their claim and thereby opposite found guilty under deficiency in its service.? 2. Whether complainant Nos.1 & 2 are entitled for the reliefs as prayed in their complaint.? 3. What order? 5. Our findings on the above points are as under:- (1) In the affirmative (2) As discussed in the body of this judgement and as noted in the final order. (3) In-view of the findings on Point Nos. 1 & 2, we proceed to pass the final order for the following : REASONS POINT NO.1 :- 6. To prove the facts involved in these two points, affidavit-evidence of the complainant No-1 was filed, she was noted as PW-1. Affidavit-evidence of the doctor of Apollo Hospital Bangalore who treated the complainant No-1 and conducted operation on her was filed and he was noted as PW-2. Totally documents Ex.P-1 to Ex.P-23 are marked. 7. On the other hand affidavit-evidence of the Manager (L&HPF) of LIC was filed who was noted as RW-1. Affidavit-evidence of one doctor from the penal of doctors of LIC by name Dr. A.Parashuram was filed, he was noted as RW-2. Totally documents Ex.R-1 to Ex.R-6 are marked. 8. On going through the pleadings of the parties, their respective affidavit-evidences and documents filed by them, we have noticed some of the following facts are undisputed facts in between the parties are:- 1. It is undisputed fact that, the complainant No-1 who is the wife of complainant No-2 and both of them have subscribed jointly LIC Health Plus Insurance Policy bearing No. 664271558 & 664271559 dt. 15-05-08 in the name of complainant No-2 from the opposite LIC. 2. It is also undisputed fact that, premiums towards the said policies paid by the complainant regularly and the policies are inforce. 3. It is further undisputed fact that, the complainant suffered chest pain during the month of December-2008, she took treatment in Rajiv Gandhi Super Specialty Hospital, Raichur and as per the advise of the doctors of the said hospital she got operated in Apollo Hospital, Bangalore by admitting herself as an inpatient for (9) days. 9. In the light of these undisputed facts, now we have to appreciate the disputed facts in between the parties. According to the complainant she suffered chronic constructive pericarditis, pericardectomy which is a decease covered under the policy as listed in the list of deceases and thereby whatever the expenditure incurred by her for taking treatment in Raichur as well as in Bangalore is liable to be paid by the opposite Insurance Company. 10. On the other hand opposite LIC of India is contending before us that, as per the summary report, the decease suffered by the complainant No-1 was Mediastinal, mass S/p Excision of mass with Pericardectomy. The said decease is not listed in the list of the deceases enclosed with the said policy and it is a different decease and thereby it not entitled to make reimbursement of the actual medical charges said to have incurred by complainant No-1. 11. In support of the claim of complainant, she filed affidavit-evidence of PW-2 doctor who conducted operation on her at that time. In support of the contention of opposite it filed affidavit-evidence of doctor who is one of the penal of doctors of LIC. 12. In view of the undisputed facts and disputed facts in between the parties let us first examine the document of parties. Ex.R-1 the claim of rejection letter issued by opposite discloses that, the surgical undergone by the complainant No-1 is not listed and the claim is not allowed. The complainant contended throughout her evidence that, she was undergone the operation Pericarditis, Periacardectomy in the Apollo Hospital by RW-2. 13. Ex.P-7 diagnostic report of CT Chest Plain & Contrasting of complainant No-1. Ex.P-8 is an Operative Notes of complainant No-1 dt. 23-12-08 maintained by RW-2, shows that, Mediastinal, mass size to the extent of 8 cm x 6 cm compressing and constricting the right ventricle. In the light of Ex.P-8 we can safely say that, there was a compressing and constricting mediastinal mass to the extent of 8 cm x 6 cm to the right ventricle. 14. In addition to the above documents affidavit-evidence of PW-2 who conducted operation as per Ex.P-8 and the list of deceases annexed to Insurance Policy Ex.R-1 and the affidavit-evidence of RW-2. It is very much understandable by us that, mediastinal mass is compressing and constricting the right ventricle. No doubt the evidence of RW-2 doctor differs in opinion to PW-2, however we cannot rule out that, compressing and constricting right ventricle due to mediastinal mass to the extent of 8 cm x 6 cm is related to constructive Periacarditis and Periacardectomy done which is as per the decease noted in Annexure No-2 list of decease and surgical procedure annexed to the policy No-2, as such we are not in a position to except the submissions made by the learned advocate for opposite in this regard as the operation conducted for a different decease which is not listed annexed to the policy and thereby we rejected the opinion of RW-2 doctor who is none else then the doctor from the penal advocates of LIC. Rejecting the claim of complainant on that ground by LIC of India is due to it is negligence and thereby there is a shortfall in service by it towards the complainant, accordingly we answered Point No-1 in affirmative. 15. Documents Ex.P-3 to Ex.P-5 filed by the complainant are prescriptions pertaining to Rajiv Gandhi Super Specialty Hospital, Raichur. Ex.P-6 & Ex.P-7 are the diagnostic report from diagnostic center Raichur. The complainant not produced any one of the bills as regards to the quantum of amount spent by them in related to treatment taken at Rajiv Gandhi Super Specialty Hospital, Raichur. Simply they claimed that they have incurred expenditure of Rs. 10,000/- in Raichur without support of any one of the bills, accordingly we have rejected the claim of complainant for to grant an amount of Rs. 10,000/- as they have incurred as medical expenditure of Rs. 10,000/- at Raichur. 16. No records placed before us to show that, complainants have incurred attendant charge of Rs. 10,000/-, more over this kind of expenditure not bearable by LIC as it was out of the terms and conditions of the policy, accordingly this claim of the complainant is rejected. 17. Ex.P-8 is the Operative Notes of Appolo Hospital, Bangalore. Ex.P-9 is the Final Cash Bill regarding payment made by the complainant in Apollo Hospital, Bangalore dt. 29-12-08. The total amount charged by the hospital is of Rs. 1,11,670.73/- Ps. out of this amount LIC paid 2800/- on 15-05-09 and the amount of Rs. 4200/- on 23-06-09 towards the said two policies, as such this total amount of Rs. 7000/- is to be deducted out of Rs. 1,13,370.73/- Ps., after deduction of the said amount, the balance amount is of Rs. 1,06,370.73/- Ps which is rounded to Rs. 1,06,400/- this is the amount entitled by the complainants from opposite LIC of India towards the medical expenditure incurred by them in Apollo Hospital, Bangalore under the said policies. 18. We have already noticed the deficiency in service on the part of LIC of India, as such a lump sum amount of Rs. 3,000/- is awarded under this head. 19. The complainants have claimed for Rs. 35,000/- towards mental shock and agony, we are of the view that, the said amount for suffering of mental shock and agony is not granted to them as prayed for, as we are awarding reasonable interest on the total sum. Hence this prayer of the complainant is rejected. 20. Towards the cost of litigation complainants are entitled for another sum of Rs. 3,000/-, as such complainants are totally entitled to get an amount of Rs. 1,12,400/-. 21. The complainants are entitled to get future interest at the rate of 9% p.a. on the total sum of Rs. 1,12,400/- from the date of the complaint till realization of the full amount, accordingly we answered Point No-2. POINT NO.3:- 22. In view of our findings on Point Nos-1 & 2, we proceed to pass the following order: ORDER The complaint filed by the complainants is partly allowed with cost. The complainants are entitled to get a total amount of Rs. 1,12,400/- from opposite LIC of India. The complainants are also entitled to get future interest at the rate of 9% p.a. on the above total sum of Rs. 1,12,400/- from the date of the complaint till realization of the full amount. Opposite is hereby granted one month time to make the payment of the above said amount with interest from the date of this judgment. Intimate the parties accordingly. (Dictated to the Stenographer, typed, corrected and then pronounced in the open Forum on 29-11-10) Sd/- Sri. Pampapathi, President, District Forum-Raichur. Sd/- Sri. Gururaj, Member, District Forum-Raichur. Sd/- Smt.Pratibha Rani Hiremath, Member. District Forum-Raichur.

JUDGEMENT By Sri. Pampapathi President:- This is a complaint filed by complainant Nos. 1 & 2 against the opposite LIC of India U/sec. 12 of Consumer Protection Act for to direct it to pay a sum of Rs. 1,13,370/- with 10,000/-, another 10,000/- and Rs. 35,000/- with cost and other reliefs as deems fit to the circumstances of this case. 2. The brief facts of the complainants case are that, complainant No-1 being the wife of complainant No-2 purchased jointly LIC Health Plus Insurance Policy dt. 15-05-2008 from the opposite Insurance Company Ltd., The said policy covering their health problems and accordingly in the month of December 2008, the complainant started suffering severe cough problems, she got treated in Rajiv Gandhi Super Specialty Hospital, Raichur. The Cardiologist Dr. Suresh Sagarad advised her to go for C.T Scanning and other tests, thereafter he advised her to take treatment in Apollo Hospital Bangalore, accordingly she took treatment in the Apollo Hospital, Bangalore wherein her decease was diagnosed as chronic constructive Pericarditis, Periacardectomy, she undergone operation by admitting as an inpatient. She was kept 4 days in ICU, totally she was in patient for (9) days in the hospital. She incurred heavy medical expenditure, she filed claim petition before the opposite but opposite sent only an amount of Rs. 2,800/- and Rs. 4,200/- in respect of the said two policies, therefore they approached opposite LIC for to settle her full claim, as per the medical bills submitted but opposite shown its negligence in settling her claim by giving untenable grounds and thereby it refused to consider their requests, as such complainant Nos-1 & 2 have filed this complaint for the reliefs as prayed in it. 3. The opposite LIC of India appeared in this case through their Advocate, filed their written version, admitted regarding the subscribing the policy by complainant Nos- 1 & 2 and payment of regular premiums vide policy. It is contended in Para-6 of its written version that, the decease suffered by the complainant No-1 as per the summary report dt. 29-12-08 is Mediastinal mass S/p Excision of mass with Pericardectomy which is a different decease from the Periacardectomy. The said decease is not listed in the list of deceases annexed to this policy, as such the complainants and not entitled for any kind of reliefs as prayed in the complainant and prayed for to dismiss their complaint among other grounds. 4. In-view of the pleadings of the parties. Now the points that arise for our consideration and determination are that: 1. Whether the complainant Nos-1 & 2 proves that, both of them have subscribed LIC Health Plus Insurance Policy in the name of complainant No-2 from the opposite thereafter complainant No-1 suffered chest problems consulted doctors in Rajiv Gandhi Super Specialty Hospital, Raichur and as per the medical advise, she admitted in Apollo Hospital, Bangalore wherein an operation conducted for periacarditis pericardectomy she admitted in the hospital as an inpatient and incurred medical expenditure to the extent of Rs. 1,13,370/-. Prior to it she incurred expenditure of Rs. 10,000/- for getting treatment in Rajiv Gandhi Super Specialty Hospital, she filed claim petition before the LIC of India for to reimbursement of medical expenditure but opposite not considered their requests they have refunded only to the extent of Rs. 2800/- on 15-05-09 and Rs. 4200/- on 23-06-09, they shown negligence in settling their claim and thereby opposite found guilty under deficiency in its service.? 2. Whether complainant Nos.1 & 2 are entitled for the reliefs as prayed in their complaint.? 3. What order? 5. Our findings on the above points are as under:- (1) In the affirmative (2) As discussed in the body of this judgement and as noted in the final order. (3) In-view of the findings on Point Nos. 1 & 2, we proceed to pass the final order for the following : REASONS POINT NO.1 :- 6. To prove the facts involved in these two points, affidavit-evidence of the complainant No-1 was filed, she was noted as PW-1. Affidavit-evidence of the doctor of Apollo Hospital Bangalore who treated the complainant No-1 and conducted operation on her was filed and he was noted as PW-2. Totally documents Ex.P-1 to Ex.P-23 are marked. 7. On the other hand affidavit-evidence of the Manager (L&HPF) of LIC was filed who was noted as RW-1. Affidavit-evidence of one doctor from the penal of doctors of LIC by name Dr. A.Parashuram was filed, he was noted as RW-2. Totally documents Ex.R-1 to Ex.R-6 are marked. 8. On going through the pleadings of the parties, their respective affidavit-evidences and documents filed by them, we have noticed some of the following facts are undisputed facts in between the parties are:- 1. It is undisputed fact that, the complainant No-1 who is the wife of complainant No-2 and both of them have subscribed jointly LIC Health Plus Insurance Policy bearing No. 664271558 & 664271559 dt. 15-05-08 in the name of complainant No-2 from the opposite LIC. 2. It is also undisputed fact that, premiums towards the said policies paid by the complainant regularly and the policies are inforce. 3. It is further undisputed fact that, the complainant suffered chest pain during the month of December-2008, she took treatment in Rajiv Gandhi Super Specialty Hospital, Raichur and as per the advise of the doctors of the said hospital she got operated in Apollo Hospital, Bangalore by admitting herself as an inpatient for (9) days. 9. In the light of these undisputed facts, now we have to appreciate the disputed facts in between the parties. According to the complainant she suffered chronic constructive pericarditis, pericardectomy which is a decease covered under the policy as listed in the list of deceases and thereby whatever the expenditure incurred by her for taking treatment in Raichur as well as in Bangalore is liable to be paid by the opposite Insurance Company. 10. On the other hand opposite LIC of India is contending before us that, as per the summary report, the decease suffered by the complainant No-1 was Mediastinal, mass S/p Excision of mass with Pericardectomy. The said decease is not listed in the list of the deceases enclosed with the said policy and it is a different decease and thereby it not entitled to make reimbursement of the actual medical charges said to have incurred by complainant No-1. 11. In support of the claim of complainant, she filed affidavit-evidence of PW-2 doctor who conducted operation on her at that time. In support of the contention of opposite it filed affidavit-evidence of doctor who is one of the penal of doctors of LIC. 12. In view of the undisputed facts and disputed facts in between the parties let us first examine the document of parties. Ex.R-1 the claim of rejection letter issued by opposite discloses that, the surgical undergone by the complainant No-1 is not listed and the claim is not allowed. The complainant contended throughout her evidence that, she was undergone the operation Pericarditis, Periacardectomy in the Apollo Hospital by RW-2. 13. Ex.P-7 diagnostic report of CT Chest Plain & Contrasting of complainant No-1. Ex.P-8 is an Operative Notes of complainant No-1 dt. 23-12-08 maintained by RW-2, shows that, Mediastinal, mass size to the extent of 8 cm x 6 cm compressing and constricting the right ventricle. In the light of Ex.P-8 we can safely say that, there was a compressing and constricting mediastinal mass to the extent of 8 cm x 6 cm to the right ventricle. 14. In addition to the above documents affidavit-evidence of PW-2 who conducted operation as per Ex.P-8 and the list of deceases annexed to Insurance Policy Ex.R-1 and the affidavit-evidence of RW-2. It is very much understandable by us that, mediastinal mass is compressing and constricting the right ventricle. No doubt the evidence of RW-2 doctor differs in opinion to PW-2, however we cannot rule out that, compressing and constricting right ventricle due to mediastinal mass to the extent of 8 cm x 6 cm is related to constructive Periacarditis and Periacardectomy done which is as per the decease noted in Annexure No-2 list of decease and surgical procedure annexed to the policy No-2, as such we are not in a position to except the submissions made by the learned advocate for opposite in this regard as the operation conducted for a different decease which is not listed annexed to the policy and thereby we rejected the opinion of RW-2 doctor who is none else then the doctor from the penal advocates of LIC. Rejecting the claim of complainant on that ground by LIC of India is due to it is negligence and thereby there is a shortfall in service by it towards the complainant, accordingly we answered Point No-1 in affirmative. 15. Documents Ex.P-3 to Ex.P-5 filed by the complainant are prescriptions pertaining to Rajiv Gandhi Super Specialty Hospital, Raichur. Ex.P-6 & Ex.P-7 are the diagnostic report from diagnostic center Raichur. The complainant not produced any one of the bills as regards to the quantum of amount spent by them in related to treatment taken at Rajiv Gandhi Super Specialty Hospital, Raichur. Simply they claimed that they have incurred expenditure of Rs. 10,000/- in Raichur without support of any one of the bills, accordingly we have rejected the claim of complainant for to grant an amount of Rs. 10,000/- as they have incurred as medical expenditure of Rs. 10,000/- at Raichur. 16. No records placed before us to show that, complainants have incurred attendant charge of Rs. 10,000/-, more over this kind of expenditure not bearable by LIC as it was out of the terms and conditions of the policy, accordingly this claim of the complainant is rejected. 17. Ex.P-8 is the Operative Notes of Appolo Hospital, Bangalore. Ex.P-9 is the Final Cash Bill regarding payment made by the complainant in Apollo Hospital, Bangalore dt. 29-12-08. The total amount charged by the hospital is of Rs. 1,11,670.73/- Ps. out of this amount LIC paid 2800/- on 15-05-09 and the amount of Rs. 4200/- on 23-06-09 towards the said two policies, as such this total amount of Rs. 7000/- is to be deducted out of Rs. 1,13,370.73/- Ps., after deduction of the said amount, the balance amount is of Rs. 1,06,370.73/- Ps which is rounded to Rs. 1,06,400/- this is the amount entitled by the complainants from opposite LIC of India towards the medical expenditure incurred by them in Apollo Hospital, Bangalore under the said policies. 18. We have already noticed the deficiency in service on the part of LIC of India, as such a lump sum amount of Rs. 3,000/- is awarded under this head. 19. The complainants have claimed for Rs. 35,000/- towards mental shock and agony, we are of the view that, the said amount for suffering of mental shock and agony is not granted to them as prayed for, as we are awarding reasonable interest on the total sum. Hence this prayer of the complainant is rejected. 20. Towards the cost of litigation complainants are entitled for another sum of Rs. 3,000/-, as such complainants are totally entitled to get an amount of Rs. 1,12,400/-. 21. The complainants are entitled to get future interest at the rate of 9% p.a. on the total sum of Rs. 1,12,400/- from the date of the complaint till realization of the full amount, accordingly we answered Point No-2. POINT NO.3:- 22. In view of our findings on Point Nos-1 & 2, we proceed to pass the following order: ORDER The complaint filed by the complainants is partly allowed with cost. The complainants are entitled to get a total amount of Rs. 1,12,400/- from opposite LIC of India. The complainants are also entitled to get future interest at the rate of 9% p.a. on the above total sum of Rs. 1,12,400/- from the date of the complaint till realization of the full amount. Opposite is hereby granted one month time to make the payment of the above said amount with interest from the date of this judgment. Intimate the parties accordingly. (Dictated to the Stenographer, typed, corrected and then pronounced in the open Forum on 29-11-10) Sd/- Sri. Pampapathi, President, District Forum-Raichur. Sd/- Sri. Gururaj, Member, District Forum-Raichur. Sd/- Smt.Pratibha Rani Hiremath, Member. District Forum-Raichur.