State Consumer Disputes Redressal Commission
Lic Of India vs Ashok Goyal on 4 November, 2013
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, STATE CONSUMER DISPUTES REDRESSAL COMMISSION, U.T., CHANDIGARH First Appeal No. : 383 of 2013 Date of Institution : 06.09.2013 Date of Decision : 04.11.2013 1. Life Insurance Corporation of India, Divisional Office, Jeevan Parkash Building, Sector 17, Chandigarh. 2. Life Insurance Corporation of India, Near Bus Stand, Ambala-Chandigarh Highway, Derra Bassi, District Patiala. Appellants/Opposite Parties No.1 and 2. Versus 1. Sh. Ashok Goyal son of Sh. Piare Lal Goyal resident of House No.3218, TBRL Housing Society, Sector 51-D, Chandigarh. .Respondent No.1/Complainant. 2. E-Mediteck Solution Limited, SCO No.56, 1st Floor, Entry from front side, Sector 30C, Chandigarh. Performa Respondent/Opposite Party No.3. Appeal under Section 15 of the Consumer Protection Act, 1986. BEFORE: JUSTICE SHAM SUNDER (RETD.), PRESIDENT. SH. DEV RAJ, MEMBER.
Argued by:Sh. Piyush Sharma, Advocate for the appellants.
Sh. Vinay Kataria, Advocate for respondent No.1.
Service of respondent No.2 already dispensed with vide order dated 10.09.2013.
PER DEV RAJ, MEMBER This appeal is directed against the order dated 01.08.2013, passed by the District Consumer Disputes Redressal Forum-II, U.T., Chandigarh (hereinafter to be called as the District Forum only), vide which it accepted the complaint, filed by the complainant and directed the Opposite Parties (now appellants) as under:-
10. So finding merit in the complaint, we allow this complaint against the Opposite Parties. The Opposite Parties are directed to make payment to the Complainant as per the claim made in terms of the percentage which is applicable for all other surgeries with regard to musculoskeletal system. The amount spent by the Complainant for the medication be paid by the Opposite Parties as per payable terms & conditions with regard to payment of medicines and other procedures. Opposite Parties shall also pay compensation of Rs.15,000/- to the Complainant for the mental pain and harassment. The Opposite Parties are also directed to pay Rs.7,000/- as costs of litigation.
11. This order be complied with by the Opposite Parties within 45 days from the date of receipt of its certified copy, failing which, the Opposite Parties shall be liable to pay the claimed amount to the Complainant, along with compensation of Rs.15,000/-, besides costs of litigation of Rs.7,000/-.
2. The facts, in brief, are that the complainant purchased an Insurance Policy bearing no.163387771 on 19.03.2008 known as LIC Health Plus Plan for himself and for the benefit of other family members. It was stated that the Policy was valid for the period from 19.03.2008 to 19.03.2035. It was further stated that the said Policy covered hospital charges, major surgical charges, and domiciliary treatment expenses, in India, payable on daily basis. It was further stated that in case of ICU admission, the benefit was payable per day double HCB covered and benefit per day increase by 5% every policy in a year for ten years. It was further stated that the purpose of major surgical benefit for the insured undergoing one of the eligible surgeries a suitable percentage of MCB sum assured was to be paid in lump sum of the actual cost of the surgery. It was further stated that under the said plan, cash benefit of Rs.2,500/- and Rs.1,500/- was to be provided and major surgical benefit was Rs.5.00 lacs and Rs.3.00 lacs, respectively for the complainant and his wife, namely, Smt. Indu. It was further stated that the complainant paid the first premium of Rs.19,500/- to the Opposite Parties, and the second and third premiums were also paid by him thereafter, for the period 2008 to 2010. It was further stated that on 18.06.2012, the wife of the complainant suffered due to disc compression. It was further stated that MRI was performed of the lumbosacral spine using dedicated body coil in MRI Centre, Chandigarh. It was further stated that the patient was admitted in Medical College and Hospital, Sector 32, Chandigarh, for the surgery of spine i.e. L-3, L-4 and L-5. It was further stated that investigation was conducted by the senior doctors in the said hospital on 21.06.2012 and after seeing the report and medical tests reports, a surgery was conducted by the senior doctors on the wife of the complainant. It was further stated that the wife of the complainant remained hospitalized from 20.06.2012 to 27.06.2012. It was further stated that during the period of hospitalization and treatment of the wife of the complainant, he incurred huge expenses on her treatment, for purchasing medicines, as well as deposited the cash in the said hospital. It was further stated that after discharge of the complainants wife, the complainant filled the claim form (Annexure C-28), with the assistance of Opposite Parties No.1 & 2 and deposited the same in the office of Opposite Party No.3, which also confirmed the same vide email dated 25.07.2012 (Annexure C-29). It was further stated that a written certificate from the Surgeon who attended the patient was also provided. It was further stated that thereafter, the complainant was surprised to receive an e-mail (Annexure C-30) from the Opposite Parties, informing that only HCB was approved but the major surgical benefits were not payable as per their Policy. It was further stated that the complainant purchased the policy, in question, from the Opposite Parties under good faith but they illegally and arbitrarily refused to reimburse his claim to the tune of Rs.3 Lacs, which he incurred on the treatment and medication of his wife. It was further stated that the aforesaid acts of the Opposite Parties, amounted to deficiency, in rendering service, as also indulgence into unfair trade practice. When the grievance of the complainant, was not redressed, left with no alternative, a complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter to be called as the Act only), was filed, directing the Opposite Parties, to reimburse the claim amount of Rs.3,00,000/- alongwith interest @18% P.A., pay Rs.19,388/- for the bills, Rs.1 Lac as compensation for mental agony and physical harassment; and Rs.33,000/- as cost of litigation.
3. The Opposite Parties, in their written version, stated that the contract of Insurance, was a contract of Uberrima fides and the relations of the parties were governed by its terms and conditions. It was further stated that the claim of the complainant did not fall within the terms and conditions of the Policy, which was supplied to him alongwith the welcome kit. It was admitted that the complainant had taken LICs Health Plus Unit Limited Health Insurance Plan bearing Policy No.163387771 for the period from 19.03.2008 to 19.03.2035. It was further stated that under the said Policy, an option of Cooling Off Period was available to the complainant, to send back the Policy within 15 days from the date of receipt of the same, in case of disagreement with the terms and conditions of the same but he did not do so. It was further stated that, as per the Policy, the complainant was the Principal insured while his wife, namely, Smt. Indu Goyal was also insured under the same Policy. It was further stated that the terms and conditions of the policy were explained to the life assured persons. It was admitted that the claim papers of Smt. Indu Goyal, for daily hospital cash benefit and also of major surgical benefit, were submitted with Opposite Party No.3. It was further stated that the doctors of Opposite Party No.3, after going through the hospital record received from Smt. Indu Goyal, allowed the daily hospital cash benefit of Rs.1,500/- for 06 days but declined the major surgical benefit as the surgery (Decompression Surgery L3-L4, L4-L5 done on 21.06.2012) performed upon Smt. Indu Goyal was not covered under the list of surgeries provided in the conditions and Privileges referred to in the Policy document. It was further stated that the claim of the complainant for major surgical benefit was rightly declined by the Opposite Parties. It was further stated that neither there was any deficiency, in rendering service, on the part of the Opposite Parties, nor did they indulge into unfair trade practice. The remaining averments, were denied, being wrong.
4. The complainant filed replication, wherein he reiterated all the averments, contained in the complaint, and repudiated the same, contained in the written version.
5. The parties led evidence, in support of their case.
6. After hearing the Counsel for the parties, and, on going through the evidence, and record of the case, the District Forum, accepted the complaint, as stated above, in the opening para of the instant order.
7. Feeling aggrieved, the instant appeal, has been filed by the appellants/Opposite Parties No.1 and 2.
8. We have heard the Counsel for the parties, and, have gone through the evidence, and record of the case, carefully.
9. The Counsel for the appellants/Opposite Parties No.1 and 2 submitted that the District Forum misread Annexure A-4 wherein in the list of Surgical Procedures under Musculoskeletal System, total replacement of Hip or Knee joint following accident, was mentioned. It was further submitted that Decompression Surgery performed upon the wife of the complainant was not covered under the said list of Surgical Procedures. It was further submitted that respondent No.1/complainant was entitled to hospital cash benefit @Rs.1,500/- per day (Annexure C-1). It was further submitted that hospital cash benefit of Rs.9,000/- for six days @Rs.1,500/- per day, as per Policy documents, was paid. Relying upon the case titled Export Credit Guarantee Corpn. of India Ltd. Versus M/s Garg Sons International, 2013 (1) CPC 192, the Counsel submitted that it was settled legal proposition that terms of contract of insurance must be given paramount importance, and it is not open for the Court to add, delete or substitute any words.
10. The Counsel for respondent No.1/complainant, on the other hand, submitted that the District Forum rightly allowed the complaint and directed the appellants/Opposite Parties, to make payment, as per the claim made, in terms of the percentage, which was applicable for all other surgeries with regard to musculoskeletal system, besides compensation and costs of litigation.
11. It is evident that respondent No.1/complainant was insured under the Policy which provided cash benefit of Rs.2,500/- to the Principal Insured and Rs.1,500/- to the spouse and major surgical benefit of Rs.5.00 Lac and Rs.3.00 Lac to the complainant and his spouse respectively. It was admitted that due premiums were paid. The wife of the complainant suffered due to disc compression and was hospitalized. During hospitalization certain expenses were incurred for which a claim was filed. The appellants/Opposite parties repudiated the claim as the same was not covered under the list of Surgical Procedures (Annexure R-1). The appellants/Opposite Parties, in Para 7 of their written statement, have categorically submitted that Decompression Surgery (L3-L4-L5), performed upon Indu Goyal on 21.06.2012, was not covered under the list of surgeries, provided in the conditions and privileges, referred to, in the Policy Document ( Annexure R-1) and that the complaint was not maintainable. Undoutedly, the submission of the Counsel for the appellants/Opposite Parties, is in consonance with the terms and conditions of the Policy Document. As the contract of Insurance is governed by the terms and conditions of the Policy, the claim was rightly denied as the surgical treatment undergone by Smt. Indu Goyal was not covered under the Policy document. In Export Credit Guarantee Corpn. Of India Ltd. Versus M/s Garg Sons Internationals case (Supra), the Honble Supreme Court of India in Para 8 held as under:-
8. It is settled legal proposition that while construing the terms of a contract of insurance, the words used therein must be given paramount importance, and it is not open for the Court to add, delete or substitute any words. It is also settled, that since upon issuance of an insurance policy, the insurer undertakes to indemnify the loss suffered by the insured on account of risks covered by the policy, its terms have to be strictly construed in order to determine the extent of the liability of the insurer. Therefore, the endeavour of the Court should always be to interpret the words used in the contract in the manner that will best express the intention of the parties. (Vide: M/s. Suraj Mal Ram Niwas Oil Mills (P) Ltd. v.
United India Insurance Co. Ltd., (2010) 10 SCC 567 = 2010 (3) CPC 222 S.C.).
12. There is force in the argument of the Counsel for the appellants/Opposite Parties that the District Forum, in Para 8 of its order, interpreted the term Musculoskeletal System in its own way. It is very strange that the District Forum failed to properly interpret the terms and conditions of the Policy. The District Forum could neither add, nor delete nor subtract anything from the Insurance Policy. It was required to interpret the terms and conditions of the Policy, as it is. It, however, failed to do so and acted arbitrarily. The ratio of the case In Export Credit Guarantee Corpn. Of India Ltd. Versus M/s Garg Sons Internationals case (Supra) fully supports the contention of the Counsel for the appellants/Opposite Parties. The appellants/Opposite Parties legally and validly repudiated the claim of respondent No.1/complainant. There was, thus, no deficiency in rendering service, on the part of the appellants/Opposite Parties, in legally and validly repudiating the claim of the complainant. The findings of the District Forum, being perverse, are liable to be reversed.
13. No other point, was urged, by the Counsel for the parties.
14. In view of the above discussion, it is held that the order, passed by the District Forum, against the appellants/Opposite Parties, being not based on the correct appreciation of evidence and law on the point, suffers from illegality and perversity, warranting the interference of this Commission. The same is liable to be set aside.
15. For the reasons recorded above, the appeal filed by the appellants/Opposite Parties, is accepted, with no order as to costs. The order impugned, passed by the District Forum, is set aside. The complaint filed by respondent No.1/complainant, is dismissed, with no order, as to costs.
16. Certified copies of this order, be sent to the parties, free of charge.
17. The file be consigned to Record Room, after completion.
Pronounced.
4th November, 2013.
Sd/-
[JUSTICE SHAM SUNDER (RETD.)] PRESIDENT Sd/-
[DEV RAJ] MEMBER Ad STATE COMMISSION (First Appeal No.383 of 2013) Argued by:Sh.
Piyush Sharma, Advocate for the appellants.
Sh. Vinay Kataria, Advocate for respondent No.1.
Service of respondent No.2 already dispensed with vide order dated 10.09.2013.
Dated the 4th day of November, 2013.
ORDER Vide our detailed order of the even date, recorded separately, the appeal has been accepted, with no order as to costs. The order impugned, passed by the District Forum, has been set aside. The complaint filed by respondent No.1/complainant has been dismissed with no order as to costs.
(DEV RAJ) MEMBER (JUSTICE SHAM SUNDER (RETD.)) PRESIDENT Ad