BEFORE THE TELANGANA STATE CONSUMER DISPUTES REDRESSAL COMMISSION:HYDERABAD (ADDITIONAL BENCH)

FA. No. 243/2021 AGAINST ORDERS IN CC. No.114/2019 ON THE FILE OF DISTRICT FORUM-II, HYDERABAD Between :

1. The Life Insurance Corporation of India, Rep. by its Senior Divisional Manager, Divisional unit, Jeevan Prakash, Secretariat Road, Hyderabad-500 063, through its authorized signatory KVSSR Krishna Kumar S/o Late Veereswara Sastry, Age:57 years, Occ:-Asst. Secretary, LIC of India, L & HPF Department, SCZO, Hyderabad.

2. The Life Insurance Corporation of India, Rep by its Branch Manager, City Branch-5, Branch Code No.650, Jeevan Jyothi Building, 3rd Floor, Basheerbagh, Hyderabad through its authorized signatory KVSSR Krishna Kumar s/o. Late Veerswara Sastry, Age:- 57 years, Occ:- Asst. Secretary, LIC of India, L & HPF Department, SCZO, Hyderabad.

.….Appellants/opposite parties And

1. Pawan Garg s/o Madan Gopal, Age:57 years, Occ:- Business, R/o. H.No.8-2-120/110/1/2, Road No.14, Banjara Hills, Hyderabad-500 034.

……….Respondent /Complainant Counsel for the Appellants : M/s. K. Venkatesh Gupta Counsel for the Respondent : M/s. M. Raj Kumar QUOR UM: HON’BLE SMT MEENA RAMANATHAN, MEMBER – (NJ)

&

HON’BLE SRI K.RANGA RAO, MEMBER – (J)

FRIDAY, THE 13^TH DAY OF FEBRUARY TWO THOUSAND TWENTY SIX *******

Order : (Per HON’BLE SRI K.RANGA RAO, MEMBER – (J).

1. This appeal is filed by the Appellants/opposite party no.2 U/s.41 of the Consumer Protection Act 2019, praying this State Commission to set aside the impugned order of the District Forum-II, Hyderabad passed in CC.

No. 114/2019 dt.05.03.2021 and pass any such other order or orders.

2. For the sake of convenience, the parties are referred to as arrayed in the complaint. The appellants herein was opposite parties and Respondent was the complainant in the complaint bearing No.CC.114/2019 before the District Forum-II Hyderabad.

3. The brief case of the complaint are as follows:-

The complainant is a Principal Insured of the opposite parties under "LIC's Health Protection plus Plan (Table-902) UIN:5121253VOI". The date of proposal of the policy was 15-11-2010 which commenced from 31-12-2010. The installment of premium amount of Rs.15,000/- per year. The due date of payment of last premium as 31-12-2025, plan and premium paying term 902-

16.

The details of Insurance Coverage are as follows:-

1. Initial Daily Hospital Cash Benefit (HCB) Rs. 2, 500/-

2. Major Surgical Benefits Sum Assured (MSB) Rs. 5,00,000/-

3. Date of Commencement of HCB from 31-12-2010 4. Date of Commencement of MSB from 31-12-2010

5. Date of Expiry of HCB & MSB on 31-12-2036.

The policy was in force for the period of claim made by the complainant for reimbursement of medical expenses incurred for his treatment. On 05-11-2018 at about 9 A.M. the complainant fall down from the ladder accidentally in his House while he was garlanding to his parents photo for which he sustained injury to his left hand shoulder. With the help of his family members he rushed to the Apollo Hospital, Jubilee Hills. Hyderabad on Apollo Ambulance Van at around 10 AM. The complainant was admitted as emergency case as per the Hospital procedure and conducted Investigation. On due Investigations he was admitted as in-patient on the same UHID:

APJ1000216564, Identifier No.IP286895 on 05-11-2018. He was underwent the surgery Under General Anesthesia for PERILOC FIXATION OF LEFT PROXIMAL HUMERUS SURGERY on 06-11-2018 which is major surgery. The surgery done by group of Doctors and the complainant was discharged from the Hospital on 07-11-2018 with the last billing generated at 13:26 P.M. Hospitalization of the complainant for treatment with record and without record laterally for more than 52 hours taking half an hour before admission half an hour after discharge with the last billing generated as registered in Hospital records. An amount of Rs.2, 65,993/- was spent for the Surgery, Investigations, Diagnosis, Medicines and other expenses.

The complainant submitted claim form with