IN THE STATE COMMISSION : DELHI

(Constituted under Section 9 of the Consumer Protection Act, 1986)

Date of Decision: 17.09.2014

First Appeal-777/2010

(Arising out of the order dated 09.06.2010 passed in Complainant Case No. 859/2009 passed by District Consumer Disputes Redressal Forum, Barracks, Kasturba Gandhi Marg, Delhi)

In the matter of:

Life Insurance Corporation of India

Divisional Office-I

Jeevan Prakash Building

25, K.G.Marg

New Delhi-110001

Through Sh. G.P.Pandey, Manager (L & HPF),    ………….Appellant

Versus

Sh. Bhusan Kumar

R/o H-244

Mangolpuri

New Delhi-110083                                         ……….Respondent

CORAM

S.A.Siddiqui, Member (Judicial)

S.C.Jain, Member

1.     Whether reporters of local newspaper be allowed to see the judgment?

2.      To be referred to the reporter or not?

S.A.Siddiqui, Member (Judicial)

JUDGEMENT

1.          Present appeal has been preferred under Section 15 of the Consumer Protection Act 1986 (in short the Act) against the order dt. 09.06.2010 passed by District Consumer Disputes Redressal Forum, Barracks, Kasturba Gandhi Marg, New Delhi in Complaint Case No. 859/09.
2.          Brief facts of the case are that are that complainant/respondent subscribed to the “Asha Deep” policy of OP bearing No. 121175262 with half yearly mode of payment @ Rs. 7068/-.  The policy was for a sum of Rs. 3 Lac commencing from 28.04.1999.  It has been alleged that the agent of the OP LIC obtained signature of the complainant on blank proposal form with the promise that as a routine formality, the blank columns of the forms will be filled.  Unfortunately, in the 3^rd week of December, 2006, the complainant had to be hospitalised in Saroj Heart Institute, Rohini Delhi and was discharged on 08.01.2007.  After discharge on 08.01.2007, the complainant/respondent was again hospitalised in Escorts Heart Institute and Research Centre, New Delhi where he was operated. A payment of Rs. 2 Lac was made to the hospital. On discharge complainant/respondent lodged a claim for payment of Rs. 1.5 Lac=50% of the policy amount.  However, the LIC of India OP/appellant repudiated the claim through its letter dt. 07.06.2007. Therefore complainant/respondent was compelled to file a consumer complaint for directions to OP/appellant for payment of insurance claim along with compensation and the costs.
3.          OP/appellant contested the case by filing written statement. In its written statement it was stated that terms and conditions of the policy were duly explained to the complainant/respondent.  The same were also printed on the insurance policy.  The claim was repudiated as it was covered under the terms and conditions of the policy.  The complainant underwent PTCA/Stent which was not covered under the policy.  There was no deficiency of service of any kind and the claim was rightly repudiated.
4.          Both the parties led evidence.  Upon evaluation of evidence on record the Ld. District Forum came to the conclusion that the policy’s terms and conditions were unilateral and were not binding upon the complainant/respondent but Foram directed the OP/appellant to pay a sum of Rs. 1.5 Lac along with bonus and other benefits.  The OP was further directed to pay compensation of Rs. 20,000/- and costs of Rs. 10,000/-.  The OP-LIC felt aggrieved and preferred this appeal on the following main grounds, besides the others:-
   1. The impugned judgment and order dt. 09.06.2010 was erroneous and illegal.  The Ld. District Forum failed to appreciate that complainant/respondent underwent PTCA/stent (Coronary Stenting) and the sum is not covered under the Asha Deep policy.  The complainant’s case fell under exclusion clause of the policy mentioned in Para 11 and 12.  Condition 12 (b) reads as follows:

        “Benefit (B) of the policy schedule shall be available on the occurrence of any of the following contingencies.”

1. The life assured undergoes open heart bypass surgery performed on significant narrowed/occlude coronary arteries to restore adequate blood supply to the heart and the surgery must have been proven to be necessary by means of coronary angiography.  All the operations (e.g. angioplasty & thrombolysis by coronary artery catherterization) are specially excluded.
2. ........
3. ........

1.         Obviously clause 12(b)(1) specially excludes angioplasty and the same is clearly mentioned in Hindi as well as in English for better understanding by any person. Therefore, the OP/appellant was not liable to be pay any amount as insurance claim and the impugned order was wholly illegal and cannot be mentioned under the law.
2.         No reply was filed by the respondent/complainant.  However, respondent’s/counsel participated in the proceedings and argued the case.
3.         We have heard Ms. Jaya Tomer Ld. Counsel for the Appellant and Sh. Deepak Singla, Ld. Counsel for the Respondent.
4.         Ld. Counsel for the appellant forcefully argued that Asha Deep II policy only covered open heart bypass surgery but it specially excluded the angioplasty & thrombolysis by coronary artery catherterization.  The Ld. District Forum failed to take into consideration this important aspect of the matter which vitiates the impugned order.
5.         On the other hand, Ld. Counsel for the OP/respondent argued that the terms and conditions of the policy were never discussed or explained to the assured.  The agent of the LIC obtained signature of the complainant on the blank proposal form with the promise that all relevant columns will be filled later on as a routine formality will be completed.  The policy bond is issued later on which contains terms and conditions of the policy which are purely unilateral; how such a policy condition can be binding upon the life assured. Policy claim was therefore wrongly repudiated and the impugned order dt. 09.06.2010 was just, proper and well discussed order.  It is liable to be maintained, as it does not suffers from any illegality or irregularity.
6.      We have carefully gone through the record and the impugned order dt. 09.06.2010. We have perused the terms and conditions of the Asha Deep II policy.  Clause 12 (b) (i) covers open heart bypass surgery.  It has specially excluded ‘angioplasty’ which was undergone by the complainant/respondent.  It is well settled law that the courts should not add or subtract anything of their own. The words used under the terms and conditions should be given their plain ordinary and naturally meaning.  Since the open heart surgery is only covered under the policy and angioplasty was specially excluded, the Ld. District Forum should have given serious thought to this important aspect of the matter. Since the Ld. Fora miserably failed to consider this aspect of the matter, the impugned order is vitiated and becomes illegal; it is liable to be set aside in the larger interest of justice. 
7.      Accordingly, the impugned judgment and order dt. 09.06.2010 passed by Ld. District Forum in Complaint Case No. is set aside. The complaint therefore, stand dismissed.
8.       Let a copy of the order be made available to the parties free of cost as per rule and a copy of the judgment and order be sent to the District Forum concerned for placing the same on record, thereafter file be consigned to record room.
9.      FDR, if any deposited by the appellant shall be released as per rule.
10.  

MEMBER (JUDICIAL)