CONSUMER DISPUTES REDRESSAL FORUM
PALAKKAD, KERALA
Dated this the 28th day of April, 2012.
Present: Smt. Seena. H, President
: Smt. Preetha. G. Nair, Member
: Smt. Bhanumathi. A.K, Member Date of filing: 07/01/2012
CC / 8/ 2012
P.S.Manoharan,
'Karthika', Kalipara, - Complainant
Kottekkad, Palakkad.
(BY ADV. U.Suresh & K.Dhananjayan)
Vs
1. The Manager (CRM),
LIC of India, Divisional Office,
P.B.No.1133, Jeevan Prakash,
M.G.Road, Ernakulam.
(By ADV.T.P.George)
2. The Authorised Signatory/Manager,
The Life Insurance Corporation of India, - Opposite parties
Regd Office,”Yogashema”,
Jeevan Bima Marg, P.B.No.19953,
Mumbai- 400 021.
(By ADV.T.P.George)
3. The Authorised Signatory,
Medi Assist India TPA Private Ltd,
Team-LIC, Shilpa Vidya, 3rd Floor,
#49, 1st Main Road, Sarakki Indl Layout,
3rd Stage, J.P.Nagar, Bangalore
560078, Karnataka.
4. The Manager,
Medi Assist India TPA Private Ltd,
Team-LIC, Shilpa Vidya,
3rd Floor, #49, 1st Main Road,
Sarakki Indl Layout,
3rd Stage, J.P.Nagar, Bangalore
560078, Karnataka.
O R D E R
BY SMT. SEENA.H, PRESIDENT
Complaint in brief:
Complainant availed a policy from opposite parties named Health Plus Plan having coverage from 19/03/2008 to 19/03/2030. The principal sum assured in Rs.1,60,000/- and premium paid is Rs.7,500/- annually. During the period complainant has undergone a angioplasty surgery using 6FJL 3.5 guiding catheter to cannulate the left coronary ostium with a stent having measurement 3 x 15 mm. Complainant sought for reimbursement of the expenses incurred which amounts to Rs.1,56,585/-. Opposite parties sanctioned only an amount of Rs.2,640/-. Majority of the claim amount was repudiated by the company stating that the surgery conducted upon the complainant is not included in the opposite parties listed out surgeries mentioned in the scheme. According to the complainant, angioplasty was told to be a major surgery reimbursable under the scheme. Complainant was also given a copy of the down loaded brochure which says that angioplasty is reimbursable @ 40% of the sum assured. At the time of delivery of the policy certificate, complainant was not provided with conditions and privileges under the plan. According to the complainant he is entitled to get 40% of the actual expenditure which comes to Rs.64,000/-. The act of opposite party in repudiating the claim amounts to deficiency in service and hence the complaint.
Opposite parties admits the policy and happening of the event within the coverage of the policy. According to the policy conditions, the policy holder is eligible for two benefits, one hospital cash benefits & other is major surgical benefits. Major surgical benefits is payable for 49 surgeries listed out in the policy conditions. Hospitalization cash benefits were already paid by opposite parties as per the rules. Complainant herein has undergone coronary angioplasty with stent implantation. There was only one block in the coronary artery and that was removed and one stent was implanted. As per the terms and conditions of the policy coronary angioplasty with two or more stent implantation alone is treated as major surgeries included in the list. Opposite parties denies the say of the complainant that the agent has lured to take away the policy by assuring that all treatments are covered. The condition and privileges is a self contained one which interprets the words is which the contract is expressed by the parties. According to opposite parties there is no deficiency in service on the part of opposite parties.
The evidence adduced by the parties consists of their respective chief affidavits. Ext.A1 to A6 marked on the side of the complainant and Ext.B1 to B3 marked on the side of the opposite parties.
Issues for consideration are:
1. Whether there is deficiency of service on the part of opposite parties?
2. If so, what is the relief and cost?
Issue No.1 &2
There is no dispute as to the policy and happening of the surgery within the period of coverage of the policy. According to the complainant, he is entitled for 40% of the sum assured as per the policy as angioplasty is a surgery which is listed as major surgery as per the policy conditions. The annexure attached to Ext.B1 policy contains the list of the surgical procedure and percentage of the sum assured. It is clearly stated that coronary angioplasty with stent implantation (two or more coronary arteries must be stented). Complainant has undergone angioplasty for one block in the artery. So as per the policy conditions it is seen that complainant is not entitled to 40% of the sum assured. Contract of insurance is a contract between the insurer and the insured. Both parties are bound by the terms and conditions of the policy. It is settled position that the forum cannot go beyond the terms and conditions attached to the policy. Further allegation that the agent of opposite parties has lured to take away the policy assuring that all treatments are covered undue the policy is not proved by any cogent evidence. The agent is neither made a party nor cited as a witness.
In view of the above stated facts and circumstances of the case we are of the view that complainant miserably failed to prove a case in his favour.
In the result complaint dismissed.
Pronounced in the open court on this the 28th day of April, 2012.
Sd/-
Smt. Seena. H
President
Sd/-
Smt. Preetha.G.Nair
Member
Sd/-
Smt. Bhanumathi.A.K
Member
A P P E N D I X
Exhibits marked on the side of complainant
Ext.A1– Photocopy of Policy dt.02/05/2008
Ext.A2– Discharge summary dt.19/01/2011 issued from Thankam Hospital of, PMRC, Palakkad.
Ext.A3- Medical bills 11/01/2011 issued from Thankam Hospital of, PMRC, Palakkad (2 in nos).
Ext.A4– Photocopy of Form of claim petition.
Ext.A5– Photocopy of the letter sent by the complainant to the opposite party.
Ext.A6 – Letter issued by the opposite party to the complainant repudiating the complainant's claim and sanctioning only Rs.2640/-
Exhibits marked on the side of opposite party
Ext.B1– Conditions and privileges referred in the policy document (Photocopy)
Ext.B2– Policy bond (Attested copy)
Ext.B3– Proposal Form (Attested copy)
Witness examined on the side of complainant
Nil.
Witness examined on the side of opposite party
Nil
Cost allowed
No cost allowed
