State Consumer Disputes Redressal Commission
The Senior Branch Manager,186, ... vs P. Kannan Marimuthu, ... on 13 September, 2010
BEFORE THE STATE CONSUMER DISPUTES REDRESSAL COMMISSION, CHENNAI BEFORE THE STATE CONSUMER DISPUTES REDRESSAL COMMISSION, CHENNAI Present Hon'ble Thiru Justice M. THANIKACHALAM PRESIDENT Thiru S. Sambandam, B.Sc., MEMBER II F.A.NO.509/2007 (Against order in O.P.NO.51/2006 on the file of the DCDRF, Nagapattinam) DATED THIS THE 13th DAY OF SEPTEMBER 2010 1.
The Senior Branch Manager Life Insurance Corporation of India Branch Office 186, Avayambalpuram Mayiladudurai Town
2. The Manager (Claims) Life Insurance Corporation of India Divisional Office, Thanjavur Appellants / Opposite parties Vs. P. Kannan Marimuthu, B.Com.,B.L., Advocate Haniffa Colony 30/10, Kamarajar Salai Mayiladurai Respondent / Opposite party The respondent as complainant filed a complaint before the District Forum against the appellants/ opposite parties praying for the direction to the opposite parties to pay Rs.1,75,000/- as compensation. The District Forum allowed the complaint. Against the said impugned order, this appeal is preferred praying to enhance the compensation ordered by the District Forum dt.10.8.2007 in CC No.51/2006.
This petition coming on before us for hearing on 25.8.2010 upon hearing the arguments of the counsels on either side, this commission made the following order.
Counsel for the Appellants/ Opposite parties:
M/s. P.G.Padmanabhan, Advocate Counsel for the Respondent/ Complainant: In person M. THANIKACHALAM J, PRESIDENT
1. The opposite parties are the appellants.
2. The facts leading to the appeal:
The complainant having taken Asha Deep policy, from the opposite party, had underwent a double valve replacement surgery on 16.3.2006, for which he was charged at Rs.2,04,743/-. Under the policy, the maximum amount assured was Rs.3 lakhs, in which the complainant is entitled to be reimbursed 50% viz. Rs.150000/-, for which a claim was made, repudiated, as if under Article 11(b), the complainant is not entitled to any expenses incurred, improperly, not properly reading the article, which should be construed as deficiency and negligence, which had caused, mental agony to the complainant. Hence the claim for the recovery of a sum of RS.1,75,000/-.
3. The opposite parties, accepting the policy, opposed the claim, that as per the condition and privileges available in the policy, a claim can be made, only on the happening of any of the contingencies, given in the policy document, which contemplates only open heart by-pass surgery, leading to surgery, necessarily, by means of coronary angiography, and not for valve replacement, on which basis, justifiably and reasonably, they have repudiated the claim, which cannot be described as deficiency in service, thereby praying for the dismissal of the complaint.
4. The District Forum, considering the conditions of the policy, the purpose of the policy, as well the actual treatment taken by the complainant, came to the conclusion, that the policy also should cover replacement of valves, and in this view, allowed the complaint as prayed for, directing the opposite party to pay the said sum, as per order dt.10.8.2001, which is under challenge.
5. Heard the learned counsel for appellant, perused the written submission of the appellant, lower court records as well as the order passed by the District Forum.
6. The complainant had taken, Asha Deep II policy, from the 2nd opposite party, commencing from 19.5.2004 to 19.5.2009, for the sum assured Rs.3 lakhs, as evidenced by Ex.A1, which covers mediclaim also. On 16.3.2006, while the policy was in force, he had undergone double valve replacement surgery, in the Madras Medical Mission Hospital, for which he had incurred an expense of Rs.2,04,743/-. Under the policy, out of Rs.3 lakhs, the complainant is entitled to 50% viz. Rs.150000/-, from the opposite party. Accordingly, a claim was made, alongwith bills etc., and it appears, the same was rejected, on the ground that the valve replacement surgery is not eligible for Asha Deep policy, as per the conditions available in Ex.B2. Thus, unable to get the amount, even after notice, as seen from Ex.A7, a complaint has been filed, which ended in favour of the complainant, resulting this appeal.
7. The only point urged before us was, that the replacement of valves, is not covered, as envisaged under article 11(b) of the policy, and therefore, the complainant is not entitled to any amount, since admittedly, he had incurred expenses, only for valve replacement, in the heart surgery. In support of the above submission, discharge summary, as well as the above said clause, were brought to our notice. As seen from the medical records, by the heart surgery, two valves by name Aortic valve and Mitral Valve were replaced, by mechanical valve, costing Rs.2,04,743/-, which is also not in dispute. It is not the case of the by-pass surgery, rectifying the narrowed/ occluded coronary artery, to restore the adequate blood supply to heart.
7. Article, or condition 11(b)(i) reads 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 Catheterization are specifically excluded). A literal reading of the above condition, may appear, as if the complainant may not be entitled to any benefits, since valve replacement is not included, for claiming benefits, in the case of contingencies, whereas, open heart by-pass surgery, alone is contemplated, which meant to restore adequate blood supply to heart. But, at the same time, while excluding certain type of contingencies, it is not the case in the policy, valve replacement is excluded. It says angioplasty and Thrombolysis by Coronary Catheterization are specifically excluded, thereby implying in a way, other kind of surgery, should include when that is meant for improving or restoring adequate blood supply to heart. By the replacement of the valves, functioning of the heart made more effective, restoring the blood circulation effectively, not only to the heart, but also to other parts, and therefore, we are of the view, that replacement of valves also should come within the benefit, since it is not specifically excluded. In this context, we have to see, the purpose of taking the policy, intention, etc., also.
8. In this case, there is no question of material suppression of facts, or any exclusion clause, as available in someother policies. When there is a doubt, or there is an ambiguity in the clauses, it is always better, and desirable, that it should be interpreted, in favour of the policy holder, and not to the detriment of the premium payer, otherwise the purpose of taking policy itself would be defeated /frustrated. Policies are taken, to have reimbursement of the medical expenses, in case of contingency arises. In this case, the contingency is the heart problem, leading to replacement of valves, which is not excluded, though certain other categories were excluded, as indicated above. By the replacement, adequate blood supply to heart, improved or restored, which is covered under the policy. The District Forum considering all these facts, in our view, correctly has come to the conclusion, that the replacement of valve, cannot be excluded, and in this view, under the policy, the complainant is entitled to the benefits, which finding required to be confirmed, not to be disturbed.
9. In the result, the appeal is dismissed, confirming the order of the District Forum in C.C.No.51/2006 dt.10.8.2007.
Considering the facts and circumstances of the case, there will be no order as to cost in the appeal.
S.SAMBANDAM M. THANIKACHALAM MEMBER II PRESIDENT INDEX : YES / NO Rsh/d/mtj/FB/ Insurance