Page 25 - Life Insurance Today April 2018

LEGAL

Legal Case Studies on
Health Claim

In the matter of due to trauma was listed in the annexure to M S B. The
insured had undergone surgery of two Maxillary (Upper
Arvind A Jethva and lower jaws). It was required as a result of accident.
As per certificate of treating Doctor K.R. Rao of Rao’s plas-
V/s
tic surgery and burns hospital dated 01/06/2015 wherein
LIC of India (Rajkot-Health) he mentioned that Mrs. Ramaben was operated for
faciomaxillary injuries – lacerations our face, forehead
Complaint No. AHD-L-029-1617-0233
upper-lip and # body of mandibh (Rt. Parasymphygal) un-
Policy No. 814548626 der general anesthesia. Despite the Doctor’s opinion, the
Respondent, the TPA had merely gone by the wordings
Brief History of the case: rather than the spirit of the terms and conditions. The TPA
The Complainant had taken Health Plus Policy on 15/12/ had failed to apply its prudent mind. It was surgery of jaws
2008. The complainant’s wife Mrs. Ramaben was hospital- due to accident and not a cosmetic surgery hence claim
ized at Ruparelia Neuro hospital Trauma Centre & ICU, became payable. The complaint is admitted.
Jamnagar from 24/05/2015 to 01/06/2015. She was diag-
nosed with Head Injury (Poly Trauma) due to vehicular In view of the foregoing, the Forum, hereby, directs the
accident. As per the discharge summary she was operated Respondent to pay Rs. 1,80,000/- to the Complainant. (60
under General Anesthesia for Maxillary Mandible #. The % of Sum Assured)
complainant had incurred an expenses of Rs.1,49,455/-
Against his claim a sum of Rs.9,750/- was settled. In the matter of

The Complainant’s wife had undergone surgery for Maxil- Mr. Yogeshkumar N. Parmar
lary Mandible # (i.e. fracture on lower jaw and upper jaw).
V/s
It fell under Surgical Benefit Annexure List of Surgical Pro-
cedure under ORO-MAXILLAFACIAL SURGERY of the policy Future Generali India Life Insurance Company
schedule. “Major reconstructive oro-maxillafacial surgery Ltd.
due to trauma or burns. It was not for cosmetic purpose.
The TPA had considered only HCB claim (Hospital Cash Complaint No. AHD-L-017-1617-0977
Benefit) and settled claim for Rs.9,750/- only. The surgery Policy Nos: 01306140
falls under Surgical Benefit Annexure where 60% of the
sum assured i.e. Rs.1,80,000/- (60% of S.A. Rs.3,00,000/-) The Complainant had stated that his friend Mr. Amrutlal
was payable..
M Prajapati had approached him to purchase a policy from
As per Respondent the claim was settled under HCB (Hos- Future Generali Life Insurance Company Ltd. His friend had
received a call from one Mr. Rohit Sharma informing him
pital Cash Benefit) clause. The surgery does not full under
that he was the HOD of IRDAI and 28 Life insurance com-
MSB (Major Surgical Benefit) there for the claim was con-
sidered for HCB only and the claim was settled accordingly. panies. He was asked to purchase a policy to get the ben-
efit of Rs. 16 lakhs from the Government. In this way his
The Forum noted that the surgery (Maxilla facial Surgery) friend had purchased 11 policies in different person’s

Life Insurance Today April 2018 25