State Consumer Disputes Redressal Commission
Bhartiya Jeevan Bima Nigam & Ors. vs Pawan Kumar Sharma on 2 May, 2015
CHHATTISGARH STATE
CONSUMER DISPUTES REDRESSAL COMMISSION,
PANDRI, RAIPUR (C.G).
Appeal No.FA/14/80
Instituted on : 05.02.2014
01. Life Insurance Corporation of India (LIC)
Through : Branch Manager, Branch Korba - 2,
Post and District Korba (C.G.)
02. Managing Director,
Life Insurance Corporation of India,
First Floor, Yogakshem, Central Office,
Jeevan Bima Marg, P.B. No.19953, Nariman Point,
Mumbai - 400-021
03. Divisional Manager,
Division Office - Dr. Shiv Dulare Mishra Parisar,
Vyapar Vihar,
Bilaspur (C.G.) 495-004
04. L.I.C. Department,
Main Office - M.D. India Health Care Services (TPA) P.Ltd.
S.N. No.46/1 E-Space, A Wing, Third Floor, Pune Nagar Road,
Badgaonsheri, Pune (Maharashtra) 411014 ... Appellants
Vs.
Pawan Kumar Sharma, S/o Gokulchand Sharma,
Gokulchand Laduram Kirana Shop, Main Road,
Korba, Tehsil & District Korba (C.G.) ... Respondent
PRESENT :
HON'BLE SHRI JUSTICE R.S. SHARMA, PRESIDENT
HON'BLE MISS HEENA THAKKAR, MEMBER
HON'BLE SHRI D.K. PODDAR, MEMBER
HON'BLE SHRI NARENDRA GUPTA, MEMBER
COUNSEL FOR THE PARTIES :
Shri D. Dutta, for the appellants.
Shri Balram Tiwari, for the respondent.
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ORDER
DATED : 02/05/2015 PER :- HON'BLE SHRI JUSTICE R.S. SHARMA, PRESIDENT. This appeal is directed against the order dated 07.01.2014, passed by District Consumer Disputes Redressal Forum, Korba (C.G.) (henceforth "District Forum") in Complaint Case No.CC/12/21. By the impugned order, the learned District Forum, has allowed the complaint filed by the respondent No.1 and directed the appellants (OPs) to pay within a period of two months from the date of order a sum of Rs.2,00,000/- which is sum assured under the policy, jointly and severally. It has been further directed that if from the above amount, the amount of Rs.11,000/- is paid by the appellants (OPs) through cheques, then the same be adjusted. The District Forum further directed that the appellants (OPs) will pay interest @ 07% p.a. on the above amount from the date of filing of the complaint i.e. 25.04.2012. If the appellants (OPs) fail to pay the amount within stipulated period, then interest @ 9% would be payable from the date of order till realisation. The appellants (OPs) have further been directed to pay a sum of Rs.5,000/- towards compensation for mental agony and Rs.2,000/- towards cost of litigation to the respondent (complainant).
2. Briefly stated the facts of the case are that the respondent (complainant) has taken an insurance policy i.e LIC's Health Plus Plan Without Profit on 23.02.2008 and the policy was commenced on // 3 // 25.02.2008. The proposal No. of the policy dated 23.02.2008 is 13942, Plan and Term is 901 24 24. The respondent (complainant) is paying the premium regularly as per the policy terms and conditions and policy is alive accordingly. Unfortunately the respondent (complainant) felt severe chest pain (cardiac arrest) on 30.12.2010 and he was admitted in Escorts Heart Centre (Hospital) at Raipur immediately at 09.45 P.M. in ICU Unit, where the disease was diagnosed as the case of Double Vessel Coronary Artery Disease with Acute Anterior Wall MI and Moderate LV Dysfunction (LVEF:30%) and as per the doctor's advice he was gone through major surgery called Coronary Angiography and primary PTCA + Stent To Lad, a major procedure of surgery on same day i.e. on 30.12.2010 and he had been shifted from ICU to WARD on 03.01.2011 at about 11:25 PM and after that he was discharged at 09:51 PM on 06.01.2011 accordingly. The matter was intimated to the appellants (OPs) through respondent's (complainant's) father Shri Gokul Chand Sharma vide letter dated 31.12.2010. The respondent (complainant) after discharge on 06.01.2011 has been brought to Korba at his residence where he has got again chest pain i.e. the minor/partly cardiac attack and he was firstly admitted to local hospital at Korba but the doctors advised and referred him to Escorts Hospital, Raipur again for better treatment, then he was again admitted in that hospital i.e. Escorts Heart Centre at Raipur on 15.01.2011 at 09:51 PM and was discharged at 09:51 PM on 18.01.2011 accordingly. The respondent // 4 // (complainant) was firstly hospitalized from 30.12.2010 to 06.01.2011 and secondly from 15.01.2011 to 18.01,.2011 i.e. total days in the hospital are 8 + 4 = 12 days. The respondent (complainant) submitted his claim form with all the relevant documents as per the oral instruction of the authorized person of the appellants (OPs) on 01.03.2011 along with the hospital records, bills, medicines bills and other documents in Korba Branch of the Insurance Corporation. The respondent (complainant) also sent the documents i.e. the actual time of admission and discharge of patient, required by the MD India Health Care Services (TPA) Pvt. Ltd. Pune, but in spite of all required documents sent to the related authorities as per the instruction, given by the concerning officers of the Insurance Corporation from time to time through telephone/mobile phone, the claim has been rejected, but the respondent (complainant) has acquainted with above facts afterwards. In spite of passing a long duration of six months, there was no response from the appellants (OPs), the respondent (complainant), complained to Insurance Ombudsman in the month of August, 2011 through internet media. Suddenly the respondent (complainant) has received two envelopes from Axis Bank Ltd. Hyderabad Branch along with two cheques No.21006643 dated 21.09.2011 for Rs.9,900/- and second cheque no.21005917 dated 17.09.2011 of Rs.1,100/- stating (printed on cheques) By order of LIC of India Health Insurance Division LIC of India, ABDIS, Hyderabad, (Andhra Pradesh. In addition to that there was no note or // 5 // description of that amount, how this much less amount is being sent to the respondent (complainant) instead of Rs.2,55,220/- as per the actual expenses occurred in the treatment of the respondent (complainant.). Therefore, the respondent (complainant) filed consumer complaint before the District Forum and prayed for granting reliefs as mentioned in the prayer clause of the complaint.
3. The appellants (OPs) filed their joint written statement and averred that the after submitting claim before them, the respondent (complainant) was instructed from time to time to submit relevant document and thereafter intimation regarding repudiation of his claim was given to the respondent (complainant). After receipt of the claim form, from the respondent (complainant), the claim form was considered as per the conditions of the insurance policy and thereafter the cheque was issued in his favour for the amount which the appellants (OPs) found appropriate against his claim. The respondent (complainant) is very well acquainted with the terms and conditions of the insurance policy, which was obtained by him. As per the insurance policy, the respondent (complainant) is entitled to get a sum of Rs.1,000/- per day towards arambhik dainik aspatal, nagad hit labh. As per terms and conditions of the insurance policy, the appellants (OPs) have paid a sum of Rs.9,9,00/- and Rs.1,100/- to the respondent (complainant) for his treatment in the hospital. According to the record of the Hospital, operation of Primary PTCA + STENT TO LAD // 6 // of the respondent (complainant) was conducted, which is not included in the Schedule 1 to 49. The treatment / operation of the respondent (complainant), is not included in the list of surgery procedure of the insurance policy, therefore, the respondent (complainant) is not entitled for getting amount in respect of the expenses incurred in the operation.
4. The District Forum after having considered the material placed before it by both the parties, has allowed the complaint and directed the appellants (OPs) to pay compensation to the respondent (complainant), as mentioned in the para 1 of this judgment.
5. The respondent (complainant) filed documents. Document P-1 is insurance policy, P-2 is letter dated 31.12.2010 sent by Mr. Gokulchand Sharma to the Branch Manager, LIC Of India, B.O.1, Korba, P2-A is intimation regarding admission, P-3 is letter dated 30.06.2011 sent by the Insurance Corporation to the respondent (complainant), P-4 is closure notice of the LIC claim, P-5 is payment reference, P-6 is payment reference, P-7 is claim intimation details, P-8 & P-9 are Certificate issued by Dr. Satish Suryawanshi, P-10 is Summary of Medical Treatment Bills, P-11 is Discharge Summary, P- 012 is Discharge Summary, P-13 is Inpatient Bill, P-14A is Outpatient Receipt, P-14-B is Inpatient Bill, P-16 are receipt issued by Escorts Heart Centre, P-17 is ECG reports, P-18 is Legal Notice dated // 7 // 21.12.2011 sent by Shri Balram Tiwari, Advocate to the Life Insurance Corporation of India, Through Branch Manager, Branch Korba (C.G.), P-19 is reply sent by Shri A.N. Maithani, Advocate.
6. The appellants (OPs) have also filed documents. D-1 is terms and conditions of the LIC's Health Plus Policy, D-2 is email message, D-3 is email message, D-4 is Case History, D-5 is letter dated 5.09.2011 sent by M.D. India Health Care Services (TPA) P.Ltd.to the respondent (complainant), D-6 is letter dated 27.05.2011 sent by M.D. India Health Care Services (TPA) P.Ltd. to the respondent (complainant).
7. Shri D. Dutta, learned counsel appearing for the appellants (OPs) has argued that as per terms & conditions of the insurance policy, the respondent (complainant) is not entitled to get any compensation from the appellants (OPs). The operation of the respondent (complainant) was conducted for Primary PTCA + STENT TO LAD, which is not include in the policy schedule. The treatment of the respondent (complainant) is also not included in the list of surgery procedure of the insurance policy, therefore, the respondent (complainant) is not entitled for getting any amount from the appellants (OPs) in respect of expenses incurred by him in the operation and learned District Forum has erroneously awarded the amount in favour of the respondent (complainant). The appeal of the // 8 // appellants (OPs) may be allowed and the impugned order passed by the learned District Forum, be set aside.
8. Shri Balram Tiwari, learned counsel appearing for the respondent (complainant) has supported the impugned order passed by the learned District Forum and submitted that the impugned order does not suffer from any infirmity, irregularity or illegality and does not call for any interference by this Commission. He placed reliance on judgment of Hon'ble National Commission in the case of Mahesh Chand Ghiya vs. New India Assurance Co. Ltd. 2011 STPL (CL) 78 (NC) = 1 (2011) CPJ 25 (NC) = 2011 (1) CPR 122 (NC).
9. We have heard learned counsel for both the parties and have also perused the record of the District Forum.
10. The respondent (complainant) filed document P-8 i.e. Certificate issued by Dr. Satish Suryavanshi, Consultant Cardiologist, Interventional Cardiologist, Escorts Heart Centre, Raipur (C.G.) in which it is mentioned that "This is to certify that Mr. Pawan Sharma, 42 years Male, Regn. No.802851 IPD NO - 10365 is a known case of Double Vessel Coronary Artery Disease. In document P-11 i.e. Discharge Summary of Escorts Heart Centre, Raipur (C.G.) it is also mentioned that the respondent (complainant) Mr. Pawan Sharma was admitted in the Hospital on 30.12.2010 and was discharged on 06.01.2011 and disease was diagnosed as Double Vessel Coronary // 9 // Artery Disease, Acute Anterior Wall MI, Moderate LV Dysfunction (LVEF : 30%) and procedure(s) for Coronary Angiography and Primary PTCA + Stent To Lad was conducted in the Escorts Heart Centre, Raipur. The appellants (OPs) have filed Conditions and Privileges referred to in the policy document in which rates of charges per annum is annexed with it. In the list of Surgical Procedures, it is mentioned that "Coronary Angioplasty with stent implantation (two or more coronary arteries must be stented). In the instant case, Dr. Satish Suryavanshi, Consultant Cardiologist, Interventional Cardiologist, Escorts Heart Centre, Raipur (C.G.) specifically mentioned in the Certificate issued (Annexure P-8) that the respondent (complainant) Mr. Pawan Sharma, 42 years Male, Regn. No.802851 IPD NO - 10365 is a known case of Double Vessel Coronary Artery Disease.
11. From the perusal of the document D-3 filed by the appellants (OPs) it is clear that the Cardiologist presumes that there is three coronary arteries, which are known as RCA, LCA and LAD, though LCX and LAD are branch of main stream of left coronary artery. On the basis of seriousness of the disease of coronary artery, the diseases are called as Single Vessel Disease, Double Vessel Disease or Triple Vessel Disease.
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12. The appellants (OPs) stated that during course of treatment of the respondent (complainant) stent was implanted in primary PTCA and Lad, therefore, the above operation is not included in the list of the surgery i.e. document D-1, and therefore, the respondent (complainant) cannot get amount of compensation under the policy. Document D-4 is Case History of the respondent (complainant) issued by Escorts Heart Centre, Raipur (C.G.) Along with document D-4, photograph of Coronary Angiogram, is also annexed. In document D-4 it is mentioned that "Mr. Pavan Sharma, underwent Coronary Angiography by Femoral Route on 30/12/2010, which revealed Double Vessel Coronary Artery Disease and Moderate LV dysfunction (by Echo, LVEF : 30%). Primary PTCA + Stent to Lad was done on 30.12.2010. The procedure was uncomplicated & uneventful. He is being discharged in haemodynamically stable condition with advice & treatment." In the said document it is also mentioned that Double Vessel Coronary Artery Disease (Report Attached). From the bare perusal of the above document, it appears that in coronary artery branch of the respondent (complainant) i.e. LAD, stent has been implanted. In coronary artery related to RCA and LCA, blockage has been shown. On the basis of LIC Health Plus Plan issued by the appellants (OPs) in the favour of the respondent (complainant), it appears that the respondent (complainant) was simply aware regarding Angioplasty operation, but it cannot be presumed that he // 11 // was aware regarding Double Vessel Coronary Artery Disease Acute, Anterior Wall MI, Moderate LV Dysfunction (LVEF : 30%). The respondent (complainant) stated in his affidavit that the Insurance Agent has not given information regarding the stent to be attached in the Agnioplasy operation.
13. On the basis of the Certificate (Annexure P-8) issued by Dr. Satish Suryavanshi, Consultant Cardiologist, Interventional Cardiologist, Escorts Heart Centre, Raipur (C.G.) and other relevant documents, we find that the District Forum has rightly reached to the conclusion that the respondent (complainant) is entitled for getting a sum of Rs.2,00,000/-, which is sum assured under the policy along with interest and Rs.5,000/- towards compensation for mental agony and Rs.2,000/- towards cost of litigation from the appellants (OPs). The finding of the District Forum, is just and proper and does not call for any interference by this Commission.
14. Hence, the appeal filed by the appellants (OPs) being devoid of any merits, deserves to be and is hereby dismissed. No order as to the cost of this appeal.
(Justice R.S. Sharma) (Ms. Heena Thakkar) (D.K. Poddar) (NarendraGupta) President Member Member Member /05/2015 /05/2015 /05/2015 /05/2015