Haryana

StateCommission

A/459/2016

NATIONAL INSURANCE CO.LTD. - Complainant(s)

Versus

SURYA KANT - Opp.Party(s)

J.P.NAHAR

04 Aug 2016

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                 

First Appeal No  :    459 of 2016

Date of Institution:    23.05.2016

Date of Decision :     04.08.2016

1.     M/s National Insurance Company Limited, Registered Office, 3 Middleton Street Post Box No.9229 Kolkata-700071.

2.     M/s National Insurance Company Limited, Policy issuing Office, Narain Shopping Complex, Civil Road, Rohtak through its Branch Manager.

         Both through its authorized signatory, Archna Aggarwal, Assistant Manager, Regional Office, SCO No.332-334, Sector 34-A, Chandigarh. 

                                     Appellants-Opposite Parties

Versus

Surya Kant s/o Shri Shardanand, Resident of House No.163/12, Kuchhal Niwas, Silani Gate, Jhajjar.

                                      Respondent-Complainant

                                   

CORAM:             Hon’ble Mr. Justice Nawab Singh, President.

                             Shri B.M. Bedi, Judicial Member.

                             Shri Diwan Singh Chauhan, Member

 

Present:               Shri J.P. Nahar, Advocate for appellants.

Shri Mewa Singh, Advocate assisted by Surya Kant-complainant.

 

                                                   O R D E R

 

NAWAB SINGH J.(ORAL)

 

         This Opposite Parties’-National Insurance Company Limited (for short ‘the Insurance Company’) appeal is directed against the order dated April 22^nd, 2016 passed by District Consumer Disputes Redressal Forum, Rohtak (for short ‘the District Forum’) whereby complaint filed by Surya Kant-complainant was allowed.  The Insurance Company was directed to pay Rs.1.00 lac alongwith interest at the rate of 9% per annum from the date of filing of the complaint, that is, March 26^th, 2015 till realization and Rs.3500/- litigation expenses to the complainant.

2.                Complainant/respondent, purchased Parivar Mediclaim Insurance Policy (Exhibit C-1/R-7) from the Insurance Company, for the period June 17^th, 2014 to June 16^th, 2015. The sum insured was Rs.2.00 lacs. The complainant fell ill and remained hospitalized from February 28^th, 2015 to March, 2^nd, 2015 in Brahm Shakti Sanjivani Hospital, Bahadurgarh (hereinafter referred to as ‘the hospital’). The hospital charged Rs.2,51,577/- from the complainant vide Detailed Final Bill Exhibit C-4. He filed claim with the Insurance Company. The Insurance Company paid the amount of Rs.1.00 lacs. Hence, complaint under Section 12 of the Consumer Protection Act, 1986 was filed before the District Forum seeking direction to the Insurance Company to pay the balance amount of Rs.1.00 lac and compensation.  

3.                The Insurance Company contested the complaint by filing written version. It was pleaded that risk of three family members, that is, Surya Kant-complainant, his wife-Payal and daughter-Soham, was covered under the policy. The liability of the insurance company was limited to 50% of the sum insured per family of the total expenses incurred for one illness and therefore 50% of the sum insured, that is, Rs.1.00 was paid. It was prayed that the complaint be dismissed.

4.                Learned counsel for the appellants-Insurance Company has urged that as per the policy (Exhibit C-1/R-7), the liability of the Insurance Company was limited to 50% of the sum insured per family of the total expenses incurred for one illness. Since the sum insured was Rs.2.00 lacs, so the Insurance Company was liable to pay Rs.1.00 lac, that is, 50% of the sum insured. In support, reliance was placed upon the note given in the policy (Exhibit R-7), reproduced as under:-

“Note:  (a)      Company’s liability would arise if the treatment of disease or injury contracted/suffered is incepted during the policy period. Total expenses incurred for any one illness is limited to 50% of Sum Insured per family. Company’s liability in respect of all claims admitted during the period of insurance shall not exceed the Sum Insured mentioned in the Schedule.

(b)       Hospitalization expenses of person donating an organ during the course of organ transplant will also be payable subject to the sub limits under “C” above applicable to the insured person within the overall sum insured of the insured person.”

5.                On the other hand, Shri Mewa Singh, learned counsel for the respondent-complainant, has urged that the terms and conditions of the Insurance Policy were not explained to the complainant at the time of its issuance, so the Insurance Company is liable to pay the sum insured, that is, Rs.2.00 lacs. In support, reliance was placed upon New India Assurance Company Limited versus Pabbati Sridevi and others, 2013(1) C.P.J. 462; United India Insurance Company Limited versus Dinaz Vervatwala and others, 2015(4) C.P.J. 376.

6.                The contention of the learned counsel for the complainant that the terms and conditions of the policy were not explained to the complainant, does not appear to be sound. It is not the case of the complainant that he did not receive the Insurance Policy containing the terms and conditions.  

7.                On the other hand, Divisional Manager of the Insurance Company filed affidavit Exhibit R-1, wherein it is specifically mentioned that the terms and conditions of the Insurance Policy were duly communicated and explained to the insured. So, the parties are bound by the terms and conditions of the policy.  

8.                A perusal of the ‘Note’ in the policy (Exhibit R-7) shows that the liability of the Insurance Company was limited to 50% of the sum insured per family of the total expenses incurred for one illness.  Since the Insurance Company has already paid 50% of the sum insured, that is, Rs.1.00 lac, so, the Insurance Company is not liable to pay the remaining amount of the sum insured, that is, Rs.1.00 lac.

9.                In BHS Industries versus Export Credit Guarantee Corp.& anr., III(2015) CPJ 1 (SC), Hon’ble Supreme Court has held that the insurance policy has to be strictly construed and it has to be read as a whole and nothing should be added or subtracted.

10.              In view of law laid down by the Hon’ble Supreme Court, the authorities referred to by the learned counsel for the complainant are of no help.

11.              For the reasons recorded supra, the appeal is accepted, the impugned order is set aside and the complaint is dismissed.

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

 

 

Announced 04.08.2016

Diwan Singh Chauhan Member

B.M. Bedi Judicial Member

Nawab Singh President

CL