IMPORTANT POINT
National Commission has to take a down to earth view.

J.M. Malik, Presiding Member—Richard D’ Souza, the complainant, obtained a policy under LIC’s Health Plus Unit Linked Insurance Plan from the LIC of India, petitioner/OP. The policy stipulated that in case of accident, it will bear the medical expenses to the tune of Rs. 1,60,000/- to the policy holder. During the subsistence of the insurance policy, the policy holder sustained fracture to his legs, hands, head, face and neck, while he was travelling in a car, on 14.03.2010. He took treatment in BGS Apollo Hospital, Mysore, in between 14.03.2010 to 26.03.2010. The complainant spent a sum of Rs. 2,50,000/-. However, the claim made by him was repudiated on the ground that Open Reductive Internal Fixation (in short, ‘ORIF’) is not covered under the list of allowed surgical procedures, as per the policy condition and privileges.

2. Both the fora below have decided the case against the LIC and granted a sum of Rs. 1,60,000/-, i.e., the amount fixed for medical treatment undergone and Rs. 7,000/- towards mental agony and litigation expenses.

3. I have heard the counsel for the petitioner. She has produced the list of approved major surgical benefits. She vehemently argued that this list does not include ‘ORIF’.

4. All these arguments did not leave an impact on me. As a matter of fact, the entire policy should be read holistically. It is not to be read in vacua to the detriment of one and benefit of another. Its definitions run as follows :-

“i) Accident means a sudden, unintended, fortuitous, violent, visible and external and does not include any naturally occurring condition or degenerative process.

i. Accidental Bodily injury means physical bodily harm or injury (but does not include any mental sickness, disease or illness) which is caused by an Accident which first occurs during the Cover Period for the Hospital Cash Benefit Cover and for the Major Surgical Benefit Cover and requires inpatient treatment or surgery in a Hospital by a Physician or surgeon, as the case may be”.

It further mentions about ‘hospital cash benefit’ clause, as under :-

“1. Hospital Cash Benefit:

In the event of Accidental Bodily Injury or Sickness first occurring or manifesting itself after the Date of Cover Commencement and during the Cover Period and causing an Insured’s Hospitalization to exceed a continuous period of 48 hours within the Policy Period, then, subject to the terms and conditions, waiting period and exclusions of the Policy, the Daily Benefit is payable by the Corporation as follows:

a. In case of Hospitalization in the general or special ward ( i.e. a non-Intensive Care Unit

b. Ward/room) of a Hospital:

The Applicable Daily Benefit in a Policy Year, reckoned under sub-clauses (i) and (ii) below, for each continuous period of 24 hours or any part thereof (after having completed the 48 hours as above) provided any such part stay exceeds a continuous period of 4 hours of Hospitalization necessitated solely by reason of the said Accidental Bodily Injury or Sickness, shall be payable.

(i) In the Policy Year being the first year of cover starting from the Date of Cover Commencement in respect of an Insured under this Policy, the Applicable Daily Benefit due to Hospitalisation shall be equal to the Initial Daily Benefit mentioned in the Schedule.

(ii) After the first year of cover and for each Policy Year commencing at a Policy anniversary on or after the first Policy anniversary and during the Cover Period in respect of an Insured, the Applicable Daily Benefit of the previous Policy Year shall be increased by arithmetic addition of an amount equal to 5% (five percent) of the Initial Daily Benefit and the resulting amount shall be the Applicable Daily Benefit for that Policy Year. Such increase in the Applicable Daily Benefit shall be effected on each Policy anniversary during the Cover Period and shall continue until the Applicable Daily Benefit in a Policy year attains a maximum amount of 1.5 times the Initial Daily Benefit. Thereaf