State Consumer Disputes Redressal Commission
Life Insurance Corporation Of India vs Sh. Narinder Krishan Malhotra C/O Mulkh ... on 2 August, 2011
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB,
S.C.O. NO. 3009-10, SECTOR 22-D, CHANDIGARH.
First Appeal No.860 of 2006
Date of institution : 30.6.2006
Date of decision : 02.8.2011
Life Insurance Corporation of India through its Authorised Officer, Manager (L &
HPF) (DM), Divisional Office, Sector 17, Chandigarh.
.......Appellant
Versus
1. Sh. Narinder Krishan Malhotra C/o Mulkh Raj & Co. (P) Ltd., Hoshiarpur
Road, Jalandhar City.
2. Dr. Rishi K. Arya, M.D. (Med.), Behind Punjab National Bank, Civil Lines,
Jalandhar City.
......Respondents
First Appeal against the order dated 17.5.2006 of
the District Consumer Disputes Redressal Forum,
Jalandhar.
Before :-
Hon'ble Mr. Justice S.N. Aggarwal President.
Mrs. Amarpreet Sharma, Member.
Present :-
For the appellants : Shri B.J. Singh, Advocate. For respondent No.1 : Shri Munish Goel, Advocate. For respondent No.2 : None.
JUSTICE S.N. AGGARWAL, PRESIDENT:
The controversy to be decided in this appeal is whether the medical expenditure claimed by respondent No.1 (in short "the respondent") fell within the purview of the life insurance policy which he had taken from the appellants? Version of respondent No.1:
2. The respondent had obtained Ashadeep Life Insurance Policy from the appellants on 20.12.1993 for an amount of Rs.1,00,000/- under Plan and Table No.110 for term 15 years. It had commenced with effect from 25.7.1993 while its maturity date was 25.7.2008. The premium was being paid regularly by the First Appeal No.860 of 2006. 2 respondent. Under this life insurance policy, the respondent was also covered for the risk of four major ailments including coronary disease where bypass surgery was required.
3. It was further pleaded that on 21.9.2001 the respondent felt pain in his left shoulder joint and he had heaviness. He consulted his family doctor in Indraprastha Apollo Hospital, New Delhi (in short "Apollo Hospital") where he was referred to Dr. S.K. Gupta, Senior Consultant, Cardiologist in Apollo Hospital. Coronary angiography was done on 29.9.2001. The disease of the respondent was diagnosed as severe aortic stenosis with coronary artery disease.
The respondent was admitted in the Apollo Hospital on 3.11.2001 for open heart bypass surgery for aortic valve replacement plus coronary artery bypass grafting surgery (i.e. CABG). The operation was performed by a team of doctors led by Dr. G.K. Mani, Senior Consultant Cardiac Surgeon on 5.11.2001 and the respondent was discharged on 13.11.2001. He had incurred an expenditure of Rs.3,08,726/- on his medical treatment.
4. It was further pleaded that the respondent had lodged the insurance claim with the appellants but it was repudiated vide letter dated 25.1.2003. The respondent was again informed by the appellants vide letter dated 18.3.2003 as the respondent had not received letter dated 25.1.2003. Hence the complaint for insurance claim. Compensation, interest and costs were also prayed. Version of the appellants:
5. The appellants filed the written reply. It was admitted that the respondent had taken the Ashadeep Insurance Policy from the appellants for an amount of Rs.1,00,000/- with Plan 110-15. The terms and conditions of the insurance policy were binding on the parties. It was denied if the respondent had felt pain in the shoulder on 21.9.2001 or if he had consulted his family doctor. Although it was not specifically denied that the respondent was subjected to bypass surgery for severe aortic valve stenosis but it was denied if the respondent had incurred an expenditure of Rs.3,08,726/-.
First Appeal No.860 of 2006. 3
6. It was pleaded that after the appellants received the insurance claim from the respondent it was shown to a competent doctor who had reported that the claim was not covered under the terms and conditions of the insurance policy. Accordingly the claim of the respondent was repudiated vide letters dated 25.1.2003 and 18.3.2003. The claim of the respondent was decided on merits and not for any ulterior motive. Dismissal of the complaint was prayed. Proceeding before the District Forum:
7. The respondent filed his affidavit Ex.C-1. He also produced his additional affidavit Ex.C-2. The respondent also proved documents Ex.C-3 to Ex.C-40.
The respondent also filed the affidavit of Dr. S.K. Gupta as Ex.C-41.
8. On the other hand, the appellants filed the affidavit of Amarjit Singh Sood, Manager (Claims) as Ex.O-1, affidavit of Dr. Rishi Kumar Arya, Consultant Physician and Cardiologist (respondent No.2) as Ex.O-2, the affidavit of Satya Badhan, Manager (Claims) as Ex.O-8 and other affidavits of Dr. Rishi Kumar Arya as Ex.O-9 and Ex.O-10. The appellants have also proved documents Ex.O3 to Ex.O7.
9. After considering the pleadings of the parties and the affidavits/documents placed on file by them, the learned District Forum accepted the complaint with costs of Rs.2,000/- vide impugned judgment dated 17.5.2006. The appellants were directed to pay the insurance claim under the policy with interest at the rate of 10% per annum from the date of repudiation till the date of payment.
10. Hence the appeal.
Discussion:
11. The respondent had admittedly taken Ashadeep Life Insurance Policy on 20.12.1993 (with profits and with accident benefit) for a sum of Rs.1,00,000/- under Plan 110 for Term 15 years from the appellants. It's date of commencement was 25.7.1993 and the date of maturity was 25.7.2008. Insurance policy has also been proved by the respondent as Ex.C-28. First Appeal No.860 of 2006. 4
12. Normally the life insurance policy covers the risk of life but Ashadeep insurance policy also covered medical reimbursement but to a limited extent. Clause 11 of the terms and conditions of the insurance policy Ex.C-28 reads as under:-
"11(a) Benefit (B) of the Policy Schedule is not applicable if any of the contingencies mentioned in Paragraph 11(b) occurs (i) at any time on or after the date on which risk under this policy is commenced but before the expiry of one year reckoned from the date of this policy or (ii) one year from the date of revival. 11(b) Benefit (B) of the Policy Schedule is not applicable on the occurrence of any of the following contingencies.
(i) the Life Assured undergoes Open Heart By-Pass surgery performed 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 or
(ii) ....
(iii) ....
(iv) ....
1. ....
2. ....
3. .... "
13. The scheme of this policy has been proved as Ex.C33. It reads as under:-
"When you need costly treatment LIC's ASHA DEEP-II POLICY will bring you a big lump sum (Rs.25,000 to Rs.1,50,000 Depending on the Sum Assured)." First Appeal No.860 of 2006. 5
"ASHA DEEP-II (Table 121).
B. Once again in India, a plan of life insurance has been introduced to cover also the risk of four major ailments namely,
i) Cancer (malignant),
ii) Paralytic stroke leading to permanent disability,
iii) Renal failure of both kidneys, or
iv) Coronary artery diseases where by-pass surgery has been done.
For details see section B Section A (Benefits): .....
Section B (Diseases covered):
Brief description of major ailments covered under this plan with relevant definitions (medical terms referred herein will bear meaning as given in the Butterworth's Medical Dictionary).
(i) Cancer(Malignant)...
(ii) Paralytic Stroke...
(iii) Renal failure...
(iv) Coronary artery disease where by-pass surgery has
been actually done:
The use of surgery on the advice of a consultant
cardiologist to correct narrowing or blockage of one or more coronary arteries.
Exclusions:
Non-surgical techniques such as the use of either balloon or laser via a catheter introduced through the arterial system are excluded.First Appeal No.860 of 2006. 6
Nature of evidence required to establish eligibility for benefits under this plan will be as stipulated by the Corporation."
14. After going through these provisions we find that there is some contradiction in clause 11(b) and policy schedule B. It appears that word not has been wrongly added in 11(b). If this word is deleted then it makes proper meaning and there is harmony.
15. It is also proved by the respondent that he was admitted in Apollo Hospital on 29.9.2001 and he was discharged on 30.9.2001 (Ex.C-8). He was again admitted on 3.11.2001. He was operated on 5.11.2001 and he was discharged on
13.11.2001 (Ex.C-9). The discharge summary dated 30.9.2001 Ex.C-8 reveals that coronary angiography was done on the respondent on 29.9.2001 and he was found to have a severe aortic stenosis with coronary artery disease and he was re- admitted on 3.11.2001 for which discharge summary has been proved as Ex.C-9. The type of procedure mentioned in the discharge summary Ex.C-9 is open heart plus bypass surgery. Particulars of operation were stated in the discharge summary Ex.C-9 as under:-
"PARTICULARS OF OPERATION Aortic Valve Replacement + Aorto Coronary Bypass Grating x1 Aortic Valve Replacement using no.: 21 St. Jude's AHP & Individual reversed Saphenous Venous Grafts to second obtuse marginal artery."
16. The brief history of the respondent was given as under:-
"BRIEF HISTORY:
Mr. N.K. Malhotra, who is a 57 years old male, a normotensive, a non diabetic a non smoker and a non alcoholic, presented with the history of angina on exertion (class II/III) for the last one & half months (since 20th Sep. 2001) for which he consulted his cardiologist who advised 2D Echocardiography which revealed First Appeal No.860 of 2006. 7 severe aortic stenosis with post stenotic dilation of ascending aorta (4.1 cm) with adequate left ventricular function (LVEF 65%). Subsequently, his cardiac catheterization + coronary angiography was done here which revealed atherosclerotic severe single vessel coronary artery disease along with severe aortic stenosis, trivial aortic regurgitation, moderate pulmonary arterial hypertension with dilated ascending aorta for which he was advised early Aortic Valve Replacement/Coronary artery bypass grafting Surgery."
17. Learned counsel for the appellants submitted that the respondent was not entitled to medical expenses incurred on angiography got done on 29.9.2001 to 30.9.2001.
18. We agree with it. Otherwise also, even if we exclude the amount spent on 29.9.2001 to 30.9.2001, it does not make difference because the policy was only for Rs. One lac while the respondent has incurred an expenditure above Rs.3 lacs. At the most the respondent will be entitled to the insurance claim of Rs. One lakh only besides other benefits, flowing from this policy if any.
19. It was further submitted by the learned counsel for the appellants that only Open Heart By-Pass surgery performed significantly narrowed/occluded coronary arteries to restore adequate blood supply to heart was permissible. In this case although the bypass surgery was performed but it was not for the purpose of restoring adequate blood supply to heart. All other operations of heart were excluded. In support of this submission, reliance was placed by the learned counsel for the appellants on the affidavits given by Dr. Rishi Kumar Arya.
20. This submission has been considered.
21. The affidavit given by Dr. Rishi Kumar Arya Ex.O-9 reads as under:-
" I, Dr. Rishi Kumar Arya, Civil Lines, Jalandhar do hereby solemnly affirm and declare as under:-
1. That the deponent has gone through the discharge summary of Narinder Krishan Malhotra, aged 57 years, resident of G-126, First Appeal No.860 of 2006. 8 Vikas Puri, New Delhi, of Inderprastha Apollo Hospital. As per this discharge summary patient undergone the open heart bye-
pass surgery for aortic valve replacement and coronary artery bye-pass grafting. It is a serious operation as aortic valve replacement using No.21 St. Judge's AHP and individual reversed Saphenous Venous Grafts to second abtuse marginal artery. These types of operations include the valve replacement.
2. That on the other hand open heart bye pass surgery to restore the adequate blood supply to heart is a very simple operation as no replacement or serious operation is there in these types of exercises."
22. Dr. Rishi Kumar Arya had also filed another affidavit Ex.O-10. Para 5 and 6 of this affidavit read as under:-
"5. That the opinion of the deponent is on the record shows that he was suffering from severe aortic valve stenosis as his main problem. He got open heart surgery mainly for replacement of aortic valve with ailment of intervention in coronary artery, so bye pass open heart surgery was there for the replacement of aortic valve with ailment of intervention of coronary artery and coronary artery bye pass grafting. It is a serious kind of operation has valve replacement and other procedure is there.
6. That open heart bye pass surgery to restore the adequate blood supply to heart is a very simple operation as no replacement is there in these types of operations, only working on blood cells is there."
23. It was submitted by the learned counsel for the appellants that the terms and conditions of the insurance policy are binding on the parties. Reliance was placed on the judgment of the Hon'ble National Commission reported as "LIC of India v. Ramesh Chandra" 1997(2) CPR 8 (NC).
First Appeal No.860 of 2006. 9
24. This law has also been settled by the Hon'ble Supreme Court in the judgment reported as "UNITED INDIA INSURANCE CO. LTD. v. HARCHAND RAI CHANDAN LAL" IV (2004) CPJ 15 (SC).
25. Now the only question to be determined is whether the medical treatment taken by the respondent was excluded under para 11(b) of the terms and conditions of the insurance policy or Benefit B of the Policy Schedule?
26. No doubt as per the terms 11(b) of the Insurance Policy (Ex.C28 and Ex.C33), the expenditure must be on the medical treatment by way of Open Heart By-Pass surgery performed significantly narrowed/occluded coronary arteries to restore adequate blood supply to heart and the surgery must have been proved to be necessary by means of coronary angiography. Dr. Arya in his affidavits Ex.O9 and Ex.O-10 has specifically deposed that the open heart bypass surgery to restore the adequate blood supply to heart is a very simple operation but the operation undergone by the respondent was more serious than the bypass surgery to restore the adequate blood supply to the heart.
27. The respondent has undergone open heart bypass surgery with aortic valve replacement and coronary artery bypass grafting. It is stated in the affidavit of Satya Badhan, Manager (Claims) Ex.O-8 that all other operations for example angioplasty and Thrombolysis by coronary artery catheterization have been specifically excluded. The operation undergone by the respondent also does not figure in the operations which have been specifically stated as excluded.
28. In other words, the operation undergone by the respondent is neither mentioned in those operations for which reimbursement is permissible nor mentioned in those operations which have been excluded specifically by name.
29. It means, therefore, that two views are possible whether the operation undergone by the respondent, falls in the permitted operations being more serious than the one which has been permitted or whether it stood excluded by the term all other operations mentioning few instances when the operation undergone by the respondent does not fall in the instances quoted.
First Appeal No.860 of 2006. 10
30. The Hon'ble Supreme Court has laid down the law in the judgment reported as "Shashi Gupta (Smt.) v. Life Insurance Corporation of India & Anr." I(1996) CPJ 15 (SC) that where two views are possible, the one favourable to the consumer should be accepted. The same view of law was reiterated by the Hon'ble Supreme Court in the judgment reported as "Life Insurance Corporation of India v. Raj Kumar Rajgarhia & Anr." II(1999) SLT 362. Hon'ble Supreme Court again reiterated this view of law in the judgment reported as "United India Insurance Co. Ltd. v. Great Eastern Shipping Co. Ltd." III(2007) CPJ 3 (SC).
31. This Commission had also taken same view in the judgment dated 22.12.2008 passed in First Appeal No.879 of 2003 "The New India Assurance Co. Ltd. and anr. v. Suresh Sachdeva and another".
32. Therefore for the reasons stated above, we find that since the disease for which the respondent had taken the medical treatment was not specifically excluded, therefore, the respondent is entitled only to that amount which is permissible under the Ashadeep Policy.
33. Learned counsel for the appellants has submitted that the rate of interest awarded by the learned District Forum at the rate of 10% per annum is on the excessive side.
34. This submission has been considered. There is merit in this submission of the learned counsel for the appellants. The rate of interest is reduced from 10% per annum to 7.5% per annum.
35. The costs of Rs.2,000/- are upheld.
36. In view of the discussion held above, the appeal is partly accepted with the only modification in the rate of interest.
37. The appellants had deposited an amount of Rs.25,000/- with this Commission at the time of filing of the appeal on 30.6.2006. This amount of Rs.25,000/- with interest accrued thereon, if any, be remitted by the registry to Narinder Krishan Malhotra respondent by way of a crossed cheque/demand draft First Appeal No.860 of 2006. 11 after the expiry of 45 days under intimation to the learned District Forum and to the appellants.
38. The interest on the amount of Rs.25,000/- shall stop running with effect from the date the appellants had deposited the same in this Commission. Interest on this amount of Rs.25,000/- shall be what has accrued on this amount when it remained deposited by this Commission in the Bank.
39. Remaining amount shall be paid by the appellants to the respondent.
40. The arguments in this case were heard on 19.7.2011 and the order was reserved. Now, the order be communicated to the parties.
41. The appeal could not be decided within the statutory period due to heavy pendency of court cases.
(JUSTICE S.N. AGGARWAL) PRESIDENT (MRS. AMARPREET SHARMA) MEMBER August 02 , 2011 Bansal