SENIOR BRANCH MANAGER, LIC OF INDIA vs VEMURI RANGAIAH

THIS appeal has been filed by the opposite parties aggrieved by the order of the District Forum, Nellore in C.P. No. 566/1996.

THE complainant Shri Vemuri Rangaiah took Asha Deep policy from opposite parties on 19.11.1993 for Rs. 50,000/- for a period of 15 years. After about 2 years on 13.7.1995 he underwent heart surgery in Madras General Hospital to restore adequate blood supply to his heart and he spent nearly Rs. 75,000/-. As per the policy conditions he submitted his claim on 11.8.1995 to the first opposite party. But it was not settled. He, therefore, filed complaint in the District Forum with a request to direct the opposite parties to pay 50 per cent of the policy amount with interest at 24 per cent and the balance as per terms and conditions of the policy. He also requested that the instalments paid subsequent to the operation should be returned with 24 per cent interest per annum with compensation of Rs. 10,000/- towards mental agony and costs. The opposite party contended that the policy covers only "open heart bypass 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 and all other operations (e.g. Angioplasty or thrombolysis by coronary artery catheterisation) are specifically excluded". It is further contended that the complainant underwent valve replacement which was not covered under the policy and hence the claim was rightly rejected.

The District Forum found that as per Ex. A4, the medical report from the Madras Government General Hospital the complainant was suffering from Rh. Mitral Stanogis (Sev) Aortic Stenosis (Severe) with Aortic Regurgitation Grade II, Pulmonary Hypertension (Severe) and was advised surgery. Therefore, there was narrowing of main artery arising out of the left ventricle of the heart clocking free flow of blood to the heart and as per the policy condition the coverage was not open heart bypass surgery performed on significantly narrowed coronary arteries to restore adequate blood supply to heart and the surgery must have been proven to be necessary by means of coronary angiography. Hence the surgery was covered as per the policy conditions. Therefore, Hon''ble District Forum directed the opposite parties to pay Rs. 25,000/- together with interest at 12 per cent per annum from 31.10.1996 the date of repudiation till the date of payment and the remaining half to be paid on maturity as per terms and conditions of the policy and also costs of Rs. 1,000/- to be complied within 3 months.

AGGRIEVED by this order the appeal has been filed. We find that there is no dispute about the Asha Deep Policy taken by the respondent/complainant and its terms and conditions. There is also no dispute that of all the surgeries related to heart are not covered by the policy and there are certain exclusions. There is also no dispute that the respondent had undergone heart surgery at Chennai and that it was necessary. The dispute is whether the surgery was covered by the policy or it came under exclusion clause since it involved Mitral valve replacement. As per the Ex. A1 the policy covers as follows : "The Life assured undergoes open heart bypass surgery performed on significantly narrowed/occluded coronary arteries to restore adequate blood supply to heart and the surgery just have been proved to be necessary by means of coronary angiography. All other operations (e.g. Angioplasty and Thrombolysis by Coronary Artery Catheterisation, are specifically excluded.)"

Ex. A2 suggests that the appellants received 8 documents including Angiography film with report and operating surgeons'' report. Therefore, the first condition that Angiography has to be done is accepted by the appellants.

HOWEVER, as per Ex. A3 dated 31.10.1996 opposite party refused the claim on the ground that the operation performed was not covered by the policy as per the medical opinion of its expert Medical Advisor. The appellants have however not filed that report nor have they produced any other expert opinion or documents. The policy excludes certain procedure which are usually done by the Cardiologist while the open heart surgery is performed by Cardio Thorasic Surgeon. Moreover, once the open heart surgery is mentioned and valve replacement is not specifically mentioned in the exclusion clause we are of the opinion that benefit of doubt should be given to the respondent. This type of ambiguity in the exclusion clause only shows the careless manner in which the policy is issued to the un-suspecting public and later declare that certain items are excluded without mentioning them specifically. It is nothing but unfair trade practice. Hence there is deficiency in service. It is very difficult for a lay person to make such fine distinctions between various kinds of open heart surgeries and once the policy includes open heart surgery it gives an impression that all surgeries which are open heart are included. Hence we do not find any reason to interfere with the order of the District Forum except reducing the interest allowed to 9 per cent. The appeal is, therefore, dismissed. Costs of the appeal Rs. 1,000/-. Time for compliance 6 weeks. Appeal dismissed.