State Consumer Disputes Redressal Commission
Senior Divisional Manager, Lic Of India ... vs Kailash Chandra Kar on 24 November, 2008
STATE CONSUMER DISPUTES REDRESSAL COMMISSION:ORISSA:CUTTACK STATE CONSUMER DISPUTES REDRESSAL COMMISSION:ORISSA:CUTTACK FIRST APPEAL NO.805 OF 2006 From an order dated 31.07.2006 passed by the District Consumer Disputes Redressal Forum, Kendrapara in C.C. No.09 of 2006 1. Senior Divisional Manager, L.I.C. of India, Cuttack Divisional Office, Jeevan Prakash, Cuttack-753001. 2. Branch Manager, L.I.C. of India, Kendrapara B.O., At/P.O/Dist- Kendrapara. Appellants -Versus- Kailash Chandra Kar, S/o. Dinabandhu Kar, Village- Bhagabanpur, P.O/District- Kendrapara. Respondent For the Appellants : M/s. S.K. Mohanty and Assoc. For the Respondent : M/s. B.P. Samal and Assoc. P R E S E N T : THE HONBLE SHRI JUSTICE A.K. SAMANTARAY, PRESIDENT A N D SHRI SUBASH MAHTAB, MEMBER. O R D E R
DATE:-
24TH NOVEMBER, 2008.
The Life Insurance Corporation of India is the appellant, represented through its Senior Divisional Manager, Cuttack Divisional Office and Branch Manager, Kendrapara. By means of this First Appeal, the appellants assail the judgment and order dated 31.07.2006 passed in C.C. No.09 of 2006 by the District Forum, Kendrapara, whereby the District Forum while allowing the complainants prayer in the complaint directed the appellants, who were opposite parties before it, to give all the benefits admissible under the policy to the complainant and pay cost of rupees 500/- within three months from the date of receipt of the order.
2. Admittedly, the complainant Kailash Chandra Kar took ASHA DEEP-II life insurance policy bearing no.581918819 for an assured sum of rupees 50,000/- having twenty years term commencing from 28.09.1997. He was all along paying the premiums regularly.
During continuance of the policy, in January, 2003 the complainant experienced sever pain in his chest and there was trouble in breathing, for which he consulted Cardiologist and according to the advice of the Physician of Apollo Speciality Clinic and Diagnostic Centre, Bhubaneswar, an Echo Cardiography was done, wherein the cardiac problem was detected and he continued to remain in treatment of the said doctor till October, 2004 and ultimately after thorough pathological tests, he had to undergo open heart surgery at Kalinga Hospital, Bhubaneswar and had to make huge expense of rupees 2 lakhs on account of such open heart surgery incurring hand loans and sale of valuables. The complainant made claim submitting all documents for payment of the assured amount, but the opposite parties repudiated the claim vide their letter dated 11.08.2005 on the ground that the complainant had undergone valve replacement surgery on 15.04.2005 and the said surgery is not covered under the provisions of the policy and as such the claim made by the complainant for benefit B was inadmissible.
3. The complainant, as we find during hearing of this appeal, is not being represented by any agent or counsel before us. He himself has not also turned up.
However, the learned counsel for the appellants Life Insurance Corporation took us through all the documents and the impugned judgment. Shri Mohanty, learned counsel for the Corporation submitted that the District Forum has gone wrong while it has recorded in the judgment that the complainant has undergone open heart by-pass surgery, which is apparent from Exts-6 and 10.
On scrutiny of these documents, it is found that there has been change of one valve through the open heart surgery and it is actually not a case of open heart by-pass surgery. But it is not disputed that the valve replacement was to be done through open heart surgery as without opening the heart, it is not possible to replace a new valve removing defunct or defective valve from the heart. The learned counsel Mr. Mohanty does not dispute that the complainant had undergone open heart surgery, but he submits vehemently supporting repudiation with reference to the insurance policy condition No.11(b)(i). which is as under;
The Life Assured undergoes Open Heart By-Pass surgery performed on significantly narrowed / occluded coronary arteries to restore adequate blood supply to heart and the surgery must have been proven to be necessary by means of coronary angiography. All other operations (e.g. angioplasty and Thrombolysis by Coronary Artery Catheterization) are specifically excluded.
According to him, since the life assured can avail the benefit only if he undergoes open heart by-pass surgery performed on significantly narrowed / occluded coronary arteries to restore adequate blood supply to heart and the same must have been proven to be necessary by means of coronary angiography and in the instant case the complainant although had undergone open heart surgery, it was not by-pass surgery of the complainant is not entitled to the benefit. He submitted further that in the said Clause 11(b)(i), there is clear mention that all other operations (e.g. angioplasty and Thrombolysis by Coronary Artery Catheterization) are specifically excluded. There is no doubt about the fact that angioplasty and Thrombolysis by Coronary Artery Catheterization does not involve open heart surgery and they are the other methods of repair of the narrowed or blocked arteries.
4. In the instant case, even though due to ignorance the complainant in the complaint petition has stated that there was open heart by-pass surgery, we find it to be a open heart surgery for replacement / change of the valve involving an expense to the tune of rupees 1,09,966/-, which is on record in the L.C.R. appearing in the final bill details of the Kalinga Hospital Limited, Bhubaneswar.
5. Interpreting the clause and restricting the benefit to an insured to only open heart by-pass surgery and repudiating his genuine claim on the ground that except open heart by-pass surgery, in no other case, even where open heart surgery is undertaken and a valve is replaced, is nothing but simply unfair trade practice by such a reputed Corporation of the Country like Life Insurance Corporation of India. The assured value is only rupees 50,000/- and after incurring loan, selling valuables and spending more than one lakh only for undergoing open heart valve replacement surgery apart from other expenses relating to pre-operation hospitalization, when the complainant makes a genuine claim, it is repudiated / turned down showing policy condition and explaining away the liability stating that it was not open heart surgery for repair of arteries to provide sufficient supply of blood through them to and from the heart. It is through the valves that the heart receives and sends blood and normal blood flow is controlled. A damaged valve creates an ailment which is life threatening and unless it is replaced on time it might cause ultimate death of the person suffering from various ailments. There is no doubt about the fact that replacement of valve can be done only through open heart surgery and in the case of the complainant that has been done, which is on record.
6. The Consumer Protection Act and the law thereunder has empowered the complainant to resort to the complainant for redressal of his genuine grievance, is a beneficial legislation and it cannot allow the Insurance Companies and specifically the Life Insurance Corporation of India to escape liability on such technical grounds to deprive the consumer of the benefit to which in our view he is entitled to.
7. In that view of the matter, without any further discussion we find appeal preferred by the opposite parties Life Insurance Corporation to be bereft of any merit and as such we direct its dismissal.
The appellants are hereby directed to comply the order of the District Forum within a period of one month from the date of receipt of this order, failing which the assured amount shall carry interest @12% per annum from the date of filing of the complaint (28.01.2006) till its final payment.
Records received from the District Forum be sent back forthwith.