Karnataka

Chitradurga

CC/315/2019

Sri.G.Chandrashekarappa S/o Girithimappa - Complainant(s)

Versus

The Manager,LIC - Opp.Party(s)

M.Nataraj Navilehal

24 Sep 2019

ORDER

 

COMPLAINT FILED ON:26/04/2019

DISPOSED      ON:24/09/2019

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHITRADURGA.

CC.NO:315/2019

DATED: 24^th  September 2019

PRESENT :-     Smt. C.M.Chanchala.                     …. President

                           B.A.L.,,LL.B.,                 

                            

                        SRI. SHIVAKUMAR.K.N    :              MEMBER

                     M.Com., LL.B.,

 

……COMPLAINANT/S	Sri. G. Chandrashekharappa S/o Girithimmappa, Aged about46 years, Advocate, R/o Kondapura Village, Holalkere Taluk, Chitradurga District. (Rep., by Sri.M. Nataraj, Advocate)
V/S
…..OPPOSITE PARTY	1. The Manager, Life Insurance Corporation of India, Chitradurga Branch, P.B. Road, LIC Building Chitradurga.   2. The Manager(Health Section) Divisional Office, Life Insurance Corporation of India, Jeevan Prakash, 100 feet road, Gopala Gowda Badavane, Shivamogga.   (Rep by OP.1 and 2 Sri.H.S. Satyanarayna Setty, OP No.3 Advocate)

 

Pronounced on 24^th of September 2019.

Written by C.M.Chanchala, President.

ORDERS

1.    This is a complaint of alleged deficiency of service filed under section 12 of the Consumer Protection Act,1986 by Sri.G.Chandrashekarappa, the Complainant against the Opposite parties (for short ‘OPs’ ) prayed reimbursement of Rs.74,287/- towards hospital expenses incurred for his son with other relief.

The Complaint:

2.  The case of the complainant is that he purchased med claim insurance policy from OPs covering himself with his wife and two children by paying yearly premium of Rs. 13,478/- . During the subsistence of policy, as his son was suffering infection in his pennis, he consulted Dr.Srinivas, and as per the advice of Dr. Srinivas he has taken his son to Dr. Manjunath. Davanagere on 07-07-2018 as an outpatient. After checkup the patient the doctor told him that his son was suffering from phimosis and given treatment. Inspite of taking treatment, when the decease not cured, the doctor advise for operation, accordingly, the complainant admitted his son to S.S Institution of Medical Science and Research Centre, Davanagere on 19-07-2018 as an in patient and after taking circumcision surgery on 20-07-2018 got discharge from the hospital on 21-07-2018.

3.    It is further case of the complainant that he incurred Rs. 22,897/- for treatment in the hospital and on 30-07-2018 he filed a claim form before the OP No.1 along with all the required documents, but claim was repudiated by OPs on the ground that complainant’s claim was not covered under the policy. Hence present complaint is filed alleging deficiency of service on the part of OPs. 

4.      After hearing on admission the complaint was admitted and  notice were ordered to be issued to the OPs  to file their written versions under section 13(2) of the Consumer Protection Act,1986 (  in short “the Act) . The OP 1 and 2 have appeared through their counsel and filed written version.

Defense:

5.    The contents of the written version filed by OPs are that, the very purpose of plan is to provide financial assistance during unforeseen hospital expenses-when the policy holder suffer from diseases mentioned in the policy bond, subject to the exclusion clause 7, the claim received from the complainant for hospitalization and treatment for ' phimosis' for which ' circumcision' surgery was made on 20-07-2018 , but as per the exclusion clause of the policy bond, the reimbursement of surgery and hospital benefit does not include the operation of circumcision, hence the claim of the complainant was not admissible for reimbursement of charge incurred towards the circumcision treatment. Hence they justified for repudiation of claim, accordingly, they prayed for dismiss the complaint. 

Evidence :

6.      The complainant got himself examined as PW-1 by filing his affidavit as a part of examination in chief and also got Ex.A-1 to A-10 marked and closed the evidence.

7.    On behalf of OP No.1 and 2 one N. Raju got himself examined as RW-1 by filing his affidavit as a part of examination in chief and also got Ex.R-1 to R-6 marked and closed the evidence.

 

 

Arguments:

8.      We have heard the complainant as well as counsel of OPs and perused the written arguments filed by both side advocates.  

9.      The points that arise for our determination are;

1. Whether the complainant proves that deficiency of service on the part of opponents?

2. Whether the complainant proves that he is entitled for the relief sought?

3. What order?

10.    Our finding on the above points are as under;

          Point No.1: In the Negative

          Point No2: In the Negative

          Point No3: As per final order,

Discussion and Reasoning:

Point No.1 and 2:

 

 11.  There is no dispute between the parties regarding, validity of policy, and payment of premium, hospitalization and treatment of sons' of the complainant. The complainant alleged that in the condition No.2 of the policy it is mentioned that, "Benefits:- Hospital Cash benefit:- In the event of accidental bodily injury or sickness first occurring or manifesting itself after the date of cover commencement and during the cover of period and causing on insureds hospitalization to exceed a continuous period of 24 hours within the cover period then subject to the terms and conditions waiting period and exclusion of policy the daily benefit is payable by the corporation as following regardless of the actual costs incurred" hence, the OPs liable to reimburse the hospital expenses incurred by him.

12.  The OPs contended that as per the exclusion clause of the policy bond, the reimbursement of surgery and hospital benefit does not include the operation of circumcision, hence the claim of the complainant was not admissible for reimbursement of charge incurred towards the circumcision treatment.

13.   Policy bond is marked as EX-B1. In front page of the policy it is mentioned that ' for detail of general exclusion under the policy refer policy conditions. For details above reviewability of installment premiums refer policy condition'. In page No.3 of EX-B 1, under clause 3 it has mentioned regarding what are the major exclusions in the policy. As per this,

vi. Circumcision, cosmetic or sesthetic treatment and description change or gender surgery, plastic surgery( unless such plastic surgery is necessary for the treatment illness or accidental bodily injury as a direct result of the insured event end performed within 6 months of the same)

As per clause 3 (vi) circumcision is excluded.

14.  Further in page No.7 of the policy, it is mentioned that," the day care procedure benefit will be payable only after corporation is satisfied on the basis of medical evidence that the surgical procedure covered under the policy has been performed".

15.   On reading of the above clauses of the policy, it made it clear that the medical expenses will be reimburse for the treatment which covered under the policy.

16.  The complainant alleged that he incurred Rs. 22,897/- for treatment of his son, hence he is claiming for reimbursement of same. Claim investigation report is marked as EX- B 5. On perusal of this document it shows that son of complainant by name Mithun gowda was suffering from PHIMOSIS and CIRRUMCISION done on 20-07-2018 by Dr. Manjunath. In para No.4 of page No.3 of the complaint, the complainant himself has stated that his son under gone surgery of Circumcission which is excluded in the policy.

17.  The Hon’ble Supreme Court in the case of Oriental Insurance Company Limited VS Sony Cherijan 1999 CTJ 556 (SC) (CP)=(1999) 6 SCC 45 held that “ The insurance policy between the insurer and the insured represents a contract between the parties. Since the insurer undertakes to compensate the loss suffered by the insured on account of risks covered by the insurance policy, the terms of the agreement have to be strictly constructed to determine the extent of liability of the insurer.”

18.  In the present complainant as the Circumcission surgery falls in exclusion class, the repudiation made by the Op is just and proper. The complainant stated that as per clauses 2 of the policy the OP is liable to reimburse the hospital expenses. But on reading of the above cited clauses it is clearly mentioned that, in the event of accidental bodily injury or sickness first occurring or manifesting itself after the date of cover commencement and during the cover of period and causing on insureds hospitalization to exceed a continuous period of 24 hours within the cover period then subject to the terms and conditions waiting period and exclusion of policy the daily benefit is payable by the corporation as following regardless of the actual costs incurred. In view of the same, the complainant is not entitled to get reimbursement of the amount incurred by him for his sons' hospitalization. Accordingly. we answered this point in the Negative.

Point No.2:-

19. As the complainant failed to prove deficiency of service on the part of OP, he is not entitled to get relief as prayed in the complaint. Accordingly. we answered this point in the Negative.

Point No.3:-

20. In view of the observation made in point No.1 and 2, we pass the following order.

                                      : ORDER:

The present complaint is dismissed.

Both parties shall bear their own cost.

The assistant registrar is directed to send free copies of this order to the all the parties free of cost within a week from today.

(Dictated to the Stenographer, typescript edited, corrected and then pronounced in the open court this 24th day of September 2019)

 

MEMBER

PRESIDENT.

             

ANNEXURE

Witness examined for the complainant side:

 

Complainant-G. Chandrashekarappa has examined-in-chief by filing affidavit as PW1.

 

 

Documents marked for the complainant side:

01	Ex-A-1:-	Rejection letter dated 12/02/2019
02	Ex-A-2:-	Complainant issued letter dated 08/12/2018
03	Ex-A-3:-	OP issued letter dated 15/12/2018
04	Ex-A-4:-	Complainant issued letter dated 17/12/2018
05	Ex.A-5:-	Xerox copy of claim application form.
06	Ex.A-6:-	Discharged card Xerox copy
07	EX.A-7:-	Outpatient Xerox copy
08	EX.A-8	Xerox copy of I.P. cash bill
09	EX.A-9	Medal bill
10	EX.A-10	Self-attested policy copy

 

 

Witnesses examined on behalf of OP No.1:

DW-1:- Sri. N. Raju S/o N. Appanna Administrative Officer, LIC of India Chitradurga Branch

 

Documents marked for the opponents 1 to 2  side:

01	Ex-B-1:-	Policy Bond
02	Ex-B-2:-	Claim Form
03	Ex-B-3:-	Diagnosis documents.
04	Ex-B-4:-	Hospital treatment form.
05	Ex-B-5:-	Discharge Card.
06	Ex-B-6:-	Claim rejection letter.

 

 

        (C.M.Chanchala  )

                       President.

                                                                                     

 

 

           ( Shivakumar K.N.)

                                                                                     Member.