LIC OF INDIA Vs. RICHARD DSOUZA

JUDGEMENT

(1.) 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.

(2.) 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.

(3.) 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 : -