State Consumer Disputes Redressal Commission
Life Insurance Corporation Of India, ... vs Sh. Shri Niwas Bansal Son Of Shri Om ... on 8 February, 2012
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, HARYANA, PANCHKULA First Appeal No.315 of 2009 Date of Institution: 26.02.2009 Date of Decision: 08.02.2012 Life Insurance Corporation of India, through its Branch Office, Branch Manager, Rohtak Opposite All India Radio, Civil Lines, Rohtak, through L.I.C. Divisional Office, Sector-17, Chandigarh. Appellant (OP) Versus Sh. Shri Niwas Bansal son of Shri Om Parkash Bansal C/o M/s AMI Lal Om Parkash, Haryana Cloth Market, Rohtak. Respondent (Complainant) BEFORE: Honble Mr. Justice R.S. Madan, President. Mr. B.M. Bedi, Judicial Member. For the Parties: Ms. Jaimini Tiwari, Advocate for appellant. Shri N.K. Malhotra, Advocate for respondent. O R D E R
Justice R.S. Madan, President:
This appeal has been preferred against the order dated 08.01.2009 passed by District Consumer Forum, Rohtak whereby complaint bearing No.555/2006 filed by complainant (respondent herein) seeking direction to the appellant-opposite party to pay the insurable benefits qua the medi-claim Insurance Policies issued by the appellant-opposite party, was accepted by granting following relief:-
As per document Ex.P6, complainant spent Rs.183704/- on his treatment. Hence as per policy, the complainant is entitled for 50% amount. Accordingly we hereby allow the present complaint with direction to the opposite party to pay 50% amount of Rs.183704/- i.e. Rs.91852/- alongwith interest @ 9% p.a. from the date of filing the present complaint till its realization and Rs.2000/- (Rupees two thousand only) as litigation expenses to the complainant within one month from the date of decision, failing which the amount of award shall carry interest @ 12% p.a. from 08.02.2009 onwards till its realization to the complainant.
Undisputed facts of the present case are that complainant had purchased three medi-claim Insurance Policies Ex.P2 to Ex.P4 from the appellant-opposite party in the year 2000 for Rs.1,00,000/- each. On 23.05.2006 i.e. during the subsistence of the aforesaid policies, the complainant suffered pain in chest, he consulted Dr. Sushil Jain, Rohtak and thereafter took treatment from Max Devki Devi Heart and Vascular Institute, Delhi for his disease and underwent Coronary Angiography on 30.05.2006. According to the complainant he spent Rs.1,83,704/- on his treatment. Accordingly, complainant submitted claim with the opposite party to pay the insurable benefits but his claim was repudiated by the opposite party vide letter dated 14.07.2006 on the ground that complainants claim was not covered under the policy.
Challenging the repudiation of his claim, complainant invoked the jurisdiction of the District Consumer Forum. Upon notice, the opposite party appeared and resisted complainants claim in view of the repudiation letter.
On appraisal of the pleadings of the parties and the evidence adduced on record District Consumer Forum accepted complaint and issued direction to the opposite party as noticed in the opening para of this order. Hence this appeal.
We have heard learned counsel for the parties and perused the case file.
On behalf of the appellant-opposite party it has been argued that Angioplasty and Angiography was not covered under the policy condition (11A). On the other hand learned counsel appearing on behalf of the complainant has justified the order of the District Forum in view of the judgments relied upon by the District Forum while disposing of the complaint.
Having taken into consideration the rival contentions of the learned counsel for the parties, we are agree with the finding recorded by the District Forum while disposing of the complaint, reproduced as under:-
After going through the file and hearing the parties we are of the considered view that firstly it is not proved on file that the policy terms and conditions were supplied to the complainant. Secondly, the affidavit of doctor Alok Gupta who has submitted on Ex.R6 that the Angioplasty is excluded from benefit, has not been placed on file. In this regard as per the authorities cited by ld. Counsel for the complainant reported in 2005(2)450 JRC titled O.I.C. Vs. Neerja Sharma, Honble Uttranchal State Commission has held that: If the policy has not been given to complainant, the Insurance Company cannot rely on its terms and conditions-Such terms and conditions should have been specifically informed to the complainant and as per IV(2006) CPJ 167 (NC) titled Hindustan Motors Ltd. Vs. P. Vasudeva & Anr., it has held that: Affidavit of person issuing the report not filed-Report not acceptable. Moreover, as per the authority reported in II(2005) CPJ 70 (NC), titled LIC of India Vs. Madiestty Rajashekaram it has held that: Complainant underwent open heart surgery-Liability denied by company-Contention, surgery not covered under policy, not acceptable Risk covered under policy in view of main purpose rule of interpretation Complainant entitled to 50% of amount with interest @ 12%.
Having taken into consideration the facts and circumstances of the case and the finding recorded by the District Forum reproduced herein above, we do not find any merit in this appeal.
Hence, this appeal is dismissed being devoid of any merit.
The statutory amount of Rs.25.000/- deposited at the time of filing the appeal and Rs.27,330/- deposited by the appellant in compliance of the order dated 10th March, 2009 passed by this Commission be refunded to the appellant against proper receipt and identification in accordance with rules, after the expiry of period of appeal and revision, if any filed in this case.
Announced: Justice R.S. Madan 08.02.2012 President B.M. Bedi Judicial Member