Life Insurance Corporation of India, which was the opposite party before the District Forum, has filed the present revision petition against the order passed by the State Consumer Disputes Redressal Commission, Andhra Pradesh in First Appeal No.507/2006 whreby the State Commission has affirmed the order passed by the District Forum, Khammam. -2- The District Forum had allowed the complaint and directed the petitioner to pay Rs.50,000/- to the respondent/complainant along with interest @ 9% p.a. from the date of filing of the complaint till realization together with costs of Rs.500/- within one month of the date of receipt of the order. Facts: Complainant/respondent is the holder of Asha Deep policy baring no.680942309 issued by the petitioner for Rs.1 Lac with duration of 25 years. The premium payable was Rs.1,024/-. The premium was to be paid quarterly in the months of March, June, September and December every year. Respondent did not pay the quarterly premiums due from June 1994, September 1994 and December 1994. The policy had lapsed. Respondent paid the three installments due for the period due from 28.6.1994 to 28.12.1994 on 23.2.1995 with interest. On payment of aforesaid installments, the policy was revived. Respondent underwent heart bypass surgery on 18.111995 at Mahavir Cardiovascular Centre, Hyderabad by incurring an expenditure of Rs.1,30,000/-. The complainant lodged a claim with the petitioner for reimbursement of the expenditure. Inspite of -3- submission of all the documents and representations made specifically on 17.6.1997, 24.10.1997 and 25.1.1998 the petitioner did not settle the claim of the respondent. Later on, petitioner repudiated the claim of the respondent on the ground that he had undergone the heart surgery within one year from the date of revival of the policy and as per conditions of the policy he was not entitled to lodge any claim within one year of the revival of the policy. Aggrieved against this, respondent filed the complaint before the District Forum. Petitioner on being served filed its Written Statement. It admitted about the issuance of the policy bearing no.680942309 commencing from 28.9.1993 for a sum of Rs.1 Lac. It was stated that the policy of the complainant had lapsed for non-payment of three quarterly premiums but was revived on payment of the premium for three quarters with interest on 23.2.1995. It is their case that the complainant had undergone the operation for Mitral Valve Replacement on 28.11.1995, i.e., within one year of revival of the policy and, therefore, he was not entitled to the benefits under the policy. It was submitted that for benefit (B) under the plan, the -4- petitioner was not liable to pay the amount as the respondent had undergone the operation within one year of the revival of the policy. District Forum allowed the complaint, aggrieved against which the petitioner filed the appeal before the State Commission, which has been dismissed by the impugned order. Respondent inspite of service is not present. Ordered to be proceeded ex-parte. Under the Ashadeep policy, a holder of Ashadeep policy, if the policy is in force, is entitled to two sets of benefits as under: Benefit (A) The sum assured with vested bonus, if any, is payable in the event of the life assured surviving the stipulated date of maturity or at his death, if earlier. Benefit (B) If any one of the contingencies given in para 11 (b), subject however to the conditions mentioned in Para 11(a) & 11(c) of the “Conditions and Privileges” within referred to occurs during the term of the policy, then the following benefits will be available. i) Immediate payment of 50% of the sum assured ii) Payment of balance 50% of the sum assured alongwith vested bonus, if any, in the event of the life assured surviving the stipulated date of maturity or at his death, if earlier. iii) Payment of an amount equal to 10% of the sum assured, every year, commencing from the policy anniversary failing on or immediately after the date of eligibility for Benefit (B) and ending with the policy anniversary preceding the stipulated date of maturity or the date of death of the life assured, whichever is earlier. iv) Waiver of premiums, if any, (including accident premium) due from the policy anniversary falling on or immediately after the date of eligibility for Benefit (B). The complainant did not claim the Benefit (A). He lodged the claim for the Benefit (B). Benefit (B) is available on the arising of any one contingencies given in para 11 (a) and (c) as under: 11 a Benefit (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. (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 Hearth By-Pass surgery performed on significantly narrowed / concluded coronary arteries to restore adequate blood supply to heart and the surgery must have been proven to be necessary by means of coronary angiography. All other operations (e.g. Angioplasty and Thrombolysis by Coronary Artery Cathererization) 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 suffered from Cancer (Malignant) (That is, the presence of uncontrolled growth and spread of cancer cells which destroy 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 acture episode. Specifically excluded are Transient/Ischaemic Attacks and Stroke like syndromes resulting from- 1. Head Injury (subdural or extradural haematoma) 2. Cerebral abscess 3. Phyogenic, tuberculosis, meningococcal meningitis. (Note: Medical terms referred to hereinabove shall bear the meaning as appearing in Butterworths Medical Dictionary –SECOND EDITIION). (c) Within 120 days from the date on which any of the contingencies mentioned in Para 11(b) hereinabove has occurred, full particulars thereof must be notified in writing to the Office of the Corporation where this policy is serviced, together with the then address and whereabouts of the life assured. Proof satisfactory to the Corporation of the contingency that has occurred, shall be furnished in the manner required. Any Medical Examiner named by the Corporation shall be allowed to examine the person of the life assured in respect of any benefits claimed under the caption “Benefit (B) mentioned under the policy schedule, in such manner and at such times, as may be required by the Corporation.” A perusal of the same would show that the insured is not entitled to Benefit of 11 (b) of the policy in case he undergoes open heart by-pass surgery within one year of the revival of the policy. Respondent had undergone the heart bypass surgery on 28.11.1995, i.e., within one year of revival of the policy and, therefore, he was not entitled to the Benefit (B) under the terms of the policy. On going through the orders passed by the fora below, we find that neither of them has adverted to the terms and conditions of the policy to determine the liability of the petitioner to indemnify the respondent in case he undergoes open heart bypass surgery within one year of revival of the policy. The fora below have acted with material irregularity in exercise of their jurisdiction as they have failed to take into consideration the material fact which was on the record. Supreme Court in “Oriental Insurance Company Ltgd. Vs. Sony Cheriyan (1999) SCC 451” has held that the insurance policy between the insurer and insured represents as contract between the parties. Since the insurer undertakes to compensate the loss suffered by the insured on account of risk covered under the policy the terms of the agreement have to be strictly construed to determine the extent of the liability of the insurer. Respondent is not entitled to any relief as per terms and conditions of the policy and, therefore, the revision petition is allowed. Orders passed by the fora below cannot be sustained and the same are set aside. The complaint is ordered to be dismissed with no order as to costs. | 
