O R D E R

(By Sri D.Shankar Rao, Member)

1. The brief facts of the complaint are that, the father of complainant has obtained ICICI Prudential Life Insurance Policy  bearing No. 07633994 in the name of complainant from the opposite parties. The policy was commenced on 02-02-2008 and it would be end on 02-02-2028. It is for Hospital Care benefit as  per plan-A. The medical reimbursement limit is for Rs. 4,00,000/- per annum and Rs. 20,00,000/- for whole life. Premium payment is yearly mode.  The father of complainant has paid premium of Rs. 2,818/- for the policy and paying yearly premium regularly.

              That on 7-6-2011, the complainant was admitted in Care Hospital, Hyderabad due to some heart-disease and he underwent surgical procedure of  “Waldhausen Aortoplasty for Supravalvar Arotic Stenosis” by Sri. Dr. B.R. Jaganath a consultant for Cardia Throraic surgeon. The complainant was discharged on 16-06-2011.

              That as per the policy, the complainant is entitled to get annual treatment amount upto Rs. 4,00,000/-. The father of complainant filed an application to opposite party No. 1 on 7-06-2011 for payment of medical expenses in advance, but no response. At last the father of complainant has sold his property and got medical treatment   for his son. Thatafter seven reminders, the opposite party No. 1 replied that the matter was referred to head office i.e opposite party No.2.  The father of complainant went to Mumbai and stayed there from 07-07-2011 to 12-07-2011 and enquired with opposite party No. 2 for sanctioning of medical expenses,  but opposite party No.2 replied that the said file not receive from opposite party No.1. The father of complainant came to Opposite party No.1 with the said information and again he went to opposite party No. 2 at Mumbai on 22-07-2011 and returned on 26-07-2011 with the same reply.

              The father of complainant has expended Rs. 1,60,000/- towards treatment , Rs.80,000/- towards medicines and further treatment from 19-06-2011 to 25-08-2011, Rs. 32,000/- towards staying at Hyderabad Rs. 15,000/- towards travelling to Mumbai and Rs. 10,00,000/- towards Medical agents. The total expenditure comes to Rs. 12,87,005/-.

              The acts of opposite parties are un-fair-trade practice, gross negligence and deficiency of services for which the father of complainant is subjected for physical and mental agony besides monetary loss. Hence this complaint.

1.           The opposite parties 1 & 2 have filed their detailed counter on factual and legal provisions with preliminary objections and submissions and denail in para-wise which runs in to 10 pages. The brief-facts set out in the counter are that the Hospital Care Policy bearing No. 07633994 was issued on 02-02-2008 in the name of complainant under plan T12 Hospital Care limit for Rs. 4,00,000/- per annum on payment of premium for Rs. 3108/- in yearly frequency. The policy is a contract entered by policy holder with Insurance company and parties to it are bound by its terms and conditions.

        The “ Hospital Care Policy” offers benefits as under:-

1.  Daily Hospital Care benefit (DHCB) upon hospitalization.
2. An additional ICU benefit upon hospitalization in ICU Ward (ICUB).
3. Surgical benefit ( SB) upon actual undergoing a surgical and
4. Convalescence benefit ( CB) is a post- hospitalization benefit.

                 The policy offers lump-sum benefits upon occurrence of one or more specific event.

               However, the benefits are subject to certain exceptions as per clause 5 of the policy terms and conditions.  The said clause extract is reproduced as under:

“5 EXCLUSIONS”:-

             b)  No benefits shall be paid for the following services, products                           and conditions:-

             Vi) Treatment for congenital conditions including physical                                     defects present from birth.

                  It is manifest from the above clause that no benefit shall be paid for the treatment for congenital conditions including physical defect present from birth.

                  In the present case, the claim has been made pertaining to hospitalization for “STENOSIS OF AORTIC VALVE” underwent surgery of “WALDHAUSEN AORTOPLASTY FOR SUPRAVALVAR AORTIC STENOSIS” due to “SUPRAVALVAR AORTIC STENOSIS”.

                 In Order to removing the ambiguity, the opposite parties have sought medical expert opinion from Dr. C.H. Asrani.

                  After examining the documents and on careful evaluation of medical literature on the said disease, the medical expert Dr. C.H. Asrani has affirmed that ‘AORTIC STENOSIS’ only in children is ‘CONGENITAL’.

        The finding of learned Doctor is mentioned as under:-

1. Waldhausen Aortoplasty for Supravalvar Aortic stenosis.
2. S/p Waldhausen Aortoplasty for Supravalvar Aortic Stenosis.
3. Supravalvar Aortic Stenosis is a congenital affliction.
4. Aortic Stenosis is a term used to describe congenital heart defects that cause obstruction of blood flow from the heart to the body.
5. Supravalvar Aortic Stenosis (SVAS) is a fixed form of congenital left ventricular out flow tract (LVOT) obstruction that occurs as a localized or diffuse narrowing of the ascending aorta beyond the superior margin of the sinuses of valsalva. It accounts for less than 7% of all fixed forms of congenital LOVT abstractive lesions.

                It is revealed that the Life Assured (L.A) (Complainant) was hospitalized for ‘STENOSIS OF AORTIC VALVE’ which is a ‘CONGENITAL’ ailment.

               The claim of the complainant squarely covered under the exclusion clause in 5(b)(VI) of the policy terms and conditions which provides that no benefit  is payable for the treatment of congenital conditions including physical defect present from birth. Accordingly the claim was rejected on 18-07-2011 which is proper, valid, justified and legal.

                It is further stated that the complainant has not utilized ‘Free Look Period’ provision soon after receipt of the policy within 15 days as per Insurance Regulatory Development Authority (IRDA)(Protection of Policy holders interests) Regulations 2002, if the policy holder not satisfied with the terms and conditions of the policy.

                There is no cause of action and Jurisdiction have arisen to entertain the complaint.  It does not raise any consumer dispute as defined under section 2(e)  nor to show any deficiency of service  on the part of opposite parties as defined under section 2(1)(g) of Consumer Protection Act 1986. The complaint is liable  to be dismissed under Section 26 of Consumer Protection Act 1986.

3.           During enquiry, the father of complainant filed his affidavit as Pw1 and marked Ex.A1 to A12 documents and closed evidence on complainant’s  side. The opposite parties 1 & 2 have filed the affidavit of Sudha Sharma Senior Manager Legal as RW1 but it was eschewed on  account of Not-adduced the RW1 into witness –box. Again, they filed another affidavit of Kiran Kumar Incharge of ICICI branch at Nizamabad as Rw2 and marked Ex.B1 to B6 and closed their evidence.

4.  Heard Arguments.

5.  The points for consideration are:-

     1)  Whether there is any deficiency of Service on the part of opposite parties                       1& 2 in rejecting the claim?

     2)  To what relief?

6.  Point No. 1 &2

                  There is no dispute that the Hospital Care policy bearing No. 07633994 was issued  by opposite parties on 06-02-2008 and commenced it from                       02-02-2008 in the name of complainant at the age of 1 year under plan T-12 with yearly mode for limited Hospital Care benefit of Rs. 4,00,000/- per annum for a period of 20 years.  It is also not in dispute the that the complainant at the age of 5 years has admitted in the care hospital Hyderabad and he underwent the surgical procedure of Waldhausen Aortopalsty for SUPRAVALVAR AORTIC STENOSIS on 09-06-2011 during the policy period. It is also an un-disputed fact that there is an exclusion clause in 5(b)(vi) of the policy terms and conditions which is excluded the treatment of congenital conditions including physical defect present from birth.

                  The dispute is that the ‘SUPRAVALVAR AORTIC STENOSIS’ is                       a ‘Congenital’ and it is squarely excluded from the claim in exclusions as per the clause 5(b)(vi) of the policy terms and conditions. Accordingly, the claim of complainant was rejected on 18-07-2011 by opposite parties.

                 In order to prove the case of complainant, that the father of complainant filed affidavit as PW1 and got marked documents in Ex.A1 to A12. The opposite parties 1 & 2 have also filed the affidavit of their Nizamabad branch incharge Kiran Kuamr as RW2 and got marked documents in Ex. B1 to B6 for substantiating their version.

                   That the complainant has not filed the treatment case-sheet from care hospital Hyderabad except a certificate in Ex.A3 and Medical bills in Ex. A4 to A12. On perusal of Ex.A3, which was issued by Sri. Dr. B.R. Jaganath who treated the complainant, denotes that the complainant has underwent the surgical procedure of Waldhausen Aortopalsty for ‘SUPRAVALVAR AORTIC STENOSIS’ on 09-06-2011 at care hospital Hyderabad and gave his opinion that the cause of disease may not be congenital, but it diagnosed as SUPRAVALVAR Ps, Mild LVH and Good Biventricular Function.

                   The opposite parties 1 &2 have filed the health claim document in                Ex. B3, out patient bill cum receipts and Discharge Summery of complainant in EX. B4 and Medical literature on ‘SUPRAVALVAR AORTIC STENOSIS ‘ and the opinion of Sr. Dr. CH. Asrani in Ex.B6 in support of their plea.

                   On perusal of Ex. B3, B4 & B6, they clearly denotes that the complainant has underwent operation of his heart for ‘SUPRAVALVAR AORTIC STENOSIS’ through a surgical procedure of ‘Waldhausen Aortopalsty’ .

                   Though it is not disputed hat the operation was done for ‘SUPRAVALVAR AORTIC STENOSIS’ but it is disputed by the complainant that ‘SUPRAVALVAR AORTIC STENOSIS’  is not congenital disease as per Ex. A3 which is issued by Sri. Dr. BR. Jaganath of care Hospital Hyderabad. It is disputed by the opposite parties 1 & 2 and submitted that ‘ SUPRAVALVAR AORTIC STENOSIS’ itself is congenital disease only in children as per opinion of Sri. Dr. CH. Asrani with supported medical literature in EX.B6. Both side doctors who issued Ex. A3 and                 Ex. B6 are not examined in this case on be-half of complainant and opposite parties 1 & 2 respectively. However we are in opinion that the said doctors evidence if adduced would not be fetched any more than the medical literature which is bound to be followed for finding the literal meaning of ‘SUPRAVALVAR AORTIC STENOSIS’ as a conclusive proof for the present fact-in-issue in the complaint.

                    We have carefully gone through the medical literature in Ex.B6 and it is reproduced as under:-

1. What is Aortic Stenosis?

Aortic Stenosis is a term used to describe congenital heart defects that cause obstruction of blood flow from the heart to the body. Significant aortic stenosis is relatively uncommon affecting about 6 of every 1000 babies born and occurs more often in boys.  It can occur alone, that is without other heart problems, or in association with bicuspid aortic valve, coarctation of the aorta, ventricular septal defect, mitral valve abnormality, and less commonly with atrial septal defect or complete atrioventricular septal defect.  

1.  What is Supravalvar Aortic Stenosis?

              Supravalvar aortic stenosis is the term used when the narrowed area is above the  valve.  Supravalvar aortic stenosis (SVAS) is a fixed from of congenital left ventricular outflow tract (LVOT) obstruction that occurs as a localized or diffuse narrowing of the ascending aorta beyond the superior margin of the sinuses of Valsalva. It accounts for less than 7% of all fixed forms of congenital LVOTA obstructive lesions. Left ventricular outflow tract (LVOT) obstructive lesions account for approximately 6 percent of cases of congenital heart disease in children;

              Supravalvar As (Aortic Stenosis) is the least common form of left ventricular(LV) outflow tract obstruction. Among children with congenital AS ( Aortic Stenosis), supravalvar AS ( Aortic Stenosis) has accounted for 8 to 14 percent of cases.

                   The Operative notes in discharge summary in Ex. B4 is mentioned that incisions were given in all three sinuses which required only in congenital.

                   Viewed in any angle we are of considered opinion that the ‘SUPRAVALVAR AORTIC STENOSIS’ is a congenital disease only in children as per Medical literature in Ex.B6 and the claim of complainant squarely excluded from the claim of policy exclusions in clause 5(b)(vi) of the policy terms and conditions. Therefore the complainant is not entitled his claim under the policy and the complaint is liable to be dismissed.

                   IN THE RESULT, the complaint is DISMISSSED without costs.

Typed to dictation, corrected and pronounced by the Member in Open Forum on this the 18^th day of October 2013.