HON'BLE MR. JUSTICE B.N.P. SINGH ,PRESIDING MEMBERHON'BLE MR. S.K. NAIK ,MEMBER
For the Petitioner :
NEMO
For the Respondent :
NEMO
Dated : 02 Feb 2010
ORDER
The respondent/complainant had subscribed to a life insurance policy on 12.01.2006 which inter-alia provided provision of treatment in case of critical illness along-with a rider. It so happened that the respondent having suffered acute stomach pain was hospitalized at Sri Dharmstal Manjunatheshar Medical Science College and Hospital where his ailment was diagnosed as sub-acute intestinal obstruction. The respondent had undergone exploratory laprotomy and was discharged from the hospital on 03.12.2007. After the insured lodged his claim with petitioner insurance company, it was repudiated holding that the disease for which the respondent had taken treatment was not covered or defined under the policy benefits of critical illness claim. Aggrieved with repudiation of claim in respect of expenses incurred for the treatment, the respondent brought a consumer complaint with District Forum which on consideration of pleadings of the parties, while accepting complaint directed petitioner insurance company to pay Rs. 1,00,000/- to respondent as assured in the policy along-with 8% interest. Litigation cost of Rs. 1,000/- too was awarded. In appeal that was preferred with State Commission, the State Commission too, having overruled contentions raised on behalf of petitioner insurance company, concurred with the finding of District Forum accepting claim of the respondent. Now the findings so recorded by the fora below are under challenge before us. Learned counsels for the parties were heard on admission. Before we appreciate the contentions raised on behalf of parties, we wish to put on record the relevant part of the policy which is as under:- Critical Illness Rider: Sudden on set of a major illness causes worries and heavy expenses. Our optional Critical Conditions Cover helps provide financial relief in such cases. It pays you the Sum Assured upfront in respect of ten major illnesses. a) Cancer b) Coronary Artery Bypass Surgery c) Heart Attack d) Stroke e) Kidney Failure f) Aorta Surgery g) Coma h) Heart Valve Replacement i) Major Organ Transplant j) Paralysis This Benefit can be availed only once against any one of the illness and the company will not pay the claim if it arises from deliberate self-injury or attempted suicide by the Life Assured, whether sane or insane. This benefit will only be given if the diseases are confirmed by a Consultant Physician. The insurance company under the aforesaid policy seeks to provide financial relief to the insured in case of 10 major critical illnesses along-with some rider, though among these aforesaid critical illnesses, some are the treatments like aorta surgery, heart-valve replacement and major-organ transplant. Manifestly, the disease for which the treatment was secured by respondent from the Hospital did not fall within the ambit of critical illness defined in the clause as specified in the policy and as such no liability could be fastened against the insurance company to reimburse expenses incurred over the treatment of the disease suffered by the respondent. Since the insurance between the insurer and the insured is a contract between the parties, the terms of the agreement including applicability of the provisions and also its exclusion had to be strictly construed to determine the extent of the liability of the insurer. Our attention has been drawn by learned counsel for the petitioner to a decision of the Honble Apex court in the matter of General Assurance Society Limited Vs. Chandumull Jain & Anr. reported in (1966) 3 SCR 500 in which the following observations were made by Honble Apex court :- In interpreting documents relating to a contract of insurance, the duty of the court is to interpret the words in which the contract is expressed by the parties, because it is not for the court to make a new contract, however reasonable, if the parties have not made it themselves. Looking at the proposal, the letter of acceptance and the cover notes, it is clear that a contract of insurance under the standard policy for fire and extended to cover flood, cyclone, etc had come into being. Putting reliance on a decision of the Honble Apex court in the matter of United India Insurance Co. Ltd. Vs. M/s. Kiran Combers & Spinners reported in AIR (2007) SC 393, the learned counsel for the respondent tried to persuade us that where the terms of contract between the parties are unfair, the courts are well within its powers even to stretch the terms and conditions. We, however, find that the logic advanced by learned counsel was contrary to well settled and acknowledged cannons of law and that apart, in the case cited before us, the claim was accepted by Honble court, there being no exclusion clause, including subsidence, Apprehending grounds loosing, lastly it was urged by learned counsel for respondent that there were circumstances to hold that there was unequal bargaining power exercised by the insurance company. Conversely, in the matter of General Insurance Society Limited Vs. Chandumull Jain (Supra), the Honble Apex court cautioned against interpreting contract of insurance contrary to the words expressed by the parties. Both fora below have misinterpreted the true spirit and ambit of provisions of policy and rushed to an erroneous conclusion. We, accordingly, while reversing the finding of the State Commission, allow this revision petition with no order as to cost. FDR/Deposits, if any, made by the parties, be adjusted accordingly, along-with interest accrued thereon.
......................JB.N.P. SINGHPRESIDING MEMBER ......................S.K. NAIKMEMBER
Consumer Court Lawyer
Best Law Firm for all your Consumer Court related cases.
