ICICI LOMBARD GENERAL INSURANCE COMPANY LTD. vs Bhaneshwar Dayal Sharma

THE complainant Bhaneshwar Dayal Sharma availed a housing loan of Rs. 4,61,000 from the ICICI Lombard General Insurance Co. Ltd. for which a mediclaim policy was also provided to him, for the period valid from 28.9.2006 to 27.9.2011. An amount of Rs. 26,756 was collected from the complainant on account of policy. On 7.7.2007, the complainant underwent an operation at Sawai Mansingh Hospital for Aerotic Beformoval Bypass Grafting Aerotic Elec Block and incurred total charges in the sum of Rs. 1,25,000. The complainant claimed this amount from the OP under his mediclaim policy, but it was rejected. Therefore, alleging deficiency in service and unfair trade practice by the OP, the complainant filed a complaint before District Consumer Disputes Redressal Forum (in short, ''District Forum'') for the recovery of complete treatment amount of Rs. 1,25,000 and compensation under several heads. The District Forum partly allowed the complaint and directed the OP to pay a sum of Rs. 1,25,000 along with interest at the rate of 10% per annum, a sum of Rs. 25,000 towards mental agony and Rs. 3,000 towards litigation expenses.

AGAINST the order of District Forum, the OP preferred First Appeal (FA. 1077/2012) the State Commission; which was dismissed. Aggrieved by the order of State Commission, the OP preferred this revision. We have heard both the parties. The learned Counsel for OP vehemently argued and denied of any deficiency in service. The claim of the complainant was repudiated on two grounds. Firstly, that the surgical procedure was outside the purview of the nine critical illness and procedure defined and covered in the Policy. Secondly, as per Exclusion Clause 2.1.4 of the Insurance Policy, the disease was diagnosed on 14.12.2006, which fell within 90 days of the inception date of the Insurance Policy. The Counsel drew our attention to the terms and conditions of said mediclaim policy, and the events which are covered under the said policy, are reproduced, as below: The following Insured Events were covered under the Policy:

(a) Diagnosis of the following illness, namely - -

List of covered illness - -

Cancer, End Stage Renal Failure, Multiple Sclerosis.

(b) Undergoing of the following surgical procedures - -

List of covered procedures - -

Major Organ Transplant, Heart Valve Replacement or Coronary Artery Bypass Graft.

(c) Occurrence of the following Medical Events:

List of covered events:

Stroke, Paralysis and Myocardial Infection

A. Death of the Insured on account of an Accident:

B. Permanent Total Disablement of the Insured on account of Accident.

Coronary Artery Bypass Graft as defined under the Policy - -

The actual undergoing for the first time of an open chest coronary artery bypass surgery to correct narrowing or blockage of one or more coronary arteries with bypass grafts provided it is recommended by Cardiologist and supported with coronary angiographic evidence but excluding balloon angioplasty and/or any other intra arterial procedures or laser relief.

IT was an admitted fact that on 7.7.2007, the complainant was operated for Aortic Bi -femoral Bypass Grafting - Aortic Iliac Block on thigh region at Sawai Man Singh Hospital and had incurred an expenditure of Rs. 1,25,000; the said claim was repudiated by OP. Clarification was given by Dr. Neerja Grova that it was not concerned with heart or CABG operation, but it was Aorto -Femoral by -pass. The Fora below clearly misunderstood the medical terminology and interpreted the term "By -pass" as coronary artery bypass graft (CABG). On perusal of operative notes, it clearly goes to show that, the operation was performed for the disease in the leg. It was not concerned at all with heart i.e., coronary arteries. Therefore, there is nothing wrong that the OP has repudiated the claim. The District Forum mixed the 2 procedures which are entirely different and done on 2 different organs viz. namely CABG for heart blockage, Aorto -Femoral Bypass graft for artery blockage, in the leg.

WE are also surprised to peruse the order of the State Commission which is absolutely a non -speaking order. It has just endorsed the order of the District Forum, without considering the evidence or medical literature or operative notes. Therefore, we set aside the order passed by the Fora below and allow this revision petition. Accordingly, the complaint is dismissed. Parties are directed to bear their own costs.