ORDER
(Passed on – 12th July, 2018)
As per Hon’ble President. Mr. Shekhar Muley.
1. This complaint of deficiency in service is made against Life Insurance Corporation of India (LIC) for not paying the insurance claim in full.
2. In the year 1993 the Opposite Party (LIC) had launched Asha Deep Policy which was purchased by the complainant for the sum assured Rs. 1,30,000/-. He regularly paid half yearly premium of Rs.3690/- till 1997. The OP had represented to public in general and the complainant in particular that said policy would cover all the risks and benefits, if the policy holder gets affected from any of the following diseases,
- Cancer (Malignant),
- Paralysis,
- Kidney Failure,
- Heart Disease or Arterial Disorder (in which Bye- pass surgery needs to be done )
The benefits promised to be given are as under,
- Immediate repayment of 50% of sum assured
(ii) Waiver of further premiums
(iii) Payment of 10% of policy amount every year commencing from next year to the policy holder who had contacted the disease and the said payment would continue upto one year before maturity, or till the death of policy holder
(iv) Rest of 50% policy amount along with bonus on the whole sum assured will be given at the time of maturity of the policy or in case of death occurs before maturity period, then at the time of death of policy holder.
3. Thereafter the complainant had experienced problem of chest pain with respiratory disorder and weakness. He consulted a doctor, who after examination advised him to do E.C.G. and chest X-ray. He was diagnosed with Moderate Aortic Regurgitation for which open heart surgery was required. He then intimated this to the OP along with medical certificate and claimed 50% of policy amount. He was informed that he would get the amount only after he underwent surgery. He therefore filed consumer complaint against the OP. the forum partly allowed the complaint and directed the OP to pay 50% amount i.e Rs. 65,000/- with 12% p.a. interest along with cost Rs. 2000/-. Being aggrieved by the order the OP filed appeal, but without success. The OP then preferred revision. During pendency of the revision it was brought to the notice of Hon´ble National Commission that the complainant underwent surgery. The OP then offered to settle the claim provided the complainant filed claim application for reimbursement of expenses. Accordingly the OP settled the claim for Rs. 91,000/-. However, the complainant was not satisfied with the amount settled. So the National Commission gave him liberty to re agitate the issue before the forum and file fresh complaint for remaining amount. Because the question as to whether the claim settled was proper or not was not gone into by the forum, hence the National Commission could not have decided it for first time .
4. It is in the above backdrop, the complainant filed the present complaint. It is sated since the OP has not fully satisfied the order of the forum dated 31/7/2001, he is entitled to get 12 % interest on Rs. 65,000/- and other benefits under the policy. Accordingly he has claimed interest amount from 23/5/1998 Rs. 1,17,000/- and 10% policy amount Rs. 1,56,000/-, total Rs. 2,73,000/- besides vested bonus on assured sum.
5. The OP has filed reply and has not denied the earlier litigations and orders passed therein. It is also admitted that as per order of the National Commission the complainant submitted claim application on 8/3/2013. It is further stated vide letter dated 1/4/2013 the complainant was informed that on the date of his operation on 15/4/2011 the policy was in lapsed condition, as premiums were paid up to November 1997 only. By the said letter he was reminded that he had been informed by letter dt/ 15/12/1998 to keep the policy in force. But he did not pay premiums from 1998. Hence his claim could not be considered. Later, as the complainant underwent surgery on 15/4/2011, his claim was settled for Rs. 91,000/- as per policy terms and conditions. Thus his claim was considered only after he was operated and not on the basis of advise of doctor to undergo surgery, as claimed by him in original complaint.
6. It is denied that as per order of the forum the complainant is entitled to interest and other benefits under the policy. The benefits are payable only if bye-pass surgery is performed on the policy holder. It is stated in view of the order of the National Commission, the order of the forum does not survive. Thus denying the claim made by the complainant, it is submitted to dismiss the complaint.
7. Heard both the sides. Perused documents. Our findings with reasons are as under.
FINDINGS AND REASONS
8. We would first point out that in the present complaint, the complainant is claiming the interest and benefits under the policy allowed by the forum by order dated 31/7/2001 in the earlier complaint. But the order of the forum, as well as of the State Commission were set aside by the National Commission in revision petition filed by the OP. The revision was allowed, which means the order of the forum was quashed. Now the orders of the forum and of the State Commission are merged into the order of the National Commission. So now, we have to go by the order of the National Commission. Since the order of the forum in earlier complaint is now no more in force, there is no question to demand interest and benefits allowed by the forum. This is what exactly claimed in the present complaint, besides vested bonus under the policy.
9. The entire dispute has cropped up due to different interpretations of the condition of policy adopted by the parties. The complainant has relied on the pamphlet of the Asha Deep policy which highlighted salient features of the policy scheme. The policy was launched to cover certain major diseases, which, inter alia, include heart and related diseases in which bye-pass surgery was performed. As per the policy features, if during subsistence of the policy, the policy holder suffers from any of those diseases he would be entitled to get 50% of the sum assured, his next two premiums would be waived and from next year he would get 10 % amount per year before expiry of policy period and balance 50% sum assured with bonus would be payable if policy holder dies before policy period. Since the complainant had heart problem we shall consider only that disease.
10. Admittedly when the complainant made claim of 50 % amount, he had not undergone heart surgery. He was only advised to go for bye-pass surgery. Question is, whether merely on such advice he was entitled to claim 50 % sum. For that purpose we have to find out correct meaning of the sentence, ज्यामध्ये बाय-पास सर्जरी करावी लागल्यास. We have perused the conditions incorporated in the policy document to gather the meaning of the sentence. It is stated, benefits under the policy shall be available on the occurrence of any of the following contingencies i.e. the life assured undergoes open heart, bye pass surgery. However, the complainant contended that if there is variance in the meaning of the sentence in Marathi and English, Marathi sentence will prevail. In our opinion there is no variance or difference in Marathi and English sentence. It is wrong to interpret that if surgery is advised the policy holder is entitled to get 50% amount of sum assured. Had it been the intention of the OP that the benefits would be given if surgery is advised, the sentence would have been in such fashion, ज्यामध्ये बाय-पास सर्जरी करण्याची गरज/आवश्यकता असल्यास. Since it is stated if surgery is undergone these benefits are payable, it is wrong to say that the OP should have released 50 % sum if doctor advised him to undergo surgery. Therefore we hold that the OP was not guilty of deficiency in service for not realising 50% amount immediately when the complainant was advised to undergo surgery.
11. It is a fact that when he first filed consumer complaint, it was allowed and the OP was directed to pay him 50 % of sum assured i.e Rs. 65,000/- with 12 % interest. The OP had preferred appeal against that order, but it was dismissed. Against that, the OP preferred revision in National Commission. In revision, the orders of the forum and of the State Commission were, in fact, not confirmed and the revision was allowed. During pendency of the revision the complainant underwent surgery in 1998 and therefore the OP allowed his claim. He was paid Rs. 65,000/-, being half of sum assured and 10% of policy amount Rs. 13,000/- p.a. due on 28/11/2011 and 28/11/2012, total Rs. 91,000/- on 23/4/2013.
12. It is also to be noted that the complainant did not pay premiums from 1998. It is not denied by the complainant. He was informed by letter dt. 15/12/1998 to keep the policy in force, but he did not pay premiums. The OP has given particulars of calculations of final amount. According to it final payment on date of maturity of policy was Rs. 2,16,190/- including 50% of policy sum Rs. 65,000/- (of Rs. 1,30,000/-), bonus @ Rs. 1123/- per thousand sum assured for 20 years (on full sum assured Rs. 1,30,000/- ) Rs. 1,45,990/- and final additional Bonus @ 40 per thousand assured Rs. 5200/-. However, since half yearly premiums @ Rs. 3690/- were not paid since 1998 to 28/11/2010 he was to pay Rs. 95,140/- unpaid premiums and interest on that Rs. 85,995/-, total Rs. 34,252/-. Thus, the OP is to receive more amount from the complainant than what he is claiming from the OP. It is for this reason the National Commission while disposing of the revision petition, advised the complainant not to file fresh complaint. Be that as it may, from the above discussed facts and circumstances the complaint is liable to be dismissed. Hence we pass the following order.
ORDER
- The complaint is dismissed.
- No order as to cost.
- Copy of judgment be given to both the parties, free of cost.
