PER SHRI S.M. SHEMBOLE, HON'BLE PRESIDING MEMBER.
Challenge in this appeal is the judgment and order dated 31/07/2001 passed by the District Consumer Disputes Redressal Forum, Nagpur partly allowing the Complaint No. 08/1999 directing the appellant/opponent Insurance Company to pay an amount of Rs.65,000/- i.e. 50% of sum insured amount with interest at the rate of 12% and further an amount of Rs.2000/- towards the cost of proceeding to respondent / Complainant.
Brief facts giving rise to this appeal are that,
In Year 1993 the appellant/original opponent had launched a scheme in the name and style Asha-Deep Policy-I wherein the plan of insurance as to introduce to cover risk of four major aliment namely (i) Cancer (ii)Paralytic stroke (iii) Renal Failure of the both kidneys (iv)Coronary artery disease (in which bypass surgery needs to be done). The pamphlets in Marathi were published mentioning there in that the policy was for the period from 07/09/1993 to 30/11/1993. On going through the pamphlet, respondent/original complainant Kailash Kanugo obtained the policy at Nagpur on 28/11/1993 through the L.I.C. Agent and paid all half yearly premiums of Rs.3690/- each to the appellant till November, 1997. In the month of May, 1998 he had experienced Chest pain with respiratory disorders. Therefore, he consulted Dr. V.S. Agrawal, a consultant & physician of C.I.I.M.S. Hospital, Bajaj Nagar, Nagpur who examined and issued certificate dated 22/05/1998 stating therein that complainant Kailas is suffering from Moderate Aortic Regurgitation with E 66 ERT Angina and needs early investigation like Coronary Angiography and Navr (Open Heart Surgery) etc. As per of the medical advice, the complainant was required to under-go Open Heart Surgery. Therefore, he applied to the opponent/appellant i.e. L.I.C. for getting benefits under the policy but opponent/appellant repudiated his claim informing by reply to his notice dated 15/12/1998.
Therefore, the complainant/respondent made the complaint with the District Consumer Disputes Redressal Forum, Nagpur.
By written version the opponents resisted the claim contending inter alia that the complainant is entitled to claim benefits of the policy only after he undergoes by-pass surgery, etc.
On hearing for both the sides and considering the documents on record the District Consumer Disputes Redressal Forum, Nagpur held that as per the scheme published by the opponent/appellant L.I.C., it is necessary to first have By Pass Surgery then only the complainant/respondent can claim the benefits of the policy as he was required to undergo By Pass surgery. In view of this finding, the District Consumer Disputes Redressal Forum, Nagpur partly allowed the claim and directed the opponent No. 1/appellant to pay an amount of Rs.65,000/- i.e. 50% sum insured amount with interest at the rate of 12% and further an amount of Rs.2000/- towards the cost of proceeding.
Feeling aggrieved by the said judgment and order the opponent/appellant came to the Commission in appeal.
We heard Ld. Counsel for both the sides and perused the copy of impugned judgment and order and also the copy of the policy and pamphlets which was published in Marathi by the opponent/appellant, so also the copy of medical certificate issued by the Dr. V.S. Agrwal.
Undisputed facts are that the appellant/opponent had launched the policy, in question, and in order to publish the policy scheme the same was published in Marathi by way of pamphlets. On 18/11/1993 the complainant/respondent through one LIC agent obtained the same policy by paying an amount of premium. He has also paid the premium as per the terms and conditions of the policy. It is also undisputed facts that in the month of May-1998 the complainant/respondent experienced Chest paid with respiratory disorders and therefore, he got medical check up by Dr. V.S. Agrwal and Dr. V.S. Agrawal advised him for open heart surgery. Therefore, on 23/05/1998 the complainant/respondent claimed the benefit to the policy with the opponent / appellant but the claim was repudiated on the ground that he has not undergone by pass surgery and therefore, he is not entitled to get benefits. According to appellant/opponent, as per the terms and condition of the policy it is necessary for the claimant to first undergo the bypass surgery and then claim to benefit of the same policy.
Mr. Ghagarkar, Ld. Counsel for the appellant argued that as per terms and condition of the policy, unless by pass surgery is done, no claim is tenable. According to him though the complainant/respondent required to undergo by pass surgery, but since he has not undergone by pass surgery, he is not entitled to get the benefits of the policy and therefore, appellant have rightly repudiated the complainant’s claim etc.
Per contra Adv. Smt. Jayshree Rao, Ld. Counsel for the complainant/respondent giving much stress on the pamphlets which were published in Marathi submitted that no such condition was published. On perusal of copy of the same pamphlets which are at page no. 34 to 37, we find much force in the submission of Smt. Rao, Ld. Counsel for the respondent. The pamphlets manifests that the insured is entitled to claim 50% an amount of the policy if he required to undergo by pass surgery. However, Mr. Ghagarkar, Ld. Counsel for the appellant pointing out the condition no. 11 (b)(i) from the copy of policy contended that in order to claim benefit of the policy, by-pass surgery must be done and unless by-pass surgery is done the insured is not entitled to claim any amount under the same policy. On perusal of this condition from the policy, it reflects that in order to claim benefit in the same policy the condition is to undergo by pass surgery first but no explanation is given on the behalf of appellant as to why such condition is not published in Marathi pamphlets. However, it is contended by the Ld. Counsel for the appellant that in case of dispute and interpretation of terms and condition, the English version shall prevail and accordingly, such note was given at the foot of the policy. It is true that there is such note at the foot of the policy but it is pertinent to note that the same note is not published in Marathi pamphlet. Therefore, the contention of the Ld. Counsel for the appellant cannot be accepted in the absence of plausible explanation. When it is obvious that the complainant/respondent required to undergo bypass surgery within the period of policy, in question, the claim cannot be repudiated. Accordingly, the District Consumer Forum has rightly held. We find no illegality or any infirmity in the impugned judgment and order. Hence, no interference is warranted.
In the result, the appeal is being devoid of any merit deserves to be dismissed. Hence the following order.
ORDER
1. The appeal is dismissed.
2. No order as to cost.
elivered on 03/10/2011.
