State Consumer Disputes Redressal Commission
The Manager, vs M.T.Varghese, on 15 January, 2013
Daily Order
Kerala State Consumer Disputes Redressal Commission Vazhuthacaud,Thiruvananthapuram First Appeal No. A/12/73 (Arisen out of Order Dated 27/10/2011 in Case No. CC/10/479 of District Ernakulam) 1. LIC OF INDIA BRANCH OFFICE,MUVATTUPUZHA IDUKKI KERALA ...........Appellant(s) Versus 1. M.T.VERGHEESE MUNDOTHIL HOUSE,PAZHOOR EAST.P.O,PIRAVOM KOTTAYAM KERALA ...........Respondent(s) BEFORE: HON'ABLE MR. JUSTICE SRI P.Q.BARKATH ALI PRESIDENT PRESENT: ORDER
KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSION VAZHUTHACAUD, THIRUVANANTHAPURAM.
APPEAL NO. 73/12
JUDGMENT DATED:15.01.2013
(Against the order in CC.479/10 on the file of CDRF, Ernakulam dtd:27.10.2011)
PRESENT:
JUSTICE SHRI. P.Q.BARKATH ALI : PRESIDENT
The Manager,
Life Insurance Corporation of India, : APPELLANT
Branch Office, Muvattupuzha.
(By Adv:Sri.G.S.Kalkura)
Vs.
M.T.Varghese,
Mundothil House, Pazhoor East.P.O, : RESPONDENT
Piravom.
(By Adv: Sri.Tom Joseph)
JUDGMENT
JUSTICE SHRI.P.Q. BARKATH ALI : PRESIDENT This is an appeal filed under section 15 of the Consumer Protection Act, 1986 by the opposite party in CC.479/10 on the file of CDRF, Ernakulam challenging the order of the Forum dated, October 27, 2011 directing the appellant to pay to the complainant Rs.5 lakhs being the amount due under the Insurance policy Ext.A1.
2. The case of the complainant as detailed in the complaint and as stated in his proof affidavit before the Forum in brief is this: The respondent/complainant took a Jeevan Anand Policy of Life Insurance Corporation of India with profit and accident benefit on March 25, 2006. He paid the premium of Rs.26,068/-. He opted for critical illness and premium benefit rider by remitting additional premiums of Rs.3700.12 and Rs.1959.21 respectively. The sum assured was Rs.5 lakhs. The complainant underwent open heart surgery on February 5, 2007 at Medical Trust Hospital, Ernakulam. Towards treatment expenses is spent Rs.1,83,000/-. But his claim for critical illness benefit was repudiated by the Insurance Company stating that the policy was in a lapsed condition and that he has not opted for critical illness benefit. The claimant claimed the sum assured under the policy with interest and costs.
3. The appellant/opposite party is Muvattupuzha Branch of Life Insurance Corporation of India represented by its Branch Manager. The appellant in his version contended thus. On receipt of claim form the opinion of Cardiologist Dr.Jose Chacko Periyappuram was called for. He reported that complainant was suffering from hyper tension since one year and was on medication. The complainant was operated for Acyanotic Congenital heart disease (Arterial Septal defect) which is not covered under the critical illness rider. That being so complainant is not entitled to get hospital expenses and the complaint has to be dismissed.
4. On the side of the complainant Exts.A1 to A4 were marked and the Branch Manager of the opposite party/Insurance Company was examined as DW1 and Exts.B1 to B5 were marked on the side of the opposite party before the Forum. On an appreciation of evidence the Forum found that the claimant is entitled to the sum assured under the policy and allowed the complaint. The opposite party has come up in appeal challenging the said order of the Forum.
5. Heard both counsels. Sri.Kalkura the counsel for the appellant/Insurance Company, argued that the disease Acyanotic Congenital heart disease (Arterial Septal defect) is not covered under Ext.A1 policy and that therefore the Forum went wrong in allowing the complaint. Sri. Tom Joseph the counsel for the respondent/complainant on the other hand supported the impugned order of the Forum.
6. The following points arise for consideration.
1. Whether Acyanotic Congenital heart disease (Arterial Septal defect) is covered under the Ext.A1 policy?
2. Whether the impugned order of the Forum can be sustained?
7. The main point to be considered is whether the disease Acyanotic Congenital heart disease (Arterial Septal defect) is covered under Ext.A1 policy. In other words the point would be whether the said disease is excluded in Ext.A1 policy. A perusal of Ext.A1 and A2 shows that clause 2(d) of the policy the disease Acyanotic Congenital heart disease (Arterial Septal defect) is not excluded. At the same time clause 2.B(9) shows that coronary artery by-pass surgery is included. That being so, the Forum is perfectly right in holding that Ext.A1 policy covers Acyanotic Congenital heart disease (Arterial Septal defect).
8. The counsel for the appellant relied on Ext.B3 wherein on the backside of the letter the medical referee, the doctor stated that claimant is not entitled to the benefit of the policy. Ext.B3 is only a photocopy. Further the said opinion of the doctor is not supported by any reasoning. The doctor who gave that opinion was also not examined as a witness by the opposite party to prove the same. That being so, in my view, the Forum has rightly rejected the said opinion of the doctor.
9. No other point is argued before me.
In the result the confirming the order of the Forum the appeal is dismissed with a costs of Rs.5000/-.
JUSTICE P.Q.BARKATH ALI: PRESIDENT VL.
[HON'ABLE MR. JUSTICE SRI P.Q.BARKATH ALI] PRESIDENT