1.      This Revision Petition No.514 of 2017 challenges the impugned order of Haryana State Consumer Disputes Redressal Commission, Panchkula (‘the State Commission’) dated 24.10.2016. Vide this order, the State Commission had dismissed Appeal No.414 of 2016 and affirmed the order of the District Consumer Disputes Redressal Forum, Sirsa (‘the District Forum’) dated 01.03.2016.

2.      Brief facts of the case, as per the Complainant, are that the Complainant purchased LIC Health Protection Plus Plan (Table 902) policy from Petitioners-LIC bearing No.178982869 dated 27.07.2011 with sum assured of Rs.4,00,000/-. The date of maturity of the policy was 27.01.2031. He continued making payment of insurance premium regularly to Opposite Parties (OPs). At the time of purchase of the insurance policy, the Complainant was got medically examined and all requisite forms were duly got filled up from him by the OPs. As the Complainant was found to be medically fit, the OPs issued the said policy. On 31.5.2012, the complainant was got admitted in Heart and General Hospital, 7, Vivekanand Marg, C-Scheme, Jaipur with complaint of chest pain, where he was surgically operated upon and was discharged on 03.06.2012. A sum of Rs.2,21,850/- was incurred by the Complainant on his treatment.

3.      Thereafter, he filed his claim with the OPs under the said policy. The same was, however, repudiated vide letter dated 28.07.2012 on the grounds of pre-existing illness irrespective of prior medical treatment or advice; and the surgery not listed in the allowed surgeries, as per policy condition. Hence, he filed a complaint before the District Forum seeking claimed amount of Rs.2,21,850/- along with interest, damages for compensation and litigation expenses etc.

4.      In their reply, the OPs admitted the purchase of the insurance policy by the Complainant with Major Surgical Benefit Sum Assured is Rs.400,000/-, for the Complainant. The date of expiry of hospitalization Cash benefit and Major Surgical Benefit is 27.07.2041. The benefits payable are fixed, subject to the claim being as per the terms and conditions of the policy. He was required to disclose the past details of hospitalization/treatment/illness/pathological tests/ health condition etc in the proposal form. Due to good faith, the declarations given by him were believed to be true. Similarly, it was believed that he had not undergone any illness/ treatment in the past. In the event of Accidental Bodily injury or sickness first occurring or manifesting itself after the commencement of the cover and during the cover period, as per policy conditions, the benefits are payable upon hospitalization of the insured subject to the terms and condition, waiting period and exclusions of the policy are Hospital cash benefit and Major Surgical Benefit.

5.      The Complainant was hospitalized at Heart and General Hospital, Jaipur from 31.05.2012 to 03.06.2012. He claimed for both the benefits i.e. Hospital Cash Benefit and Major Surgical Benefit. His claim was processed for Hospital Cash Benefit and after claim evaluation, rejected the claim on the said grounds. Hence, the claim is not admissible as per policy conditions and there is no deficiency of service on the part of the respondents.

6.      The learned District Forum vide order dated 01.03.2006, allowed the complaint and directed the Petitioners/Opposite Parties as under:

“6. From the above, it is clear that treating hospital authorities found the complainant suffering from hyper tension since 1-1/2 years. However, there is no evidence on the record to establish the fact that he was suffering from any type of heart disease for which he had been issued undergone coronary Angioplasty with stent implantation in one artery (IAD) only. In our view, the fact that he has any kind of heart disease was not in the knowledge of complainant before diagnosing by the hospital authorities of Jaipur where his Angioplasty has been taken. In these circumstances, question of concealing the pre-disease does not arise. In our view, denying of reimbursement of the hospital charges to the complainant amounts to deficiency in service on the part of the Ops. Accordingly, we held the Ops guilty for their deficient service. Under the provisions of Section 14 of the Consumer Protection Act, 1986, we direct the Ops to pay sum of Rs.2,21,850/- to the complainant along with interest @ 9% p.a. from the date of institution of this complaint i.e. 22.4.2013 till payment. Ops are also directed to pay cost of litigation amounting to Rs.3000/- to the complainant. Compliance of this order be made within 45 days, failing which the complainant will be entitled to initiate the legal proceedings u/s 25& 27 of Consumer Protection Act. Copy of this order be supplied to the parties free of cost. File be consigned to record room after due compliance.”

7.      Being aggrieved by the impugned order, the Petitioners filed an Appeal before the State Commission.  The learned State Commission, vide order dated 24.10.2016 directed as follows:

“5.      The impugned order has been assailed by relying upon the repudiation letter Exhibit R-4 whereby complainant's claim was denied on the following four grounds:-

1. Pre-existing illness irrespective of prior medical treatment or advice.

2. Pre-existing illness irrespective of prior medical treatment or advice.

3. Surgeries not listed in the allowed surgeries (1-49).

4. Pre-existing illness irrespective of prior medical treatment or advice"

6.  The grounds taken in the repudiation letter (Exhibit R-4) are not supported by leading any cogent and convincing evidence. No evidence has been led by the appellants-LIC that the complainant at any point of time suffered any disease prior to the purchase of the policy which could be said to have been covered under the exclusion clause, to be termed as the pre-existing disease as per clause 3.

7.  Learned counsel for the appellants-LIC referred to Clause 2(ii) under heading "Major Surgical Benefit" reproduced as under:-

"(ii) Major Surgical Benefit:

In the event of an Insured under the Policy undergoing any specified Surgery in a Hospital due to Accidental Bodily Injury or Sickness first occurring or manifesting itself after the Date of Cover Commencement and during the Cover Period then, subject to the terms and conditions of the Policy, the benefit amount reckoned as the percentage of the Sum Assured as mentioned in the Surgical Benefit Annexure against the specified Surgery performed, shall be payable by the Corporation."

8. Schedule of Surgeries was referred to and a perusal of which shows that the disease suffered by the insured was covered under the policy. The complainant had undergone angioplasty with stent implantation, which is certainly covered under the policy. The District Forum, thus, has rightly allowed the complaint and no case for interference is made out. Hence, the appeal is dismissed.

9.  The statutory amount of Rs.25,000/- deposited at the time of filing the appeal be refunded to the complainant against the against proper receipt and identification in accordance with rules, after the expiry of period of appeal/revision, if any.”

8.      The learned counsel for the Petitioners reiterated the grounds stated in the Revision Petition and asserted that the Complainant had concealed the pre-existing disease and the repudiation of claim was justified as per terms and conditions of the insurance policy. He sought the impugned orders of the lower fora be set aside.  He has relied upon the following judgments:

(a) Ekjot Singh Vs. E-meditek Solution Ltd. & Anr., R.P. No.4779/2012 decided on 26.02.2016 by NCDRC;

(b) P.C. Chacko & Anr. Vs. Chairman, LIC of India & Ors., (2008) 1 SCC 321;

(c) Mithoolal Nayak Vs. LIC of India, AIR 1962 SC 814;

(d) Branch Manager, LIC of India Vs. Jyothi Sudhir, R.P. No.1134/2016 decided on 20.10.2016 by NCDRC;

(e) Rakesh Patel Vs. LIC of India, R.P. No.408/2013, decided on 16.01.2015 by NCDRC;

(f) Satwant Kaur Sandhu Vs. New India Insurance Co., (2009) 8SCC 316;

(g) Manager LIC Vs Dolly Jose, 2023 SCC OnLine NCDRC 356.

9.      The learned Counsel for the Respondent/Complainant argued in support of the impugned orders passed by the learned District Forum and the State Commission.

10.    I have examined the pleadings and associated documents placed on record, including the reasoned orders of the learned District Forum and the learned State Commission and rendered thoughtful consideration to the arguments advanced by the learned Counsels for both the parties.

11.    The learned District Forum issued a well-reasoned order based on evidence and arguments advanced before it. The learned State Commission, after due consideration of the pleadings and arguments, determined that no intervention is warranted on the District Forum's order. This was primarily because the grounds relied upon in the repudiation letter are not supported by leading any cogent and convincing evidence and no evidence has been led by the Petitioners-Life Insurance Corporation of India that the Complainant at any point of time had suffered any disease prior to the purchase of the policy which could be said to have been covered under the exclusion clause, to be terms as the pre-existing disease as per Clause 3. This order is now under challenge at the revision stage.

12.    It is a well settled position in law that the scope for Revision under Section 21(b) of the Consumer Protection Act, 1986 and now under Section 58(1)(b) of the Consumer Protection Act, 2019 confers very limited jurisdiction on this Commission. In the present case, there are concurrent findings of the facts and the revisional jurisdiction of this Commission is limited. After due consideration of the entire material, I do not find any illegality, material irregularity or jurisdictional error in the impugned Order passed by the learned State Commission warranting our interference in revisional jurisdiction under the Act. I place reliance on the decision of the Hon’ble Supreme Court in the case of ‘Rubi (Chandra) Dutta Vs. M/s United India Insurance Co. Ltd., (2011) 11 SCC 269.

13.    In addition, Hon’ble Supreme Court in ‘Sunil Kumar Maity vs. SBI & Anr.  Civil Appeal No. 432 OF 2022 Order dated 21.01.2022 observed as follows:-

“9. It is needless to say that the revisional jurisdiction of the National Commission under Section 21(b) of the said Act is extremely limited. It should be exercised only in case as contemplated within the parameters specified in the said provision, namely when it appears to the National Commission that the State Commission had exercised a jurisdiction not vested in it by law, or had failed to exercise jurisdiction so vested, or had acted in the exercise of its jurisdiction illegally or with material irregularity. In the instant case, the National Commission itself had exceeded its revisional jurisdiction by calling for the report from the respondent-bank and solely relying upon such report, had come to the conclusion that the two fora below had erred in not undertaking the requisite in-depth appraisal of the case that was required. .....”

14.    Similarly, in a recent order the Hon'ble Supreme Court in Rajiv Shukla Vs. Gold Rush Sales and Services Ltd. (2022) 9 SCC 31 has held that:- 

As per Section 21(b) the National Commission shall have jurisdiction to call for the records and pass appropriate orders in any consumer dispute which is pending before or has been decided by any State Commission where it appears to the National Commission that such State Commission has exercised its jurisdiction not vested in it by law, or has failed to exercise a jurisdiction so vested, or has acted in the exercise of its jurisdiction illegally or with material irregularity. Thus, the powers of the National Commission are very limited. Only in a case where it is found that the State Commission has exercised its jurisdiction not vested in it by law, or has failed to exercise the jurisdiction so vested illegally or with material irregularity, the National Commission would be justified in exercising the revisional jurisdiction. In exercising of revisional jurisdiction the National Commission has no jurisdiction to interfere with the concurrent findings recorded by the District Forum and the State Commission which are on appreciation of evidence on record.

15.    Based on the deliberations above, I do not find any merit in the present Revision Petition and the same is, therefore, Dismissed.

16.    Keeping in view the facts and circumstances of the present case, there shall be no order as to costs.