LIC OF INDIA vs Richard Dsouza

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.

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.

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

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. 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. Thereafter, the Applicable Daily Benefit in each Policy Year in future shall remain at that maximum level attained.

II) Major Surgical Benefit: In the event of an Insured under this Policy undergoing any specified Surgery in a Hospital due to Accidental Bodily injury or Sickness first occurring or manifesting itself after the Date of Cover Commencement and during the Cover Period then, subject to the terms and conditions of this Policy, the Benefit Amount, reckoned as the percentage of the Sum Assured as mentioned in the Surgical Benefit Annexure against the specified Surgery performed, shall be payable by the Corporation.

THE Discharge Summary reveals the following : - "Diagnosis : 1. RTA with concussive head injury. 2. Posterior ace tabular fracture with femoral head fracture dislocation (Left). 3. Scaphoid fracture of right wrist. 4. Distal 1/3rd of comminuted fracture left ulna. 5. Multiple cut would over the neck and face. 6. Fracture of 5th metacarpal left hand.

I have gone through the list of surgical procedures. It mentions about surgical benefit with percent of the sum assured, some of them include the following : JUDGEMENT_50_LAWS(NCD)2_2015.htm

IN short, the policy holder received injuries during the subsistence of the insurance policy and got the above said injuries, which are covered by the policy, if read, as a whole composite document. This Commission has to take a down to earth view. There is a wee bit difference between brain and head, leg fracture and replacement of knee joint. This is also covered under clause (2), cited above. The duty cast on the petitioner is to winnow truth from falsehood. Mere technical formality should not come in the way. The revision petition has no merit and, therefore, the same is dismissed. No order as to costs.