PER:

Varinder Pal Singh Saini, Member

1        The complainant has filed the present complaint by invoking the provisions of Consumer Protection Act under Section 34, 35 and 36 against the opposite party on the allegations that the complainant’s husband deceased Paramjit Singh availed one Insurance Policy of the opposite party having policy name as “Lifestyle Protection Critical Care Basic” with policy No. LTPRCC020050693, whereby the deceased was having an insurance cover of Rs. 10 Lakh in case of his death from any ailment by paying premium of Rs. 42,798/- to the opposite party. The validity of the insurance policy mentioned above was from 16.12.2017 till 15.12.2020 i.e. for three years and deceased Paramjit Singh nominated the complainant as the nominee in this policy being his wife. Unfortunately husband of the complainant Paramjit Singh died on 15.7.2020 after he was diagnosed with some heart ailment in the month of June 2020 i.e. a month prior to his death and after knowing the ailment he took treatment from Dr. Surinderpal Singh of SBS general & Eye Hospital, Jandiala Road Tarn Taran for at least one month and at last could not recover and succumbed to this ailment on the date mentioned above.  The deceased Paramjit Singh was a police official posted at Amritsar as an ASI and so as to fulfill the formalities as required by the department in case of during service deaths, the post mortem of deceased Paramjit Singh was conducted on 16.7.2020 and the cause of death given by the Medical officer on duty as heart attack and the department also conducted proceeding under Section 174 Cr.P.C. at Amritsar through Police station Mohkampura whereby it was also reported that the cause of death of deceased Paramjit Singh was due to heart attack  and as such whole of the paper work were done by the police department in this regard. As the deceased was insured with the opposite party with the amount of Rs. 10 Lakh so the complainant being the nominee approached the opposite party to obtain he claim amount and also supplied all the required documents which included death certificate, treatment record and police proceedings and other documents to the opposite party and this party assured the complainant that the insurance claim will be released to her in a month’s time and one claim No. LTPRCC127 was issued to the claim case, so the complainant awaited for this time but instead of receiving the claim amount, the opposite party denied the claim of complainant by giving vague reason and as such the complainant was embarrassed and harassed by the opposite party through this denial. The complainant again approached the opposite party several times so as to get the claim amount but nothing was done by the opposite party in this regard and same was the false reason given by this party for denying the claim. The complainant has prayed the following relieves :-

1.  Self attested copy of affidavit of complainant Ex. C-1
2. Self attested copy of insurance policy Ex. C-2,
3. Self attested copy of treatment record Ex. C-3,
4. Self attested copy of death certificate Ex. C-4,
5. Self attested copy of Post Mortem report Ex. C-5,
6. Self attested copy of proceeding under Section 174 Cr.P.C. Ex. C-6,
7. Self attested copy of denial mail Ex. C-7.

2        Notice of this complaint was sent to the opposite party and opposite party appeared through counsel and filed written version by interalia pleadings that the complainant had with malafide intention and dishonest intention not only concealed the material facts but had also twisted the distorted the same to suit his convenience and to mislead this commission. The complaint therefore deserves outright dismissal. The present complaint does not disclose any cause of action for filing the present complaint against the opposite party. On scrutiny of claim documents submitted by complainant, it was observed that the complainant/ nominee has claimed for critical benefit , however, there is 30 days survival period which means the benefit payment shall be subject to survival of the insured person for at least 30 days following the first diagnosis of the Critical Illness/ undergoing the Surgical procedure for the first time after diagnosis of any critical illness. As per the documents, on 15.7.2020, while doing office work insured suddenly fell from chair and was taken to Mata Kaulan Ji Missan Hospital, Amritsar where he was brought dead, as per the doctor’s certificate. The insured was never diagnosed with any Critical illness listed in the policy. Therefore, the claim was repudiated. Thus no cause of action arose in favour of complainant. Therefore, in absence of any cause of action against the opposite party, the present complaint is liable to be dismissed. The complaint is liable to be dismissed as the complainant has failed to show any deficiency in service on the part of the opposite party. Since there is no deficiency in services on the part of the opposite party, this Commission has no jurisdiction to try and entertain the present complaint.  The complainant has miserably failed to demonstrate any deficiency in services nor has been able to prove any fault, imperfection, shortcoming or inadequacy in the quality, nature and manner of performance; which is required to be maintained in pursuance of a contract. In the present case, on 15.7.2020, while doing office work insured suddenly fell from chair and was taken to Mata Kaula Ji Mission Hospital, Amritsar where doctor declared him to be brought dead the same day. For payment of Critical Illness Benefit, there is 30 days survival period which means the benefit payment shall be subject to survival of the insured person for at least 30 days following the first diagnosis the first diagnosis of the Critical illness/ undergoing the surgical procedure for the first time after diagnosis of any critical illness. the policy is a legal contract between the insured and the insurance company and the party to it are bound by its terms and conditions. The terms of the policy are in the nature of a contract and their interpretation has to be made in accordance with the strict construction of the contract. The words in an insurance contract must be given paramount importance and interpreted as expressed without any addition, deletion or substitution. The present complaint is baseless and flagrant abuse of process of law to harass the opposite party as the complainant has not approached this commission with clean hands. The complainant has stated in her questionnaire that the insured was not suffering from any critical illness of Heart. Now when the claim has been rejected on the ground of one month survival period, the complainant has created for forged and fabricated prescription to show that the insured was suffering from heart ailment just one month prior to his death. From the prescription it can be made out that the insured might have consulted with the doctors for fever and not for any heart ailments. The complainant has tried to twist and distort the same to suit her own convenience and to mislead this commission I order to grab unjustified monies from the opposite party which is a company of high repute. Therefore, the complainant as not approached this commission with clean hands. It is well settled legal proposition that “One who seeks justice must come to the court with clean hands”. The opposite party is under no liability to pay the amount as claimed by complainant as the criteria for payment of critical illness was not met as per the terms and conditions of the policy.  The complainant had submitted a duly filled and signed proposal form, alongwith the requisite documents and duly, for procuring Lifestyle Protection- Critical Care basic Plan for the opposite party. On receipt of the Proposal form, believing the information provided in the proposal form to be true and correct in all aspect, the policy was issued to the complainant on the  basis of information provided by him in the proposal form. The details of the policy are as below:-

The opposite party always sends the policy document alongwith copies of all the supporting documents to the policyholder to enable him to go through the details in entirety once again. In the present case as well, in accordance with clause 6(2) of the Insurance Regulatory and Development Authority (Protection of Policyholders’ interest) Regulations 2002 the opposite party had dispatched the policy documents alongwith the copy of proposal form and the declaration to the complainant. The said policy document alongwith the copy of the application form was duly received by him as no dispute has been raised by the complainant in this regard. The insured never approached the opposite party alleging any discrepancy in the proposal form and any grievance relating to the policy or its terms and conditions during free look period implying that the complainant had agreed to the contents in the application form, the policy and its terms and conditions. Thereafter the opposite party received a claim from the complainant informing that on 15.7.2020 while doing office work insured suddenly fell from chair and was taken to Mata Kaulan Ji Mission Hospital Amritsar where doctor declared him to be brought dead. The claim benefits are payable under the policy for the ailments listed in the policy terms and conditions. As per statement given by the doctor during investigation the cause of death was not known, further never suffered any critical illness relating to heart. Therefore no amount becomes payable to the complainant under the said policy. Since the insured never suffered any critical illness, the claim was repudiated.  In view of abovementioned facts and circumstances, it is clear that the present complaint against the opposite party is meritless and legally not tenable. The present complaint, therefore, is liable to be dismissed with exemplary cost. The opposite party has denied the other contents of the complaint and prayed for dismissal of the same. Alongwith the written version, the opposite party has placed on record copy of proposal form Annexure. OP-1,  Copy of policy schedule and policy terms and conditions Annexure OP-2, copy of Claim form Annexure OP-3,  Copy of questionnaire for claim Annexure OP-4, copy of Repudiation letter Annexure OP-5.

3        The complainant has filed the rejoinder and denied the stand taken by the complainant in the written version and reiterated the stand as taken in the complaint.

4        We have heard the Ld. counsel for the complainant and opposite parties and have carefully gone through the record placed on the file.

5        In the present case the complainant’s husband deceased Paramjit Singh availed one Insurance Policy of the opposite party having policy name as “Lifestyle Protection Critical Care Basic” with policy No. LTPRCC020050693, whereby the deceased was having an insurance cover of Rs. 10 Lakh in case of his death from any ailment by paying premium of Rs. 42,798/- to the opposite party. The validity of the insurance policy mentioned above was from 16.12.2017 till 15.12.2020 i.e. for three years and deceased Paramjit Singh nominated the complainant as the nominee in this policy being his wife. It is further case of the complainant that husband of the complainant Paramjit Singh died on 15.7.2020 after he was diagnosed with some heart ailment in the month of June 2020 i.e. a month prior to his death and after knowing the ailment he took treatment from Dr. Surinderpal Singh of SBS general & Eye Hospital, Jandiala Road Tarn Taran for at least one month and at last could not recover and succumbed to this ailment on the date mentioned above.  The deceased Paramjit Singh was a police official posted at Amritsar as an ASI and so as to fulfill the formalities as required by the department in case of during service deaths, the post mortem of deceased Paramjit Singh was conducted on 16.7.2020 and the cause of death given by the Medical officer on duty as heart attack and the department also conducted proceeding under Section 174 Cr.P.C. at Amritsar through Police station Mohkampura whereby it was also reported that the cause of death of deceased Paramjit Singh was due to heart attack  and as such whole of the paper work were done by the police department in this regard. As the deceased was insured with the opposite party with the amount of Rs. 10 Lakh so the complainant being the nominee approached the opposite party to obtain he claim amount and also supplied all the required documents which included death certificate, treatment record and police proceedings and other documents to the opposite party and this party assured the complainant that the insurance claim will be released to her in a month’s time and one claim No. LTPRCC127 was issued to the claim case, so the complainant awaited for this time but instead of receiving the claim amount, the opposite party denied the claim of complainant by giving vague reason.

6        On the other hands, the stand of the opposite party is that on scrutiny of claim documents submitted by complainant, it was observed that the complainant/ nominee has claimed for critical benefit , however, there is 30 days survival period which means the benefit payment shall be subject to survival of the insured person for at least 30 days following the first diagnosis of the Critical Illness/ undergoing the Surgical procedure for the first time after diagnosis of any critical illness. As per the documents, on 15.7.2020, while doing office work insured suddenly fell from chair and was taken to Mata Kaulan Ji Missan Hospital, Amritsar where he was brought dead, as per the doctor’s certificate. The insured was never diagnosed with any Critical illness listed in the policy. The opposite party has denied the claim of the complainant vide reputation letter Ex. OP-5 and denial reason in repudiation letter Ex. OP-5 is as follows:-

“On scrutiny of documents it is observed that nominee has claimed for critical illness benefit, however there is 30 days survival period after diagnosis of any critical illness and as per the documents received and through investigation it is observed that the same criteria is not fulfilled hence we regret to inform that the claim stands repudiated.”

In the present case, the complainant has failed to prove on record any critical illness of the deceased. Both the parties are bound by the terms and conditions of the policy. The terms and conditions of the Insurance Policy have to be strictly construed. Hon’ble Supreme Court in the case of Export Credit Guarantee Corporation of India vs. Garg Sons International 2013 (1) SCALE 410 (SC) held in Para Nos.8 to 11 as under:

“8.  It is a 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 well 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). 

9.  The insured cannot claim anything more than what is covered by the insurance policy. The terms of the contract have to be construed strictly, without altering the nature of the contract as the same may affect the interests of the parties adversely. The clauses of an insurance policy have to be read as they are consequently, the terms of the insurance policy, that fix the responsibility of the Insurance Company must also be read strictly. The contract must be read as a whole and every attempt should be made to harmonize the terms thereof, keeping in mind that the rule of contra proferentem does not apply in case of commercial contract, for the reason that a clause in a commercial contract is bilateral and has mutually been agreed upon. (Vide : Oriental Insurance Co. Ltd. v. Sony Cheriyan AIR 1999 SC 3252; Polymat India P. Ltd. v. National Insurance Co. Ltd., AIR 2005 SC 286; M/s. Sumitomo Heavy Industries Ltd. v. Oil & Natural Gas Company, AIR 2010 SC 3400; and Rashtriya Ispat Nigam Ltd. v. M/s. Dewan Chand Ram Saran AIR 2012 SC 2829). 

10.   In Vikram Greentech (I) Ltd. & Anr. v. New India   Assurance Co. Ltd. AIR 2009 SC 2493, it was held:  “An insurance contract, is a species of commercial transactions and must be construed like any other contract to its own terms and by itself. The endeavour of the court must always be to interpret the words in which the contract is expressed by the parties. The court while construing the terms of policy is not expected to venture into extra liberalism that may result in rewriting the contract or substituting the terms which were not intended by the parties. (See also: Sikka Papers Limited v. National Insurance Company Ltd & Ors. AIR 2009 SC 2834).” 

11.  Thus, it is not permissible for the court to substitute the terms of the contract itself, under the garb of construing terms incorporated in the agreement of insurance. No exceptions can be made on the ground of equity. The liberal attitude adopted by the court, by way of which it interferes in the terms of an insurance agreement, is not permitted. The same must certainly not be extended to the extent of substituting words that were never intended to form a part of the agreement.” 

7        While repudiating the claim of the complainant the opposite party has not committed any deficiency in service and unfair trade practice and the claim has been validly repudiated by the opposite party.

8        In view of the above discussion, we do not find any merit in the present complaint and the same is hereby dismissed with no order as to costs. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Commission and due to COVID-19. Copies of the order be furnished to the parties as per rules. File is ordered to be consigned to the record room.

Announced in Open Commission

25.04.2024