DISTRICT CONSUMER DISPUTES REDRESSAL FORUM PALAKKAD
Dated this the 22nd day of December 2012
Present : Smt.Seena H, President
: Smt. Preetha.G. Nair, Member
: Smt. Bhanumathi.A.K, Member Date of filing: 10/08/2012
(C.C.No.154/2012)
Sri.Johnson M.C
S/o.Cheru,
Mandumpala House,
Chettithara,
Vadakkenchery Post,
Palakkad. - Complainant
(By Adv.G.Ananthakrishnan)
V/s
1.The Manager Claims,
L.I.C.of India, Thrissur.
(By Adv.T.P.George)
2.The Branch Manager,
L.I.C. of India,
Wadakkanchery Branch,
Thrissur – 680 590
(By Adv.T.P.George)
3.The Branch Manager,
L.I.C.of India,
Vadakkencherry Branch,
Palakkad. - Opposite parties
(By Adv.T.P.George)
O R D E R
By Smt.SEENA.H, PRESIDENT
Complaint in brief :
Complainant had taken an Asha Deep Policy II with profits (Medicals) on 21/6/2001 for a sum assured of Rs.1 lakh with yearly premium of Rs.5,361/-. The policy no.is 773746932 and date of maturity of the policy is 21/6/2021. The complainant had remitted the premium due promptly till date at opposite party’s branch at Vadakkencherry, Palakkad District.
The complainant was admitted at Lakeshore Hospital on 14/2/2012 with diagnosis of CAD. His angiogram showed triple vessel disease and the lesions were amenable to angioplasty. In view of high risk status of the patient, balloon angioplasty was preferred over Coronary Artery Bypass Graft. He underwent angioplasty with drug eluting stents to LAD and OM on 14/2/2012 which is an equally successful and alternative to surgical procedure. The complainant so far spent around Rs.4 lakhs for the treatment and he submitted a claim with opposite party on 29/2/12 together with copies of relevant bills and medical certificates. The opposite party rejected the claim vide letter dated 22/3/2012 on the ground that the treatment is not covered by the policy. Complainant states that the rejection is not valid in law nor binding on the complainant. The opposite parties have not considered the fact that at the time of the angioplasty the complainant was not fit to undergo open heart surgery and hence the opposite parties are liable to pay the claim amount. There is clear deficiency of service on the part of the opposite party in rejecting the claim. Hence the complaint. Complainant claims Rs.1,00,000/- incurred for treatment and Rs.1,00,000/- as compensation and cost of the proceedings.
Opposite party resisted the complaint with the following contentions.
Opposite party admitted that the complainant has taken an Asha Deep Policy with accident benefit on 26/6/2001 for a sum assured of Rs.1 lakh with yearly premium of Rs.5,361/- and the date of maturity of the policy is 21/6/2021.
Under this policy, if the policy is in force for full sum assured, one of the two benefits A or B defined in the policy will be provided subject to the conditions mentioned in the policy. Either of the benefits only is payable during the term of the policy. Benefit (A) The sum assured with vested bonus, if any, is payable in the event of the life assured surviving the stipulated date of maturity or at his death if earlier. Benefit (B) if anyone of the contingencies given in para 11(b), subject however to the conditions mentioned in para 11(a) of the conditions & Privileges within referred occurred during the term of the policy, immediate payment of 50% of the sum assured. Balance payment of the 50% along with the vested bonus, if any, in the event of the life assured surviving the stipulated date of maturity or at his death, if earlier.
11(b) of the conditions and privilege mentioned in the policy schedule is that Benefit (B) of the policy schedule shall be available on the happening of any of the following contingencies (1) The life assured undergoes open heart by-pass surgery on significantly narrowed / occluded coronary arteries to restore supply to heart and the surgery must have been proven to the means of coronary angiography. All other operations are specifically excluded. Non surgical techniques such as the use of either balloon or laser via catheter introduced through the arterial system are excluded. These clauses are included even in the proposal form-addendum signed by the complainant.
In this case the complainant underwent an Angioplasty which was not a benefit covered under the terms of the policy. Hence the claim was rejected.
A claimant is not entitled to claim the full sum assured of the policy even as per the terms of the policy in the event of happening of the contingencies mentioned under clause 11 (B). Even if a policy holder undergoes an open heart by pass surgery, he is entitled to get only 50% of the sum assured and balance 50% with bonus, at the time of maturity or at his death whichever is earlier. So as per the terms of the policy itself the petitioners claim for Rs.1,00,000/- is unsustainable.
There was no breach of policy conditions on the part of these opposite parties. The complainant is not entitled to get reimbursement as per the terms of the policy. There is no deficiency of service on the part of these opposite parties.
Both parties filed their respective chief affidavit. Ext.A1 to A9 marked. Ext.B1 to B3 also marked.
Issues that arise for consideration
1. Whether there is any deficiency in service on the part of opposite parties ?
2. If so, what is the relief and cost complainant is entitled to ?
Issue No.1 & 2
Policy stands admitted by opposite party. On going through Ext.B1, policy copy, we find that the claim of the complainant for Rs.1,00,000/- will not stand in view of benefit B of the policy which only provides for immediate payment of 50% of the sum assured. The sum assured as per the policy is Rs.1,00,000/-. So the claim of the complainant if any will be limited to Rs.50,000/-.
Now the next question is whether the complainant is entitled for benefit B as per the policy. Complainant undergone Angioplasty is evident from Ext.A9 documents and is not disputed also. According to the complainant he was forced to undergo balloon angioplasty because of the high risk factors like diabetic and liver cirrhosis. Ext.A9 certificate by the treated doctor was produced in this behalf. According to opposite party there is specific exclusion for angioplasty as per the terms of the policy. The said clause read as follows:
11(b) of the conditions and privilege mentioned in the policy schedule is that Benefit (B) of the policy schedule shall be available on the happening of any of the following contingencies (1) The life assured undergoes open heart by-pass surgery on significantly narrowed / occluded coronary arteries to restore supply to heart and the surgery must have been proven to the means of coronary angiography. All other operations are specifically excluded. Non surgical techniques such as the use of either balloon or laser via catheter introduced through the arterial system are excluded. These clauses are included even in the proposal form-addendum signed by the complainant.
Opposite party has also relied on the decision rendered by the Hon’ble National Commission in LIC of India V/s Abdul Salim. R.P.No.1103 of 2007 where the similar policy was questioned and it was held that
“The policy document clearly stipulates that Angioplasty is specifically excluded under the policy and policy covers coronary artery diseases only where by-pass surgery has been done. While it is a fact that there is also provision that the Petitioner can pay 50% of the sum assured to the respondent who filed a claim for medical treatment, this will only be admissible in respect of treatment for diseases specifically mentioned in the policy. It cannot cover diseases which are not stated or are specifically excluded as in the instant case. It is also well established that an insurance policy is a contract between the two parties and its terms and conditions, once accepted, are binding on both parties.”
We are also of the view that even if the terms and conditions of the policy are liberally construed , it cannot liberalized to that extent to include a specifically excluded item. We understand that it is the risk factors that necessitated the complainant to undergo angioplasty instead of open surgery, but we are not in a position to attribute deficiency in service on the part of opposite party as the repudiation is as per the terms and conditions of the policy.
In view of the above discussions, we are of the view that repudiation is justifiable and there is no deficiency in service on the part of opposite party.
In the result complaint dismissed.
Pronounced in the open court on this the 22nd day of December 2012.
Sd/-
Seena H
President
Sd/-
Preetha G Nair
Member
Sd/-
Bhanumathi.A.K.
Member
APPENDIX
Exhibits marked on the side of the complainant
Ext.A1 – Insurance Policy No.773746932
Ext.A2 – Percutaneous Transluminal Coronary Angioplasty Report of Lakeshore
Hospital.
Ext.A3 – Coronory angiogram report of Lakshore Hostpial
Ext.A4 – Discharge bill issued by Lakeshore Hospital
Ext.A5 – In-Patient settlement receipt
Ext.A6 – Photocopy of claim letter sent by complainant to opposite party dated
29/2/2012
Ext.A7 – Reply letter dated 22/3/12 rejecting the claim of the complainant by
the opposite party
Ext.A8 – Renewal Premium Receipt
Ext.A9 – Certificate issued by Dr.Cibi Issac of Lakeshore Hospital.
Exhibits marked on the side of the opposite party
Ext.B1 – Attested copy of Policy No.773746932
Ext.B2 – Attested copy of proposal form
Ext.B3 – Attested copy of Addendum to the proposal
Cost
No cost allowed.
