National Consumer Disputes Redressal
Lic Of India vs Shri Niwas Bansal on 12 April, 2013
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI REVISION PETITION NO. 2333 of 2012 (From the order dated 8.2.2012 in Appeal No. 315 of 2009 of Haryana State Consumer Disputes Redressal Commission, Panchkula) LIC of India Through Balihar Singh Asstt. Secretary, LIC of India Circle Office Legal Cell, Delhi Petitioner/Opposite Party (OP) Versus Shri Niwas Bansal S/o Sh. Om Prakash Bansal C/o M/s. Ami Lal Om Prakash, Haryana Cloth Market, Rohtak Respondent/Complainant BEFORE HONBLE MR. JUSTICE K.S. CHAUDHARI, PRESIDING MEMBER HONBLE DR. B.C. GUPTA, MEMBER For the Petitioner : Mr. Arunav Patnaik, Advocate Ms. Mahima Sinha, Advocate For the Respondent : Mr. Deepak Jain, Advocate PRONOUNCED ON 12th April, 2013 O R D E R
PER JUSTICE K.S. CHAUDHARI, PRESIDING MEMBER This revision petition has been filed by the Petitioner/OP against the impugned order dated 08.02.2012 passed by the Haryana State Consumer Disputes Redressal Commission, Panchkula (in short, the State Commission) in Appeal No. 315 of 2009 LIC of India Vs. Shri Niwas Bansal by which, while dismissing appeal, order of District Forum allowing complaint was upheld.
2. Brief facts of the case are that Complainant/Respondent purchased three medi-claim Insurance Policies from the petitioner/OP in the year 2000 for Rs.1,00,000/- each. During the subsistence of the Policies, on 23.5.2006, complainant suffered pain in chest and took treatment from Max Devki Devi Heart and Vascular Institute, Delhi for his disease and underwent Coronary Angiography and Angioplasty and spent Rs.1,83,704/- on his treatment. Complainant submitted claim with the OP, but claim was repudiated by OP on the ground that complainants claim was not covered under the Policy.
Alleging deficiency on the part of OP, complainant filed complaint. OP resisted claim and submitted that Angiography and Angioplasty are not covered under the Policy and prayed for dismissal of the complaint. Leaned District Forum after hearing both the parties, allowed complaint and directed OP to pay Rs.91,852/- along with 9% p.a. interest and awarded Rs.2,000/- as litigation expenses. Appeal filed by the petitioner was dismissed by learned State Commission vide impugned order against which, this revision petition has been filed.
3. Heard learned Counsel for the parties at admission stage and perused record.
4. Learned Counsel for the petitioner submitted that as per terms & conditions of the policy, Angioplasty has been excluded from the coverage, even then, learned State Commission has committed error in dismissing appeal and learned District Forum has committed error in allowing complaint; hence, revision petition be allowed and impugned order be set aside and complaint be dismissed. On the other hand, learned Counsel for the respondent submitted that order passed by learned State Commission is in accordance with law; hence, revision petition be dismissed.
5. Clause 11 (b) of the Insurance Policy runs as under:
11 (b) Benefit (B) of the Policy Schedule is applicable on the occurrence of any of the following contingencies.
(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 an geography. All other operations (e.g.), an gioplasy and Thrombulysis by Coronary Artery Catheterization) are specially excluded
6. Perusal of policy clause clearly reveals that complainant was entitled to reimbursement only in case of open heart by-pass surgery, but Angioplasty has specifically been excluded from its coverage. Learned Counsel for the petitioner placed reliance on I (2012) CPJ 31 (NC) Life Insurance Corporation of India Vs. Abdul Salim the facts of which, are similar to the present case in which, orders of Fora below allowing complaint were set aside. Learned Counsel for the respondent placed reliance on II (2005) CPJ 70 (NC) LIC of India & Anr.
Vs. Madisetty Rajashekaram in which, claim was allowed on the ground that it was an open heart surgery. Facts of aforesaid case are not similar to the present case and in such circumstances, the aforesaid citation does not help to the respondents cause.
7. On account of specific exclusion of Angioplasty, the complainant is not entitled to reimbursement of medical expenses and petitioner has not committed any deficiency in repudiating claim, but District Forum has committed error in allowing complaint and learned State Commission has committed error in dismissing appeal.
8. Consequently, revision petition is allowed and impugned order dated 8.2.2012 passed by learned State Commission in Appeal No.315 of 2009 - LIC of India Vs. Niwas Bansal and order of District Forum dated 8.1.2009 passed in Complaint No.555 Shri Niwas Bansal Vs. LIC of India is set aside and complaint is dismissed with no order as to costs.
..Sd/-
( K.S. CHAUDHARI, J) PRESIDING MEMBER ..Sd/-
( DR. B.C. GUPTA ) MEMBER k