F.A.No.804 OF 2009 AGAINST C.C.NO.15  OF 2008 DISTRICT FORUM WARANGAL

Between:

The Divisional Manager,
Life Insurance Corporation of India
Divisional Office, P.B.No.17,
Jeevan Prakash, Balasamudram
Hanamkonda Warangal-001

                                                        Appellant/opposite party

                A N D

Mr.Anukari Ashok S/o Damodar
aged about 41 years, occ:Agriculture
R/o Shyampet Village and Mandal
Warangal District

                                                        Respondent/complainant

Counsel for the Appellants                    Smt G.Shyamala

Counsel for the Respondent                  Sri V.Gourisankara Rao

        QUORUM:   SRI R.LAKSHMINARASIMHA RAO, HON’BLE MEMBER

                                                AND

SRI THOTA ASHOK KUMAR, HON’BLE MEMBER

WEDNESDAY THE NINETH DAY OF NOVEMBER

                                TWO THOUSAND ELEVEN

Oral Order (As per Sri R.Lakshminarasimha Rao, Hon’ble Member)

                                        ***

1.     The Life Insurance Corporation of India has filed the appeal on the premise that the District Forum had arbitrarily allowed the complaint directing it to pay the amount and benefits provided under Asha Deep-II Policy with interest @ 7.5% per annum and costs.

2.     The respondent had obtained insurance policy bearing No.681502047 in the year 1996 with commencement of the policy from 28.3.1996 for the sum assured `50,000/-.  The premium was payable at `1035/- in every six months.  The respondent did not pay two premiums and the policy was lapsed.  On 16.5.2006 he was permitted to pay the premium with interest for revival of the insurance policy. 

3.     The version of the respondent is that in the first week of November 2006 he suffered from pain and swelling in his left scrotum for which he consulted Dr.Damodar Kasikar of Warangal.  The doctor treated it for hydrocele.  As there was no relief to the respondent, the doctor advised him to undergo surgery.  The respondent was admitted to Hira Hospital Warangal on 25.11.2006 and the doctor performed surgery treating it as hydrocele and in the course of the operation, the doctor found red fluid instead of watery fluid around the testicle.  The doctor removed the testicle and sent it for biopsy to rule out possibility of malignancy. The biopsy report dated 29.11.2006 revealed that the testicle was effected with cancer and the respondent advised to undergo treatment at Saint Ann’s Hospital Warangal.  The respondent lodged claim for the benefits as per the terms and conditions of the policy.  The appellant insurance corporation repudiated the claim on the ground that the respondent got treatment for cancer within one year from the date of revival of the policy. 

4.     On behalf of the appellant insurance company it is contended that as per the condition No.11 of the policy, the respondent is not entitled to the benefits under the policy for one year from the date of commencement of the policy or one year from the date of revival of the policy.  It is contended that the claim had arisen within one year from the date of revival of the policy. 

5.     The respondent has filed his affidavit and the documents Exs.A1 to A6.  On behalf of the appellant insurance company its Branch Manager, B.Bhaskar filed his affidavit and got marked Asha Deep Insurance Policy as Ex.B1.

6.     The point for consideration is whether the respondent is entitled to the benefits conferred by the insurance polic? 

7.     The facts which have been admitted and which do not require elaborate discussion are that the appellant insurance company had issued Asha Deep Insurance Policy for a sum assured of `50,000/- in favour of the respondent and the insurance policy was lapsed for non-payment of premiums from the month of march 2004.  The insurance policy was revived on 16.5.2006 upon submission of personal statement and medical report by the respondent.  The respondent had lodged claim for payment of 50% of the sum assured under the policy. 

8.     The appellant insurance company repudiated the claim on the premise that it had arisen within one month from the date of revival of the insurance policy.  The benefits mentioned in the schedule annexed to the policy are governed by condition 11 (a) and (b) of the insurance policy.  Condition No.11(b) elaborately deals with the situation giving rise to claim the benefits and clause 11(b) in turn is controlled by 11(a) of the insurance policy.  Clause 11(b) reads as under:

(b) Benefit (B) of the policy Schedule shall be available on the occurrence of any of the following contingencies.

i)                    The Life Assured undergoes Open Heart By-Pass Surgery performed on significantly narrowed/occuluded coronary arteries to restore adequate blood supply to heart and the surery msut have been proven to be necessary by means of coronary angiography.  All other operations (angioplasty and Trhombolysis by Coronary Artery Cathetetarization are specifically excluded)

OR

ii)                  the Life Assured undergoes renal dialysis or renal transplantation as a result of an end stage renal failure presented as chronic irreversible failure of both kidneys to function

OR

iii)                The Life Assured suffers from Cancer (Malignant) (That is, the presence of uncontrolled growth and spread of cancer cells which destroyed the tissues in which they arise with a potential for invading adjacent structures and capable of spreading to distant organs).  This includes Leukaemia, Hodkin’s Disease and invasive malignant melanoma of skin but excludes Carcinoma in situ, tumours associated with HIV infections, non-invasive localized cancers and all other skin cancers

OR

iv)                The Life Assured suffers from paralytic stroke, (that is, cerebrovascular accident or incident producing neurological sequelae lasting more than 24 hours) resulting into complete and permanent disability of two or more limbs persisting for more than three months from the date of acute episode.  Specifically excluded are Transient/ischaemic Attacks and Stroke like syndromes resulting from –

(1)        Head Injury (subdural or extradural haematoma)

(2)        Cerebral abscess

(3)        Pyogenic tuberculosis, meningococcal meningitis.

9.     Clause 11(b) gives rise to the effect to confer the benefits under the policy and the various situations whereunder the claimant can lodge for the benefits as per the policy schedule have been extracted hereinabove.  The seminoma left testis suffered by the respondent subsequent to the revival of the insurance policy is not disputed.  Clause 11(b) has been rightly invoked by the respondent and in fact the appellant insurance company has admitted the treatment the respondent had undergone for seminoma left testis in St.Ann’s Hospital Warangal. 

10.    The seriousness of the dispute centers around the application of clause 11(a) of the insurance policy which requires the respondent to lodge claim only after one year from the date of commencement of the policy or a year from the date of revival of the insurance policy.  The insurance policy was revived on 16.5.2006 and the respondent had undergone treatment in he month of November 2006 and the surgery was performed upon him on 25.11.2006 and as such he had lodged the claim basing on the circumstances that arose within one year from the date of revival of the insurance policy.  The revival of the policy is subjected to duration of one year from the date of commencement of the policy and in case of revival a year thereafter.  Clause 11(a) of the policy thus reads:

11(a)                Beneft (B) of the Policy Schedule is not applicable if any of the contingencies mentioned in Para 11(b) occurs (i) at any time on or after the date on which the risk under this Policy is commenced but before the expiry of one year reckoned from the date of this Policy, or (ii) one year from the date of revival.

11.    Clause 11(a) which controls the conferment of the benefits mentioned under the policy schedule in the circumstances stated in clause 11(b) is the governing factor.  The claim of the respondent thus is rightly repudiated by the appellant insurance company.  The District Forum erroneously opined that some of the clauses like 11(a) of the insurance policy are not mandatory.  We are of the considered opinion that there had been no deficiency of service on the part of the appellant insurance company.

12.    In the result the appeal is allowed.  Order of the District Forum is set aside.  Consequently the complaint is dismissed.  There shall be no order as to costs.

                                                                                  Sd/-

                                                                        MEMBER

                                                                           Sd/-

                                                                        MEMBER

                                                                   Dt.09.11.2011

KMK*