National Consumer Disputes Redressal
Lic Of India vs Abdul Salim on 26 August, 2011
The Petitioner (LIC of India) has filed the present revision petition against the order of the State Commission which dismisse NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI REVISION PETITION NO.1103 of 2007 (from the order dated 20.09.2006 in Appeal No.1007/04 of the State Commission, A.P.) Life Insurance Corporation of India Petitioner Versus Abdul Salim ..Respondent BEFORE: HONBLE MR.JUSTICE ASHOK BHAN, PRESIDENT HONBLE MRS.VINEETA RAI, MEMBER For the Petitioner : Mr.Ashok Kashyap, Advocate For the Respondent : Nemo. Pronounced on 26th August, 2011 ORDER
PER VINEETA RAI, MEMBER The Petitioner (LIC of India) has filed the present revision petition against the order of the State Commission which dismissed their Appeal No.1007/2004 wherein Abdul Salim was the Respondent.
The facts of the case according to the Respondent are that he had obtained an insurance policy called Asha Deep with accident benefits for a sum of Rs.50,000/- for a period of 15 years w.e.f. 28.11.1993 and for which the quarterly payable premium was Rs.1009/-. Respondent had been regularly paying the required premium. During the policy period on 03.09.1997, Respondent suffered acute chest pain and on medical advice he approached a medical expert, Dr.Sudheer Nayak at Mediciti Hospitals, Hyderabad who after examining him admitted him in the hospital for further medical examination at the end of which he was informed that he is suffering from Coronary Artery Disease and an emergency coronary angiogram was conducted 03.09.1997. Thereafter, as advised, Respondent underwent Angioplasty with stent for which he had to pay a total amount of Rs.1,15,000/-.
Respondent filed a claim along with relevant documents including all the medical reports with the Petitioner/Insurance Corporation on 18.11.1997. In response, the Petitioner/Insurance Corporation informed the Respondent that the disease for which the Respondent had filed a claim was not covered under the said policy and, therefore, the claim could not be entertained. Since, according to the Respondent, he was entitled to the claim within the scope of Para 11(i) of the Policy and therefore the repudiation of his policy amounted to deficiency in service, he filed a complaint before the District Forum requesting that the Petitioner be directed to pay the Respondent Rs.50,000/- under the Policy, Rs.5,000/- for mental agony and Rs.2,000/- as litigation costs.
Petitioner denied any deficiency in service and stated that as per the Policy taken by the Respondent, Angioplasty is specifically excluded and in respect of Coronary Artery Disease, the benefit is applicable only for open heart by-pass surgery. Therefore, the claim of the Respondent was rightly repudiated.
The District Forum after hearing both parties partly allowed the complaint and as per its interpretation of the policy, the District Forum concluded that the Respondent was entitled to 50% of the claim which amounts to Rs.25,000/-. The District Forum, therefore, directed the Petitioner to pay the Respondent this amount along with 9% interest from December, 1997 till realization, Rs.3,000/- was awarded as compensation and Rs.500/- as costs.
Petitioner filed an appeal against this order before the State Commission which dismissed the same by upholding the order of the District Forum in toto. The operative part of the order of the State Commission reads as follows:
Ex.A.4 (Conditions and Privileges under the said policy) clearly shows that the policy holder would be eligible for the Benefits (i) Immediate payment of 50% of the sum assured (ii) Waiver of subsequent premiums falling due from the Policy anniversary immediately following the date on which the conditions for the eligibility to the benefits are established (iii) Payment of an amount equal to 10% of the sum assured, every year commencing from the Policy anniversary falling on or after the date of affliction and ending with the Policy anniversary preceding the date of maturity or the date of death of the life assured, whichever is earlier (iv) Payment of balance 50% of the sum assured and vested bonuses on the date of maturity or on death of the life assured, whichever is earlier. The bonuses will be calculated on the full sum assured even though 50% of the sum assured would have been paid earlier. Admittedly in this case the risk is commenced from 28.11.1993 and the complainant underwent operation on 3.9.1997 i.e. after more than three years. So the complainant is entitled to claim the benefit as per the above mentioned benefits.
The complainant is entitled to claim only 50% of the assured amount. Further, on the date of maturity, the complainant is entitled to claim the balance of 50% of the sum assured with Bonus calculated on the full sum assured.
Since the Policy is not matured in this case, the complainant is entitled to claim only 50% of the assured sum. The District Forum has rightly allowed the complaint directing the opposite parties to pay 50% of the assured sum to the complainant with interest @ 9% per annum from December, 1997 till realization and also to pay Rs.3,000/- towards compensation besides costs of Rs.500/-.
Hence, the present revision petition.
Counsel for Petitioner was present. Despite service, none appeared on behalf of the Respondent. It was, therefore, decided to proceed with the case ex parte.
Counsel for Petitioner brought to our notice, the terms contained in the Policy Bond and specifically terms No.11(b) & (b) (i) which read as follows:
11(b) Benefit (B) of the policy schedule shall be available on the occurrence of any of the following contingencies.
11(b)(i) The Life Assured undergoes Open Heart By-Pass 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. All other operations like Angioplasty and Thrombolysis by Coronary Artery Catheterization are specifically excluded.
There is no ambiguity that under this operative provision, Angioplasty is specifically excluded. Unfortunately, the Fora below erred in awarding 50% of the assured amount to the Respondent by taking note of only the Benefits part of the policy i.e. Section (A) wherein it is stated that immediate payment of 50% of the sum assured can be made, without taking note of the fact that Section (A) will be applicable only in respect of the treatment for specifically listed ailments. In the instant case, as noted earlier, this does not include Angioplasty.
There are various rulings including of the Apex Court that an insurance policy between two parties is in the nature of a contract and both parties are bound by the terms and conditions of the policy.
Petitioner strictly followed the terms and conditions of the policy in repudiating the claim and the Fora below erred in reaching its conclusion of deficiency in service on the part of Petitioner.
We have heard learned Counsel for petitioner and have gone through the documents which have been filed in evidence.
The facts pertaining to the Respondent having taken an insurance policy from the Petitioner and also having undergone the Angioplasty are not in dispute. In fact, it is the Respondent who has filed the certificate stating that he has undergone Angioplasty. We have perused the policy document in question and there is no confusion or ambiguity regarding its terms and conditions. The policy document clearly stipulates that Angioplasty is specifically excluded under the Policy and the Policy covers coronary artery diseases only where by-pass surgery has been done. While it is a fact that there is also provision that the Petitioner can pay 50% of the sum assured to the Respondent who files a claim for medical treatment, this will only be admissible in respect of treatment for diseases specifically mentioned in the policy. It cannot cover diseases which are not stated or are specifically excluded as in the instant case. It is also well established that an insurance policy is a contract between the two parties and its terms and conditions, once accepted, are binding on both parties. Further, the ruling of the Honble Supreme Court in United India Insurance Co.Ltd. Vs. M/s Harchand Rai Chandan Lal AIR 2004 SC 4794 is also relevant in this case wherein it has been ruled that the terms of the policy have to be construed as it is and we cannot add or substract something. Howsoever liberally we may construe the policy but we cannot take liberalism to the extent of substituting the words which are not intended. In view of the facts stated above, we set aside the orders of the Fora below and accept the revision petition with no order as to costs.
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(ASHOK BHAN J.) PRESIDENT Sd/-
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(VINEETA RAI) MEMBER /sks/