1.         The present Revision Petition (RP) has been filed by the Petitioner against Respondents as detailed above, under section 21(b) of Consumer Protection Act, 1986 against the order dated 26.09.2019 of the State Consumer Disputes Redressal Commission, Chhattisgarh (hereinafter referred to as the ‘State Commission’), in First Appeal (FA) No. 18/645  in which order dated 21.05.2018 of District Consumer Disputes Redressal Forum, Raigarh (hereinafter referred to as District Forum) in Consumer Complaint (CC) No. 31/2018 was challenged, inter alia praying for setting aside the order dated 26.092019 passed by the State Commission and for dismissing the Complaint filed by Respondent-1/complainant before the District Forum.

2.         While the Revision Petitioner (hereinafter also referred to as OP-3/Insurance Company) was Appellant before the State Commission and OP-3 before the District Forum and the Respondent-1 (hereinafter also referred to as Complainant) was Respondent-1 before the State Commission and Complainant before the District Forum and Respondent-2/HDFC Ltd. (hereinafter referred to as Bank) were Respondent-2 before the State Commission in FA/18/645 and OPs- 1 & 2 before the District Forum in Complaint No. 31/2018.

3.         Notice was issued to the Respondents on 04.12.2019.  Parties filed Written Arguments on 23.02.2024 (Petitioner),  17.11.2020 & on dated nil (Respondent-1) and 10.11.2023 (Respondent-2) respectively. 

4.         Brief facts of the case, as emerged from the RP, Order of the State Commission, Order of the District Commission and other case records are that: -

Respondent-1/Complainant’s son (deceased) had taken home loan of Rs.14,45,000/- from Respondent-2 Bank/OPs- 1 & 2 on 26.08.2015 for purchasing a Flat No. 307, Third Floor in Chandra Paradise, Raigarh. Bank had obtained Life insurance policy from OP-3/Petitioner herein in the name of Ashok Patel to secure the loan account. The policy was valid from 30.09.2015 to 29.09.2020. In the said period of Insurance, on 20.09.2017 assured was admitted to Sanjivini Nursing Home, Raigarh.  The condition being serious, on 21.09.2017 the assured was shifted to O.P. Jindal Hospital, Raigarh. During the treatment assured died due to cardiac arrest on 21.09.2017.  The  complainant, the mother of the assured, filled claim form for the payment/adjustment of said home loan of Rs.14,45,000/-, but OP-3 did not settle the claim. The Complainant sent a legal notice dated 12.01.2018 to OP-3, but the OP did not settle the claim and did not give reply to the legal notice.  Bank vide reply dated 19.01.2018 informed the complainant that claim has already been repudiated vide letter dated 15.11.2017 on the ground that death of assured was due to Acute Respiratory Distress Syndrome (ARDS) , Acute Respiratory Failure, Sickle Cell Crisis. The said ailments are not covered under policy.  Hence, the complainant filed complaint.

5.         Vide Order dated 21.05.2018, in the CC No. 31/2018, the District Forum allowed the complaint and passed the following order directing the OP-3:

“a) The respondent No. 3 will pay Rs.14,45,000/-(Rupees fourteen lakh, forty five thousand only) to the applicant within a period of one month.

b) The respondent No. 3 will pay Rs.20,000/- (Rupees twenty thousand only) as compensation towards mental agony and Rs.2,000/- (Rupees two thousand only) towards litigation expenses to the applicant within period of one month.

 c) The respondent No. 3 should pay the decretal amount within a period of one month, in default will be liable to pay interest @ 9 per cent per annum from the date of filing the complaint on dated 26.02.2018 till realisation.”

6.         Aggrieved by the said Order dated 21.05.2018 of District Forum, Petitioner/Insurance Company appealed in State Commission and the State Commission vide order dated 26.09.2019 in FA No. 18/645 dismissed the Appeal and affirmed the order passed by the District Forum.

7.         Petitioner have challenged the said Order dated 26.09.2019 of the State Commission mainly on following grounds:

(i)        The impugned order passed by the State Commission is bad both in law as well as on facts and ought to be set aside.  The impugned order is passed without due application of mind and the same is erroneous and is based on conjunctures and surmises. The State Commission failed to appreciate that the Policy only covered the illnesses/ailments which were specifically mentioned in the list of Major Medical Illnesses in the Policy Schedule itself i.e. 1) Cancer 2) End Stage of Renal Failure 3) Multiple Sclerosis 4) Major Organ Transplant 5) Heart Valve Replacement 6) Coronary Artery Bypass Graft 7) Stroke 8) Paralysis 9) Myocardial Infarction.  It was also mentioned in the said Policy Schedule that “the coverage provided to the insured under the Policy was restricted only to the above mentioned 9 Major Illnesses and Procedures.  The insured had been diagnosed and treated on “Acute Respiratory Distress Syndrome” (ARDS), “Accute Respiratory Failure” (ARF) and “Sickle Cell Crisis”.  Bare perusal of the list of the “Major Medical Illness” mentioned in the Policy Schedule confirms that the said illnesses/ailments were not covered under the Policy. Therefore, the claim of the Respondent-1 had been rightly repudiated.

ii)        The Fora below failed to appreciate the ratio decidendi given by the Hon’ble Supreme Court in the case of Oriental Insurance v. Sony Cheriyan (1999) 6 SCC 451, wherein it was held that the insured is not liable to get anything more than what is covered under the policy.

iii)       The State Commission failed to appreciate the settled law that the onus is on the insured to prove that the claim falls under the purview of the policy.  As per the Claim Forum, Respondent-1 had lodged claim for “Stroke” but failed to establish that the insured had suffered or died due to stroke.  Therefore, the impugned order is liable to be set aside on this sole ground itself.

iv)       The State Commission erred in observing in the impugned order that the Petitioner had failed to produce any documentary evidence on record and merely relied on the oral evidence.  The State Commission failed to appreciate that the treatment records were provided by the Respondent-1 to the Petitioner at the time of processing of the claim. The    Respondent-1 had produced the treatment record, policy, repudiation letter and other relevant documents before the District Forum.  Therefore, all the documents/evidences which were germane to adjudicate the matter and decide the case on merits and substantiate the ground of repudiation were already available on record.  Once the documents were already on record, it was not mandatory for the Petitioner to produce the same again on record.   The State Commission erred in observing in the impugned order that the Petitioner should have produced on record the Proposal Form and other Policy related documents, if the claimed illness/diseases were outside the purview of the Policy.  The State Commission further erred in observing that the letter sent by the Petitioner to insured during his life time contains that the Policy covers “Major Medical Illnesses and Procedures” and the said fact remained unrebutted, the District Forum relied on documentary evidences and therefore, the order of District Forum was justified.

v)        The State Commission failed to appreciate that the Policy itself was absolutely clear and coverage under the head of “Major Medical Illnesses and Procedures” was also explained with a detailed list of 9 illnesses.  Perusal of the Policy Schedule reveals that the claim of Respondent-1 was not covered  under the Policy and therefore, Proposal Form was not at all required to adjudicate this Issue.  The State Commission also misinterpreted the letter of the Petitioner written to the insured during his lifetime.  The said letter was covering letter of the Policy and it only mentioned about the fact that “Major Medical Illnesses and Procedures” were also covered under the Policy.  All the illnesses which were covered under the Policy had been defined in the Policy Schedule, which had been ignored by the State Commission. The State Commission failed to deal with the grounds raised by the Petitioner.  The State Commission dismissed the appeal arbitrarily. 

vi)       The District Forum erred in making the observations which were imaginary in nature and the same were also beyond the pleadings made by the Respondent-1 in the complaint qua the coverage given under the policy and explaining the same to the insured. 

vii)      The State Commission failed to appreciate that the insurance is a contract like any other commercial contract and the terms of the contract are binding on both the parties.  Same view has been upheld by the Hon’ble Supreme Court in the judgments i) Export Credit Guarantee Corp. of India v. Garg Sons International (2013) 1 SCALE 410; ii) United India Insurance Company Ltd. Vs. Harchand Rai Chandan Lal (2005) ACJ 570 and  iii) National Insurance  Company Vs. Anjana Shyam (2007) ACJ 2155.

8.         Heard learned counsel of both sides.  Contentions/pleas of the parties, on various issues raised in the RP, Written Arguments, and Oral Arguments advanced during the hearing, are summed up below.

8.1       Petitioner has repeated most of the averments as contained under the grounds (para 7), hence the same are not repeated here.  Petitioner has contended that after appreciating the documents supplied by the Respondent-1, facts of the claim, the terms and conditions of the policy and the settled law, the petitioner repudiated the claim.  It is also contended that the State Commission failed to appreciate that insured never raised any grievance about coverage of policy during his lifetime.  He voluntarily purchased the policy, after understanding all its features, coverage, terms and conditions of the policy.

8.2       On the other hand Respondent-1 contended that the State Commission also held that if there was any error in the insurance proposal or in the insurance condition of insurance policy, if the said disease was out of cover of the policy, then the petitioner should have produced the copy of that proposal with regard to that conditions of the policy.   It is also contended that the petitioner has denied the claim of the Respondent-1 without any valid reason or justification.  It is an admitted fact that the policy was valid during the relevant period and there were no lapses in payment of premium amount even then the petitioner has denied the claim of Respondent-1 without supporting its case with any document. The petitioner has not filed any document before the courts below to show that the claim of Respondent-1 is not admissible.   The Fora below have rightly allowed the complaint of the Respondent-1.

8.3       It is contended by Respondent-2 that there was no relief sought by the complainant against Respondent-2 in the complaint.  No order has also been passed by both the Fora below on Respondent-2.  It is further contended that HDFC Ltd. now merged with HDFC Bank Ltd. is a bona fide secured lender and has a right to recover its entire dues.  Respondent-2 is a proforma party in the present matter and no relief has been sought from them.  Thus, based on the aforesaid facts and circumstances, the present Revision Petition be decided on merits.

9.         Heard learned counsel of both parties. The contention of the Insurance Company is that the policy covers only nine diseases which are listed in the policy and each of these have been further defined in the detailed policy documents and that the insured did not die from any of these nine diseases. As the cause of death of the deceased was other than of these nine diseases, the claim is not covered under the policy. Counsel for Insurance Company fairly agrees that even if atleast one of these nine diseases is the cause of death, death due to multiple reasons will stand covered under the policy. On the other hand, Counsel for Respondent-1 contended that the deceased died due to stroke which is covered under Sr.No.7 of the list of nine diseases covered and in support of his contention, he has relied upon the death summary according to which the patient had sudden bradycardia with hypot. and according to the Counsel for Respondent-1, this is a type of cardiac arrest/stroke, the counsel further contends that under Sr.No.7 all strokes are covered whether it is heart relating and brain related, while the counsel for Insurance Company contends that stroke related to brain only is covered under the policy and only first heart attack of specified severity is covered and both of these are well defined in the detailed policy documents. Counsel for Insurance Company stated that he is not pressing other issue relating to respondent no.1, mother of the deceased not being consumer as she was the nominee under the policy.

10.       We have carefully gone through the orders of the State Commission, District Forum, other relevant records and rival contentions of the parties. District Forum in its order has observed as follows:

“16.The respondent No. 3 has not produced documents, only has rebutted the claim of the applicant in the written statement, whereas the applicant has proved her complaint, letter and documents on Evidence by way of Affidavit, which we do not find to be incredible. In our opinion the applicant, nominee is entitled to receive Rs.14,45,000/-(Rupees fourteen lakh, forty five thousand only), compensation for mental agony and cost of the complaint. Therefore, by admitting the complaint of the applicant this order is passed against the respondent No. 3:-

a) The respondent No. 3 will pay Rs.14,45,000/-(Rupees fourteen lakh, forty five thousand only) to the applicant within a period of one month.

b) The respondent No. 3 will pay Rs.20,000/- (Rupees twenty thousand only) as compensation towards mental agony and Rs.2,000/-(Rupees two thousand only) towards litigation expenses to the applicant within a period of one month.

c) The respondent No. 3 should pay the decretal amount within a period of one month, in defaults, will be liable to pay interest @ 09& per annum from the date of filing the complaint i.e. dated 26.02.2018 till realisation.”

State Commission in its order has observed as follows:

“As the complainant was the nominee, therefore, she was entitled to file the complaint. No any document on behalf of appellant/opposite party No. 3 was filed. In view of the well- established provisions of Evidence Act, 1872, the facts which can be proved through documents, on that only oral evidence will not be dependable. If there was any error in the Insurance proposal or in the condition of Insurance Policy, if the said disease was out of cover of the policy, then the appellant party should have produced the copy of that proposal with regard to conditions of Policy documents. On the other side when we peruse the document Ex. C-5 is the letter which was written on behalf of appellant party to the deceased Ashok Kumar Patel during his life time with regard to that policy, in which, it was mentioned that Insurance Policy for Home Security Plus, with the other things "Major Medical Illness in Procedures" also covers, this fact has remained unrebutted. And from other documentary evidence and averments by admitting the complaint of the complainant, concerned District Forum, after considering the entire facts, had awarded the desirable relief, we do not come across any error in law or evidence in which any intervention is needed.”

11.       Perusal of policy document show that it covers following risks:

12.       The main issue in the present case is with respect to Section III “Major Medical Illness and Procedures” Illness has been defined in the Policy as:

“19.         Illness means a sickness or a disease or pathological condition leading to the impairment of normal physiological function which manifests itself during the Policy Period and requires medical treatment.”

In the Policy Schedule following 9 diseases have been mentioned under Major Medical Illnesses & Procedures Section following illnesses are covered:

“(1)Cancer (2) End Stage Renal Failure (3) Multiple Sclerosis  (4) Major Organ Transplant (5)  Heart Valve Replacement (6) Coronary Artery Bypass Graft  (7) Stroke (8)  Paralysis (9) Myocardial Infarction.”

This portion of the schedule further states that “the list of Major Medical Illnesses and procedures enlisted under Section III has 18 illnesses/procedures.  However,  “please note that the coverage provided to you under this policy is restricted only to the above mentioned 9 Major Medical illnesses and Procedures.”

13.       Section 3 of policy contains details of Major Illness & Procedures, relevant portions of which are extracted below:

“a. First Diagnosis of the below-mentioned Illnesses more specifically described below:

1. Cancer;

2 End Stage Renal Failure;

3. Multiple Sclerosis; or

4. Benign Brain Tumor

5. Parkinson's Disease before the age of 50 years

6. Alzheimer's Disease before the age of 50 years

7. End Stage Liver Disease

b. Undergoing for the first time of the following surgical procedures, more

specifically described below:

1. Major Organ Transplant;

2. Heart Valve Replacement;

3. Coronary Artery Bypass Graft;

4. Surgery of Aorta;

c. Occurrence for the first time of the following medical events more

specifically described below:

1. Stroke;

2. Paralysis;

3. Myocardial Infarction;

4. Major Burns;

                 5. Loss of Speech;

6. Deafness

7. Coma

The Insured Event under this Section 3 and the conditions applicable to the same are more particularly defined below:

Cancer of specified severity:

A malignant tumour characterised by the uncontrolled growth & spread of malignant cells with invasion & destruction of normal tissues. This diagnosis must be supported by histological evidence of malignancy & confirmed by a pathologist. The term cancer includes leukemia, lymphoma and sarcoma.

The following are excluded:

• Tumours showing the malignant changes of carcinoma in situ & tumours which are histologically described as pre-malignant or non invasive, including but not limited to: Carcinoma in situ of breasts, Cervical dysplasia CIN-1, CIN -2 & CIN-3.
• Any skin cancer other than invasive malignant melanoma
•  All tumours of the prostate unless histologically classified as having a Gleason score greater than 6 or having progressed to at least clinical TNM classification T2N0M0.
• Papillary micro - carcinoma of the thyroid less than 1 cm in diameter
•  Chronic lymphocyctic leukaemia less than RAI stage 3
•  Microcarcinoma of the bladder All tumours in the presence of HIV infection

First Heart Attack-of Specified Severity:

 The first occurrence of myocardial infarction which means the death of a portion of the heart muscle as a result of inadequate blood supply to the relevant area. The Diagnosis for this will be evidenced by all of the following criteria:

• A history of typical clinical symptoms consistent with the diagnosis of Acute Myocardial Infarction (for e.g. typical chest pain)
• new characteristic electrocardiogram changes
• elevation of infarction specific enzymes, Troponins or other biochemical markers.

 The following are excluded:

• Non-ST-segment elevation myocardial infarction (NSTEMI) with only elevation of Troponin I or T
• Other acute Coronary Syndromes
• Any type of angina pectoris

Open Chest CABG:

The actual undergoing of open chest surgery for the correction of one or more coronary arteries, which is/are narrowed or blocked, by coronary artery bypass graft (CABG). The diagnosis must be supported by coronary angiography and the realisation of the surgery has to be confirmed by a specialist Medical Practitioner.

The following are excluded:

• Angioplasty and/or any other intra-arterial procedures
• Any key-hole or laser surgery

Stroke resulting in Permanent symptoms:

Any cerebrovascular incident producing permanent neurological sequelae. This includes infarction of brain tissue, thrombosis in an intra-cranial vessel, haemorrhage andembolisation from an extracranial source. The Diagnosis has to be confirmed by a specialist Medical and evidenced by typical clinical symptoms as well as typical findings in CT Scan or MRI of the brain. Evidence of permanent neurological deficit lasting for at least 3 months has to be produced.

 The following are excluded

• Transient ischemic attacks (TIA)
• Traumatic injury of the brain
• Vascular diseases affecting only the eye or optic nerve or vestibular functions

 Permanent Paralysis of Limbs:

Total and irreversible loss of use of two or more limbs as a result of injury or disease of the brain or spinal cord. A specialist Medical Practitioner must be of the opinion that paralysis will be permanent with no hope of recovery and must be present for more than 3 months.

Kidney Failure Requiring Regular Dialysis:

End stage renal disease presenting as chronic irreversible failure of both kidneys to function, as a result of which either regular renal dialysis (haemodialysis or peritoneal dialysis) is instituted or renal transplantation is carried out. Diagnosis must be confirmed by a specialist Medical Practitioner.

Major Organ/Bone Marrow Transplant:

The actual undergoing of transplant of:

• One of the following human organs: heart, lung, liver, pancreas, kidney, that resulted from irreversible end stage failure of the relevant organ or;
• Human bone marrow using haematopoietic stem cells. The undergoing of a transplant must be confirmed by a specialist Medical Practitioner

The following are excluded:

• Other Stem cell transplants
• Where only islets of langerhans are transplanted.

Multiple Sclerosis with persistent symptoms:

The definite occurrence of Multiple Sclerosis. The diagnosis must be supported by all of the following:

• Investigation including typical MRI and CSF findings, which unequivocally confirm the diagnosis to be multiple Sclerosis.

• There must be current clinical impairment of motor or sensory function, which must have persisted for a continuous period of atleast 6 months.

• Well documented clinical history of exacerbations and remissions of said symptoms or neurological deficits with atleast two clinically documented episodes atleast 1 month apart.

• Other causes of neurological damage such as SLE and HIV are excluded.

Open Heart Replacement or Repair of Heart Valves:

The actual undergoing of open-heart valve surgery is to replace or repair one or more heart valves, as a consequence of defects in, abnormalities of, or disease- affected cardiac valve(s). The diagnosis of the valve abnormality must be supported by an echocardiography and the realization of surgery has to be confirmed by a specialist medical practitioner. Catheter based techniques including but not limited to, balloon valvotomy/valvuloplasty are excluded.

Benign Brain Tumor

A benign intracranial tumor where the following conditions are met:

i.      The tumor is life threatening

ii.    It has caused damage to the brain and

iii. It has undergone surgical removal or, if inoperable has caused permanent neurological deficit certified by a neuro-surgeon.

 The following are excluded: Cysts, Granulomas, Vascular Malformations, Haematomas, Tumors of the pituitary gland or spine or tumors of acoustic nerve

Parkinson's disease before the age of 50 years

The occurrence of Parkinson's Disease where there is an associated Neurological Deficit that results in Permanent Inability to perform independently atleast three of the activities of daily living as defined below

i. Transfer. Getting in and out of bed without requiring external physical assistance.

ii. Mobility: The ability to move from one room to another without requiring any external physical assistance.

 iii. Dressing: Putting on and taking of all necessary items of clothing without requiring any external physical assistance.

iv. Bathing/Washing: The ability to wash in the bath or shower (including getting in and out of the bath or shower) or wash by other means.

v. Eating: All tasks of getting food into the body once it has been prepared.

Parkinson's disease secondary to drug and/or alcohol abuse is excluded.

End Stage Liver Disease

End stage liver disease resulting in cirrhosis and evidenced by all of the following criteria: a) permanent jaundice, b) ascites, c) encephalopathy, d) portal hypertension.

Liver disease secondary to alcohol or drug misuse is excluded.

Surgery of Aorta

The actual undergoing of medically necessary surgery for a disease of the aorta needing excision and surgical replacement of the diseased aorta with a graft. For the purpose of this definition aorta shall mean the thoracic and abdominal aorta but not its branches. Traumatic injury of the aorta is excluded.

 Alzheimer's disease before the age of 50 years

Clinically established diagnosis of Alzheimer's Disease (presenile dementia) resulting in a permanent inability to perform independently three or more activities of daily living – bathing, dressing/undressing, getting to and using the toilet, transferring from bed to chair or chair to bed, continence, eating/drinking and taking medication – or resulting in need of supervision and permanent presence of care staff due to the disease. These conditions have to be medically documented for at least 3 months.

 Major Burns

Third Degree burns covering atleast 50% of body surface area.

 Loss of Speech

Total and irreversible loss of the ability to speak due to physical damage to the vocal chords due to Illness or Injury. The condition has to be medically documented for atleast 6 months.

Deafness

Total and irreversible loss of hearing in both ears as a result of Illiness or Injury. The diagnosis has to be confirmed by an ear, nose and throat specialist (ENT specialist) and proven by means of audiometry.

Coma of Specified Severity

1. A state of unconsciousness with no reaction or response to external stimuli or internal needs. This diagnosis must be supported by evidence of all of the following:

1. no response to external stimuli continuously for at least 96 hours;
2. life support measures are necessary to sustain life; and
3. permanent neurological deficit which must be assessed at least 30 days after the onset of the coma.

II. The condition has to be confirmed by a specialist medical practitioner. Coma resulting directly from alcohol or drug abuse is excluded.

A. BENEFIT PAYABLE UNDER SECTION 3

The Company hereby agrees, subject to the terms, conditions and exclusions applicable to this Section and the terms, conditions, General Exclusions stated in this Policy, to pay the Sum Insured in relation to the Insured as stated against Section 3 under the Schedule on the occurrence of an Insured Event as stated above, under this Section.

B. SPECIFIC CONDITIONS APPLICABLE TO SECTION 3

The cover under this Policy, for the specific insured shall  terminate in the event of claim in respect of such insured becoming admissible and accepted by the Company under this Section. In consequence thereof no beneft shall be payable  under any other section of the Policy.

 C. EXCLUSIONS APPLICABLE TO SECTION 3

 The Company shall not be liable to make any payment directly or indirectly arising out of the following everts:

 1 Any Pre-Existing illness-Any Insured Event arising  on  account of or in connection with any Pre-Existing illness.

 2. If the Insured does not submit medical certificate from the Doctor evidencing diagnosis of illness or injury or occurrence of the medical event or the undergoing of the medical surgical procedure.

3. The Company shall not be liable to make any  payment under the Policy in connection with or in respect of any Insured Event, and in this Section occurred or suffered before the commencement of Period of Insurance or arising within the first 90 days of the commencement of the Period of Insurance .

4 Any congenital illness or condition including internal and external congenital Illnesses.

 5 Any medical procedure or treatment, which is not medically necessary or not performed by a Doctor.

6.  Any physical, medical or mental condition or treatment or service that specifically excluded in the Policy is a Part of the Schedule under Special Conditions

7. Treatment relating to birth defects.

8. Birth control procedures and hormone replacement therapy.

9. Any treatment/ surgery for change of sex or any cosmetic surgery or treatment/surgery/complications/illness arising as a consequence thereof.

10.Treatment by a family member and self-medication or any treatment that is not scientifically  recognized.

 D. CLAIMS SETTLEMENT PROCESS APPLICABLE TO SECTION 3

In the event of a claim arising out of an Insured Event covered under Section, the Insured Event as described above shall be intimated to the Company with thirty (30) days date of first diagnosis of the illness, date of surgical procedure or date of occurrence of the medial event as the case may be and the insured shall arrange for submission of the following documents to the Company:

 1. Certificate from the attending Doctor of the Insured confirming, inter alia,

a. Name of the Insured;

b. Name, date of occurrence and medical details of the Insured Event.

c.  Confirmation that the Insured Event does not relate to any Pre-Existing Illness or any Illness or Injury which existed within the first 3 months of commencement of Period of Insurance. 

2.  Certificate, applicable, from the Bank/Financial Institution stating the amortization schedule, the EMI Amounts, Principal Outstanding, etc.

3.  Duty completed claim farms;

 4. Original Discharge Certificate/ Card from the hospital/Doctor;

 5. Original investigation test reports, indoor case papers; Any other documents as may be required by the Company

6. Any sexually transmitted diseases. Acquired Immune Deficiency Syndrome (AIDS), AIDS related complex syndrome (ARCS) and all diseases caused by and/or related to HIV.

14.       Discharge note dated 21.09.2017 of Sanjivani Nursing Home shows the Diagnosis as :    ARDS ꞇ SCD Cirosis”.  Death summary of O.P. Jindal Hospital and Research Centre states the cause of death as:

“Patient had sudden Bradycardia with hypotension.  According to ACLS CPR start & all Emergency Medicines given.  After admin. of  resuscitation patient could not get revival.  Declare death at 5:15 P.M.”

Admission Notes of the said O.P. Jindal Hospital shows Final Diagnosis as “ARDS with ARF with Sickle Cell Crisis”

 Examination sheet mentions Provisional diagnosis as “? ARDS with ARF with Sickle Cell Crisis”

15.       Claim has been repudiated vide letter dated 15.11.2017, relevant extract of which is reproduced below:

“We refer to the above claim lodged by you and all the documents received at our end-

As per the Case Summary received, Late Mr. Ashok Kumar Patel was diagnosed to be suffering from Acute Respiratory Distress Syndrome (ARDS), Acute Respiratory Failure, Sickle Cell Crisis.  The said ailments are not covered under policy, Hence claim is rejected.

However, the said disease is not covered in the Critical illness section of policy.

1. First Heart Attach of Specified Severity;
2. Open Chest CABG:
3. Stroke resulting in Permanent symptoms;
4. Cancer of Specified Severity;
5. Permanent Paralysis of Limbs;
6. Kidney Failure Requiring Regular Dialysis’
7. Major Organ/Bone Marrow Transplant
8. Multiple Sclerosis with persistent symptoms;
9. Open Heart Replacement or Repair of Heart Valves:

Since the losses claimed under Major Medical Illness are not covered as per above policy wording, we treat the claim as “NO Claim”.

16.       In support of their case, the Petitioner have relied upon certain judgments of this Commission and Hon’ble Supreme Court, which are briefly stated below alongwith extract of relevant paras:

(a)       Karuna Sharma V. ICICI Lombard General Insurance Co. Ltd. RP No. 618 of 2016, decided on 28.03.2016 (2016 SCC Online NCDRC 1408).  The SLP filed against the said decision was dismissed by the Hon’ble Supreme Court on 23.02.2017.  The relevant extract of the order passed by the National Commission in RP/618/2016 is reproduced below:

“5.      It is evident from a perusal of the insurance policy taken by the deceased that the said policy covered the life of the insured only in the event he suffered from any of the diseases specified in the said policy.  Chronic liver disease/Leptospira Infection and Hepatic Encephalopathy and Hemolysis are not amongst the diseases covered under the policy taken by the deceased.  Therefore, even if the deceased was not suffering from the diseases resulting in his death, at the time of taking the policy, he having died on account of having contracted disease not covered by the insurance policy, the petitioner/complainant is not entitled to any payment from the insurer.  The learned counsel for the petitioner/complainant submits that no documents were supplied to the deceased and therefore, he was not aware of the terms and conditions of the policy.  In our opinion, the complainant/petitioner can have no personal knowledge as to which documents were made available by the insurer to the deceased.  This is a matter which could be in the knowledge either of the insurer or of the insured.  No communication was ever sent by the insured to the insurer alleging therein that the documents relevant to the policy had not been supplied to him.  Had the requisite documents not been supplied to him, the least the deceased would have done was to write a letter to the insurer expressing such a grievance.  That having not been done, the inevitable inference is that all the documents had been supplied to him and that is why no such grievance was expressed by him to the insurer.

6.      More importantly, as far as this case is concerned, the illnesses covered under the policy are given in the policy itself.  Here they are not indicated in some other documents such as an annexure to the policy or the terms and conditions applicable to the policy.  Therefore, from a bare perusal of the insurance policy itself, it would have been known that the said policy covered only the diseases specified in Section 1 of the policy.”

(b) Oriental Insurance Co. Ltd. vs. Sony Cheriyan (1999) 6 SCC 451. Relevant extract is reproduced below:

16. Admittedly, the respondent was carrying ether solvent which has been described as a hazardous and highly flammable article. Since under the “permit” granted to the respondent he could transport only non-hazardous articles, and the insurance policy covered only those goods which were permissible under the Motor Vehicles Act to be carried by the respondent, the judgments dated 24-4-1996 and 10-2-1997 passed by the State and National Commissions respectively, are incorrect.

 (c)      Export Credit Guarantee Corp. of India V. Garg Sons International CA No. 1557 of 2004 with connected CAs decided on 17.01.2013 (MANU/SC/0039/2013). Relevant extract  is reproduced below:

“8. It is a settled legal proposition that while construing the terms of a contract of insurance, the words used therein must be given paramount importance, and it is not open for the Court to add, delete or substitute any words. It is also well settled, that since upon issuance of an insurance policy, the insurer undertakes to indemnify the loss suffered by the insured on account of risks covered by the policy, its terms have to be strictly construed in order to determine the extent of the liability of the insurer. Therefore, the endeavour of the Court should always be to interpret the words used in the contract in the manner that will best express the intention of the parties. (Vide: M/s. Suraj Mal Ram Niwas Oil Mills (P) Ltd. v. United India Insurance Co. Ltd., (2010) 10 SCC 567).

9. The insured cannot claim anything more than what is covered by the insurance policy. “…the terms of the contract have to be construed strictly, without altering the nature of the contract as the same may affect the interests of the parties adversely.” The clauses of an insurance policy have to be read as they are…Consequently, the terms of the insurance policy, that fix the responsibility of the Insurance Company must also be read strictly. The contract must be read as a whole and every attempt should be made to harmonize the terms thereof, keeping in mind that the rule of contra proferentem does not apply in case of commercial contract, for the reason that a clause in a commercial contract is bilateral and has mutually been agreed upon. (Vide : Oriental Insurance Co. Ltd. v. Sony Cheriyan AIR 1999 SC 3252; Polymat India P. Ltd. v. National Insurance Co. Ltd., AIR 2005 SC 286; M/s. Sumitomo Heavy Industries Ltd. v. Oil & Natural Gas Company, AIR 2010 SC 3400; and Rashtriya Ispat Nigam Ltd. v. M/s. Dewan Chand Ram Saran AIR 2012 SC 2829).

10. In Vikram Greentech (I) Ltd. & Anr. v.  New India Assurance Co. Ltd. AIR 2009 SC 2493, it was held :

“An insurance contract, is a species of commercial transactions and must be construed like any other contract to its own terms and by itself…. The endeavour of the court must always be to interpret the words in which the contract is expressed by the parties. The court while construing the terms of policy is not expected to venture into extra liberalism that may result in re- writing the contract or substituting the terms which were not intended by the parties.” (See also : Sikka Papers Limited v. National Insurance Company Ltd & Ors. AIR 2009 SC 2834).

11. Thus, it is not permissible for the court to substitute the terms of the contract itself, under the garb of construing terms incorporated in the agreement of insurance. No exceptions can be made on the ground of equity. The liberal attitude adopted by the court, by way of which it interferes in the terms of an insurance agreement, is not permitted. The same must certainly not be extended to the extent of substituting words that were never intended to form a part of the agreement.”

17.       In view of the foregoing and keeping in view the clear clauses/conditions of the policy, we are in agreement with the contentions of the Petitioner-Insurance Company that Complainant/Respondent-1 is entitled to claim under the policy only if it is covered under any one of the nine diseases covered under the policy.  Hence, the question that remains for determination now is whether the disease leading to death of the insured is one of the nine covered under the policy.  It is the case of the Complainant/Respondent-1 that deceased died due to stroke, which is covered under Sr. No. 7 of the list of nine diseases covered.  According to Complainant/Respondent-1,  bradycardia with hypot … is a type of cardiac arrest/stroke and under Sr.No.7 all strokes are covered, whether it is heart related or brain related. A review of some of the medical literature shows that Bradycardia is a slow or irregular heart rhythm, usually fewer than 60 beats per minute.  At this rate, the heart is able to pump enough oxygen-rich blood to pump enough oxygen-rich blood to the body during normal activity or exercise.  Hypotension refers to low blood pressure.  Bradycardia with hypotension means a person has both a slow heart rate and low blood pressure. A stroke is a medical emergency that occurs when the blood supply to a part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients.  While Bradycardia itself is not a type of stroke, but it can related to stroke risk factors.  Although Bradycardia and stroke are two distinct medical conditions, bradycardia may affect blood flow to brain, potentially increasing the risk of ischemic events.

18.       We have carefully gone through the policy coverage clauses, exclusions and other relevant contents.  The description of covered conditions narrated there are not easy to understand for any normal individual who gets such an insurance policy.  Only a medical expert in the field can exactly understand the detailed implications of such coverage and exclusion clauses.  Normally an insured will look at broad description of coverage while taking such policy.  The policy schedule states 9 major medical illnesses and procedures as listed therein are covered.  Listing of such 9 major items is in  broad terms.  It is difficult for an insurer to understand whether any specific health condition he may face under such broad heads will get covered or not.  Hence, we find that there is some ambiguity in the coverage clauses and the insured was justified in interpreting the coverage clauses to assume that the diseases for which he has undergone treatment will get covered.  As was held by Hon’ble Supreme Court in Canara Bank Vs. United India Insurance Co. Ltd. & Ors. (2020) 3 SCC 455 that “Insurance Policy must be read holistically so as to give effect to reasonable expectations of all the parties including the insured and the beneficiaries-  it must be interpreted in a commercially sensible manner- coverage clauses to be read broadly, and ambiguity, if any, to be resolved in favour of insured-exclusions to be read narrowly.” 

19.     The State Commission while dismissing the appeal filed by the Petitioner Insurance Company has observed as follows:

          “Arguments were presented on behalf of respondent no. 1 that the document Exhibit C-5 which was presented by the appellant to the deceased at the time of insurance, mentions that this insurance policy, along with others, will also apply to "Major Medical Illness and Procedures". He also submits that no documents were produced by the appellant side from which it can be ascertained that the disease suffered by the deceased was not covered by the insurance policy. According to them, the complainant was the nominee of the deceased, hence she had the right to file a claim and since the opposite party number-3/present appellant did not produce any documents from which it can be ascertained that the deceased Ashok Kumar Patel had given any wrong information in the proposal form of the policy. Therefore, the arguments of the appellant are not acceptable in the absence of any documentary evidence to support them. They cannot be accepted on the basis of mere pleadings, hence the concerned forum has not committed any error by accepting the complaint. Therefore, the appeal should be dismissed and the order passed should be confirmed.

It was pleaded on behalf of respondents No. 2 and 3 that no order has been passed against them by the concerned forum and the complainant has not challenged the order passed by the concerned forum as no order has been made against respondents No. 2 and 3. Therefore, the said order of the concerned forum is final in respect of them and in any case, they are stare-holders in the insurance in this case. Hence, they have nothing to say in favour or against this appeal.

We have perused the order dated 21.05.2016 passed by the concerned forum in case no. 31/2018. Perused the record.

Since the complainant was the nominee, she had the right to file the complaint. No documents were presented on behalf of the appellant/opposing party No. 3. In the light of the well-established provisions of the Evidence Act, 1872, facts which can be proved by documentary evidence cannot be relied upon by mere oral evidence. If there was any error in the insurance proposal or if the illness alleged in the terms of the insurance policy was outside the coverage of the policy, then the appellant should have submitted a copy of the proposal and submitted the necessary documents as per the terms of the policy. On the other hand, when we peruse the document Exhibit C-5 in which a letter was written by the appellant side to the deceased Ashok Kumar Patel during his lifetime regarding the said policy, it was mentioned that the insurance policy Home Suraksha Plus, with other things, also covers "Major Medical Illness in Procedures", this fact remains undisputed and on the basis of other documentary evidence and pleadings, the concerned forum accepted the complaint of the complainant and granted her the desired relief, in which after overall consideration, we do not find any error in law, evidence or any other matter, which does not justify any interference.”

20.     District Forum in its order has observed as follows:

“16. Non-applicant no.3 has not presented the document, only in the reply, the claim of the applicant has been denied, whereas the applicant has certified her complaint and documents by affidavit evidence. We do not find it un-trust worthy. In our opinion, the applicant nominee is entitled to get Rs. 14,45,000/- (fourteen lakh forty five thousand rupees), compensation mental agony and litigation expenses from non-applicant no.3. Therefore, the applicant's complaint is accepted and this order is passed against non-applicant no.3:-

A. Non-applicant No.3 shall pay Rs.14,45,000/- (Rupees Fourteen Lakh Forty Five Thousand) to the applicant within one month.

B. Non-applicant No.3 shall pay compensation of Rs.20,000/- towards mental agony and Rs. 2,000/- towards litigation expenses to the applicant within one month.

C. Non-applicant No. 3 should pay the amount within one month, failing which, interest at the rate of 09% per annum will be payable from the date of filing of complaint i.e. 26.02.2018 till the date of payment.”

21.     As has been held by Hon’ble Supreme Court in catena of judgments^[1] that the revisional jurisdiction of the National Commission is extremely limited, it should be exercised only in case as contemplated within the parameters specified in the provision i.e. when 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.  It is only when such findings are found to be against any provisions of law or against the pleadings or evidence or are found to be wholly perverse, a case for interference may call for at the second appellate (revisional) jurisdiction. In exercising of revisonal jurisdiction, the National Commission has no jurisdiction to interfere with concurrent findings recorded by the District Forum and the State Commission, which are on appreciation of evidence on record.

22.     After giving a thoughtful consideration to the entire facts and circumstances of the case, various pleas raised by the parties, we find that there is  no illegality or material irregularity or jurisdictional error in the order of the State Commission, hence the same is upheld. Accordingly, Revision Petition is dismissed.

23.     The pending IAs in the case, if any, also stand disposed off.