State Consumer Disputes Redressal Commission
L.I.C. Of India vs Pardeep on 15 October, 2015
2nd Additional Bench
STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
PUNJAB, DAKSHIN MARG, SECTOR 37-A, CHANDIGARH.
First Appeal No.229 of 2014
Date of institution: 10.03.2014
Date of decision: 06.11.2015
Life Insurance Corporation of India, through its Senior
Divisional Manager/Person Over All Incharge having its office
at LIC Ranjit Avenue, Amritsar
.......Appellant/Opposite Party
Versus
Mrs. Pardeep wife of Sh. Satinder Singh resident of village
Khatib, Ward No.1, Batala District Gurdaspur, Punjab.
........Respondent/Complainant
First Appeal against the order dated
06.01.2014 passed by the District
Consumer Disputes Redressal Forum,
Amritsar.
Quorum:-
Shri Gurcharan Singh Saran, Presiding Judicial Member
Sh. Jasbir Singh Gill, Member
Smt. Surinder Pal Kaur, Member
Present:-
For the appellant : None
For the respondent : Sh. Vipan Mahajan, Advocate
MRS. SURINDER PAL KAUR, Member
ORDER
The appellant/OP (hereinafter referred as 'OP' ) has filed the present appeal against the order dated 06.01.2014 passed by District Consumer Disputes Redressal Forum, Amritsar (hereinafter F.A. No. 229 of 2014 2 referred as "District Forum") in Consumer Complaint No.156 dated 22.02.2013 vide which complaint filed by the respondent/complainant(hereinafter referred as complainant) was partly allowed and OP was directed to pay Rs.1,50,116/- and Rs.2,000/- as litigation costs within 30 days from the date of receipt of the copy of this order, failing which, OP will be liable to pay interest @ of 9% from the date of filling the complaint till payment.
2. A complaint was filed by the complainant under Section 12 of the Consumer Protection Act 1986(in short `the Act') against OP on the averments that during the subsistence of insurance policy bearing NO.H047/472159235 which was valid from 29.09.2009 to 29.09.2042 for a sum insured Rs.4 lac. During the subsistence of the policy complainant had suffered heart problem and was diagnosed "Ant. Wall Ischemic with inferior wall". Complainant was advised EECP treatment as another option to improve her myocardial blood flow to decrease her chest pain. Complainant was admitted in Dukh Niwaran Hospital, Kuchehry Chowk Ranjit Avenue, Amritsar on 16.07.2012 and was discharged on 25.08.12 Complainant completed 35 sessions of EECP therapy and she spent a sum of Rs.1,50,000/- on the above said treatment. Complainant had never obtained any medical treatment relating to heart problem preceeding three years from the date of purchase of insurance policy i.e.29.9.2009. Complainant had submitted all the documents and bills regarding treatment to OP. Vide letter dated 27.12.2012 claim was rejected on the ground that procedure/treatment was outpatient department (OPD) and was not payable under the policy, whereas, U.S. Food and Drug Administration (FDA) cleared "Vasomedical EECP" therapy systems for patients with stable and unstable angina. In June 2002, FDA cleared EECP therapy for F.A. No. 229 of 2014 3 congestive heart failure (CHF). EECP therapy was a non invasive treatment for patients who were refractory to or inappropriate for other interventions. It was further submitted that EECP treatment was a proprietary treatment system to inflate and deflate a series of pneumatic cuffs in enclosing the lower extremities. Cardiology society of India through Indian Heart Journal had published review articles recommended EECP for cardiac patients. Currently more than 100 countries which included reputed super specialty and university hospitals were offering EECP treatment in India. OP wrongly repudiated her genuine claim. The above said act of the OP amounted to deficiency in service. Hence, she filed complaint before the District Forum seeking following directions:-
(i) to pay Rs.1,50,000/- i.e. amount spent by the complainant towards medical treatment alongwith interest @ 12% per annum
(ii) to pay Rs.25,000/- as compensation and litigation costs.
3. Complaint was contested by OP, who filed written reply by taking preliminary objections that complainant was not entitled for Rs.1,50,000/- along with interest because the claim of complainant was not covered under the health Insurance policy. Complaint was bad for mis-joinder of necessary parties. Third Party Administrator 'Medi Assist India TPA Pvt.Ltd. Bangalore was not made a party in the complaint. On merits, it was admitted that complainant had taken LIC Health Protection Plus policy bearing no.472159235 from 29.9.2009 to 29.09.2042. There were two types of benefits under the policy namely:
i. HOSPITAL CASH BENEFIT {HCB}, per day benefit for each continuous period of 24 hours {after excluding first 48 hours or two F.A. No. 229 of 2014 4 days} ii. MAJOR SURGICAL BENEFITS {MSB}, fixed percentage of MSB sum assured in respect of only listed or covered 49 surgeries. Complainant had submitted bill of treatment taken from Dukh Nivaran Hospital Ranjit Avenue Amritsar i.e. Rs.79,270/-. It was denied that complainant had given information regarding treatment and admission in hospital to OP at the time of admission, whereas, complainant informed OP only at the time of submission of claim on 22.11.2012. EECP treatment was non-invasive treatment for angina and for the above said treatment 5 sittings per week were required and patient was discharged within one and two hours on the same day after taking the treatment. When no surgery was done as per terms of the policy Major Surgical Benefit (MSB) was not payable, therefore, Hospital Cash Benefit (HCB) was rejected by TPA as Treatment/Procedure was done in OPD. There was no hospitalization exceeding a continuous period of 24 hours. It was also found that treatment of the complainant was not recognized and scientifically documented cardiac procedure. They had rightly repudiated claim of the complainant and there was no deficiency in service on their part. They prayed for dismissal of the complaint with costs.
4. The parties were allowed by the learned District Forum to lead their evidence.
5. In support of the averments, the complainant had tendered into evidence her affidavit Dr. R.P.S. Boparai Ex.CW1/A, affidavit Ex.CW2/A along with documents Ex.C1 to Ex.C-23 and closed their evidence. On the other hand OP tendered into evidence affidavit of Sh.
Makhan Lal, Manager Legal Ex.OP-1 along with documents Ex.OP-2 to Ex.OP-5 and closed their evidence.
6. After going through the allegations alleged in the complaint, F.A. No. 229 of 2014 5 written reply filed by the OP, evidence and documents brought on the record, the learned District Forum partly allowed the complaint as referred above.
7. Aggrieved against the order passed by the Ld. District Forum, the appellant/OP has preferred the present appeal.
8. We have heard learned counsel for the complainant as no one appeared on behalf of the appellant/op and have carefully gone through the record of the District Forum.
9. In the grounds of appeal Op alleged that EECP (Enhanced External Counter Pulsation) treatment did not fall under any listed procedure. This treatment was non-invasive treatment for angina and required five sittings per week for 7 weeks and the patient was discharged within one and two hours on the same day after taking the session. Under policy Major Surgical Benefit was not payable. Therefore, they repudiated the claim as treatment procedure was done in OPD. There was no hospitalization for a continuous period of more than 24 hours on any day and for Major Surgical Benefits as a fixed percentage of MSB sum assured in respect of listed 49 surgeries. EECP procedure was not listed in the list of surgeries for which the claim was payable. District Forum has ignored the evidence brought on the record. He has prayed for acceptance of the appeal and to set-aside the impugned order.
10. It has been submitted by the counsel for the complainant that as per certificate given by Dr. A.P. Singh Ex.C-23 EECP treatment is recognized procedure by the U.S. Food and Drug Administration cleared by FDA in June 2002. There was admission of the complainant in the hospital and admission slip was proved on the record as Ex.C-20 which showed the admission of the patient from 16.07.2012 to F.A. No. 229 of 2014 6 25.08.2012.Therefore, the findings were rightly recorded by the District Forum and order passed by District Forum be affirmed.
11. We have to determine whether the claim of the complainant falls under the terms and conditions of the policy.
According to condition No.2 (1) of the policy:-
"Under Hospital Cash Benefit there should be continuous hospital admission for a period of more than 24 hours and under the Major Surgical Benefits it should be listed for 49 surgeries. EECP treatment is not a invasive surgery, therefore, the case of the complainant does not fall out of listed 49 surgeries under the policy. If we left with the point whether there was admission of the complainant for continuous period of more than 24 hours as per terms and conditions of the policy. No doubt hospital slip Ex.C-20 shows the admission of the complainant from 16.07.2012 to 25.08.2012 but it is first page of the admission card. There is no day to day admission treatment record on the file. However it was specifically mentioned in certificate of treating doctor as Ex.C-23 dated 04.10.2012 that "Treatment protocol consists on one and half hour sessions, six days a week for six week". At the end he has mentioned that the total cost paid for 35 days of one hour session EECP therapy is Rs.80,000/- + hospital expenses. This certificate makes it clear that EECP therapy was take only for one hour session, although it was covering for six weeks which did not prove that complainant was admitted in the hospital for a continuous period of more than 24 hours on any day. So, record does not help the complainant that she was admitted in hospital for a continuous period of more than 24 hours on any day as per condition No.2 (1) of the policy. Before the District Forum complainant had failed to prove that there was F.A. No. 229 of 2014 7 admission of more than 24 hours on any day in the hospital. Therefore his claim is not covered under the terms and conditions of the policy. The District Forum had only appreciated the hospital slip Ex.C-20 where there was reference regarding her admission and discharge date but District Forum had failed to appreciate the affidavit of Dr. A.P. Singh wherein he had mentioned that treatment protocol consists of one hour session. Therefore, the claim of the complainant does not fall within terms and conditions of the policy. It is a well established proposition of law that the Forum cannot travel beyond the terms and conditions of the policy. Entire record was not properly appreciated by the District Forum and had allowed the claim only on the basis of one admission card of the patient. Therefore, the order passed by the District Forum is not justified on the basis of evidence on the record.
12. In view of the above discussion appeal of the appellant/OP is allowed, order of the District Forum is set-aside. Consequently, complaint filed by the complainant is dismissed.
13. The appellant/OP had deposited of Rs.25,000/- + 55,000/- at the time of filing of the appeal along with interest which had been accrued thereon, if any, shall be remitted by the registry to Appellant/OP by way of a crossed cheque/demand draft after the expiry of 45 days of the sending of certified copy of the order to the parties subject to stay if any by higher Fora/Court.
14. The arguments in this appeal were heard on 15.10.2015 and the order was reserved. Now, the order be communicated to the parties as per rules.
F.A. No. 229 of 2014 8
15. The appeal could not be decided within the statutory period due to heavy pendency of court cases.
(GURCHARAN SINGH SARAN) Presiding Judicial Member (JASBIR SINGH GILL) MEMBER (SURINDER PAL KAUR) th November 6 , 2015 MEMBER SK