Tripura

West Tripura

CC/68/2015

Shri Biplab Chandra Deb. - Complainant(s)

Versus

The Manager, Birla Sun Life Insurance Company Ltd. & 1 another. - Opp.Party(s)

Mrs. R.Shil, Mr. S.Choudhury.

27 Jun 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSSAL FORUM
WEST TRIPURA  :  AGARTALA

CASE   NO:   CC- 68 of 2015

Sri Biplab Deb,
S/O- Late Raman Chandra Deb,
Banamalipur, Itakhola Road,
P.O. Agartala Head Post Office,
P.S. East Agartala, West Tripura.        ...….…...Complainant.

VERSUS

1. The Manager,
    Birla Sun Life Insurance Company Ltd.,
    Registered Office: One Indiabulls Centre,
    Tower 1, 15th & 16th Floor, Jupiter Mill
    Compound, 841,     Senapati Bapat Marg,
    Elphinstone Road, Mumbai- 400013.

2. Branch Manager,
    Birla sun Life Insurance Company Ltd.,
    47, H.G.B. Road, Singhapara, 
   Opp. Sarkar Nursing Home, Agartala,  
   Tripura- 799001.                     ..............Opposite parties.

      __________PRESENT__________

 SRI A. PAL,
PRESIDENT,
  DISTRICT CONSUMER  
DISPUTES REDRESSAL FORUM,
      WEST TRIPURA, AGARTALA. 

SMT. Dr. G. DEBNATH
MEMBER,
  DISTRICT CONSUMER 
DISPUTES REDRESSAL FORUM, 
  WEST TRIPURA,  AGARTALA.

SRI U. DAS
MEMBER,
  DISTRICT CONSUMER 
DISPUTES REDRESSAL FORUM, 
  WEST TRIPURA,  AGARTALA.

C O U N S E L

For the Complainant        : Sri Sampad Choudhury,
                      Smt. Rinku Shil,
                      Advocates.

For the O.Ps                 : Sri Dip Datta Choudhury,
                      Advocate,                    

        JUDGMENT  DELIVERED  ON:    27.06.16

J U D G M E N T

        This case arises on the petition filed by one Biplab Deb. Fact of the case in short is that the petitioner purchased Birla Sun Life Insurance Policy 'Dream Endowment Plan'. Premium Rs.10,391/- was paid. Policy commenced from 27.12.11. The basic sum assured was Rs.1,20,000/-. The policy assured Rider Sum Benefit. As per that term in case of critical illness under Rider Sum Benefit, policy holder will get Rs.1,16,000/-. For that Rs.4781/-  was paid as 'Annual Rider Premium'. Petitioner paid second premium Rs.10,391/- after 6 months. In the first week of June 2012 petitioner felt pain in the chest and underwent treatment at Agartala. The doctor advised him to go Narayana Hrudayalaya Hospital, Bangalore. Narayana Hrudayalaya Hospital doctors diagnosed that the complainant suffered coronary artery disease and immediately suggested open heart surgery to prevent stroke or heart attack. Accordingly he underwent open heart surgery for prevention of heart attack or stroke. After recovery after treatment petitioner approached the O.P. No.2, Branch Manager of Birla Sun Life Insurance Company to get benefit under Rider Sum Benefit scheme as he subscribed premium for that benefit. On 02.05.13 the Manager, Birla Sun Life Insurance Company turned down his request stating that he is not entitled to get Rider Benefit for his critical illness as the treatment was not covered under the heading 'Heart Attack'. So, the petitioner filed this case for redress before the District Forum. 
    
2.        Opposite party appeared, filed W.S denying the claim. The only contention raised by the opposite party is that the petitioner is not a consumer and his hospitalization at Narayana Hrudayalaya, Bangalore was not within the knowledge of the opposite party. The condition with which the complainant was diagnosed can not be termed as 'Cardiac Heart Attack' as per  medical science. Coronary artery bi-pass grafting was done to improve the blood flow into the heart. Such surgery is termed as CABG to treat people who have severe Coronary Artery Heart attack but it is not fall under heart attack heading as described in the policy. Therefore petitioner is not entitled to get any compensation. 
        
3.        On the basis of contention raised by both the parties following points cropped up for determination. 
        (I) Whether treatment done to the complainant was related to heart attack or stroke?
        (II) Whether the petitioner is entitled to get compensation for deficiency of service?

4.        Petitioner side produced Dream Endowment Plan, renewal premium receipt, letter dated 31.03.13, prescription of Narayana Hurdayalaya, operation note, treating doctors certificate, discharge certificate of complainant, bill cum receipt of Narayana Hrudayalaya Hospital. Petitioner also examined one witness that is the complainant himself. 

5.        O.P. on the other hand, produced no evidence inspite of giving several chances. Chances given for producing any expert or cardiologist who not produced. So, on the basis of evidence as produced before us we shall now determine the points.

Findings and decision on point no.1 & 2:
6.        It is admitted fact that petitioner purchased the Birla Sun Life Insurance Policy in the year 2011. His claim for treatment cost as per terms and conditions of the critical illness rider policy was turned down by the letter dated 31st March 2013 and reply was given to that legal notice also sent by the company on August 2015. The claim therefore, is not time barred. Petitioner claimed the policy benefit and wanted to get the service of Birla Sun Life Insurance company but service was not provided to him as his claim not covered by policy terms. Therefore, he being a consumer has the locus standi to file prayer before this Forum for redress. The fact of treatment in the Narayana Hrudayalaya is not denied by the opposite party. We have gone through the operation note, prescription issued by Dr. Binoy C of Narayana Hurdayalaya Hospital. We have also gone through the certificate of Consultant Cardiac Surgeon, Discharge certificate. From all the medical papers and vouchers it is clear that Mr. Biplab Dev was treated in the Narayana Hrudayalaya, Bangalore and CABG was done to him. His total expenditure as per the receipt of chief Medical Officer, Narayana Hurdayalaya was Rs.1,60,637/-. Apart from this, there was expenditure for conveyance from Agartala to Bangalore, fooding, lodging etc. But the petitioner claim is to be confined Rs.1,16,000/- as per policy certificate. 

7.        The contention of the opposite party is that as per policy condition petitioner is entitled to get critical illness benefit. In regard he is only entitled to get treatment cost for critical illness like, stroke, heart attack, cancer etc. Now the question is whether under Rider Provision the person is only entitled to get the benefit after heart attack or before heart attack. We have gone through the terms and conditions where heart attack is defined. As per definition, Heart attack is ''first occurrence on heart attack or myocardial infraction which means death of portion of heart muscle as a result of acute interruption of blood supply to the myocardium''. Coronary artery bypass grafting surgery is done for regular supply of blood into the myocardium. It is done to treat the coronary artery disease. Coronary artery disease is the narrowing of coronary arteries-, the blood vessels that supply oxygen and nutrients to the heart muscle. So this bypass surgery was done to treat the block arteries. An artery from the wrist may be used and it is attached above the blockage. The other end is attached below the blockage. This is called coronary artery bypass surgery. Its symptom is  chest pain, palpitations, abnormal heart rate, tiredness etc. 

8.        In this case, the contention of the Birla Sun Life Insurance Company is that the petitioner did not suffer 'heart attack' or 'stroke'. Admittedly after the diagnosis of the critical illness he survived for more than 30 days. The diagnosis occurred  while the rider scheme was in effect. In such a case benefit amount shall be equal to the riders sum assured payable upon first occurrence of heart attack. There is no specific evidence before us that heart attack was occurred. But we are satisfied that treatment was in respect of prevention of heart attack. The person was on the brink of heart attack as his coronary artery was narrow. In order to prevent it surgery was done. Insurance policy is to be construed having reference only  to stipulation contained in it and no artificial farfetched meaning can be given to the words. The duty of the court is to interpret the word  in which the contract is expressed by the parties. It is not that the court to make new contract however, reasonable if the parties do not make it necessary. 

9.        In this case it is clear that the treatment done at Naryana Hrudayalaya was in respect of heart attack. As per Rider provision when there was acute interruption of blood supply then the portion of heart muscle may die. In this case on the prescription CABG was advised. He underwent 'Elective Coronary Bypass Grafting' as per the certificate. From the prescription nothing found to support the death of heart muscle but the operation was done for saving the heart muscle. Therefore, from the above discussions it is clear that as per policy condition petitioner was entitled to get insured amount as his treatment related to heart attack and cardiovascular disease related to supply of blood into the heart muscle. The 'Dream Endowment Plan' policy support that clause of policy in regard to treatment cost for critical illness to be paid by the company. The amount was Rs.1,16,000/-. Petitioner claimed the amount but company, O.P. No.1 and 2 repudiated his claim on mis-interpretation of terms and condition. This is deficiency of service. Petitioner is therefore, entitled to get compensation for this deficiency of service. As the O.P. failed to understand the clause clearly and medical certificate also not clear on this fact, we consider that deficiency is not full but partly it was done. So for the deficiency of service, we direct the Insurance company to pay compensation Rs.10,000/- and also litigation cost Rs.5000/-. In addition the O.P. is to pay the critical illness benefit Rs.1,16,000/- to the petitioner. Points are decided accordingly.

10.        In view of our above findings over the two points the case of the petitioner is partly allowed. We are of the opinion that there was deficiency of service by the Birla Sun Life Insurance Co.  We therefore, direct the O.P. to pay critical illness benefit Rs.1,16,000/- (Rupees One Lac Sixteen Thousand) to the petitioner also pay Rs.10,000/-(Rupees Ten Thousand)  + Rs.5,000/-(Rupees Five Thousand) as compensation & cost of litigation to the petitioner. In total amount stands as Rs.1,31,000/-(Rupees One Lac Thirty One Thousand). The amount is to be paid within 2(two) months, if not paid it will carry interest @ 9% P.A.   
    
                          Announced.

SRI A. PAL
PRESIDENT,
DISTRICT CONSUMER  DISPUTES 
REDRESSAL FORUM,
WEST TRIPURA,  AGARTALA.

 

SMT. DR. G. DEBNATH,
MEMBER,
 DISTRICT CONSUMER DISPUTES 
REDRESSAL FORUM, 
WEST TRIPURA, AGARTALA    SRI U. DAS,
MEMBER,
 DISTRICT CONSUMER DISPUTES 
REDRESSAL FORUM, 
WEST TRIPURA, AGARTALA