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MAHARASHTRA STATE CONSUMER DISPUTES REDRESSAL COMMISSION, MUMBAI
S.M. Shembole, Presiding Judicial Member, K.B. Gawali, Member
L.I.C. Of India - Appellant
Versus
Bhaskarrao Daulat Rao Hon. Died Through His Lrs & Ors. - Respondents
First Appeal No. 174 of 2011
Decided On : 01-12-2014
Advocate Appeared:
For the Appellant :Mr. M.D. Narwadkar, Advocate.
For the Respondents:Mr. A.D. Shinde, Advocate.
The insured was entitled to claim surgical charges in the event of surgery due to accidental bodily injury, as per the terms and conditions of the policy.
Headnote:
Insurance - Medical Expenses - Interpretation of Policy Terms
Fact of the Case:
The complainant had obtained a health insurance policy from LIC, and after sustaining injuries in a car accident, he incurred medical expenses for surgeries. The insurance company repudiated the claim for reimbursement of the surgery charges, leading to the consumer complaint.
Finding of the Court:
The District Consumer Forum found that the insurance company committed deficiency in service by repudiating the complainant’s claim for reimbursement towards surgery charges and partly allowed the complainant’s claim.
Issues: The main issue was whether the complainant's claim for reimbursement of medical charges was covered by the insurance policy or not.
Ratio Decidendi: The court interpreted the terms and conditions of the policy, specifically the exclusion clause, and found that the insured was entitled to claim surgical charges in the event of surgery due to accidental bodily injury, which was not excluded from the policy.
Final Decision: The court dismissed the appeal, upholding the District Consumer Forum's decision and finding no error or infirmity in the impugned judgment and order.
ORDER :
S.M. Shembole, Presiding Judicial Member
This appeal is directed against the judgment and order dated 8.12.2010 passed by District Consumer Forum Ahmednagar partly allowing complainant’s claim directing opponent LIC to pay to the complainant amount of medical expenses at Rs. 1,15,000 with interest @ 10% p.a. with effect from 18.3.2010, compensation of Rs. 1,000 towards mental agony and Rs. 1,000 more towards cost of proceedings.
(For the sake of brevity appellant is herein after referred as opponent LIC and respondents L.Rs. of complainant Bhaskarrao Hon who died pending the appeal).
2. Brief facts giving rise to this appeal are that:
On 29.10.2008 complainant late Bhaskarrao Hon had obtained policy under LIC Health Plus plan and amount insured under the policy was to the extent of Rs. 2 lakh. The policy was for the period from 29.10.2008 to 29.10.2019. During the subsistence of policy on 11.9.2009 insured late Bhaskarrao met with car accident and was seriously injured. His left hand wrist bone was fractured. Therefore, he was required to admit in the Lakeside Nursing Home, Bandra where he had undergone operation. On 14.9.2009 his wrist bone was replaced. Thereafter again on 14.10.2009 he had undergone operation for second time. He was required to spend total amount of Rs. 1,18,000. After his discharge from hospital he submitted his claim for reimbursement of medical bill. But opponent LIC paid amount of Rs. 3000 only towards hospital charges for 3 days. However, opponent repudiated his claim for reimbursement of the medical bills pertaining to surgery on the ground that same are not covered under the policy. Accordingly complainant late Bhaskarrao was informed. Therefore alleging deficiency in service on the part of opponent, complainant late Bhaskarrao filed consumer complaint claiming reimbursement of surgery charges at Rs. 1,18,000, special diet charges of Rs. 10,000 , Rs. 20,000 towards mental agony and Rs. 2,000 more towards cost of the proceedings total Rs. 1,50,000.
3. Opponent LIC by its written version resisted complaint contending Inter alia that it has rightly repudiated the complainant’s claim towards surgery charges as the same is not covered by the policy. It has denied all other adverse averments made by complainant and submitted to dismiss the complaint.
4. On hearing both side and considering evidence on record District Consumer Forum held that opponent LIC committed deficiency in service by repudiating the complainant’s claim for reimbursement towards surgery charges. In keeping with this finding District Consumer Forum partly allowed the complainant’s claim as noted above.
5. Feeling aggrieved by that judgment and order opponent LIC came to this Commission in appeal. Pending appeal on 26.11.2012 complainant Bhaskarrao Hon died and his L.Rs. are brought on record.
6. We heard Counsel for both side and perused the written notes of arguments submitted by them. We have also perused the copy of impugned judgment and order, copies of complaint, written version, insurance policy including terms and conditions of the policy, medical certificate and bills, etc. Almost all the facts except terms and conditions of the policy are not disputed. Therefore the crux in this matter is as to whether complainant’s claim for reimbursement of medical charges is covered by insurance policy or not?
7. It is submitted by Mr. Narwadkar learned Counsel for opponent/appellant that as per terms and conditions of the policy except major surgery and other surgery is not covered and therefore opponent LIC has rightly repudiated complainant’s claim. He has tried to support his contention by pointing out the terms and conditions of the policy specifically exclusion clause.
8. Per contra Mr. A.D. Shinde learned Counsel for complainant/respondent submitted that as per terms and conditions of the policy all types of surgery are covered. Pointing out from exclusion clause he has submitted that no surgical benefits are excluded from the policy. Bu
