R. K. AGRAWAL, J., PRESIDENT

1.            Challenge in this Revision Petition is to the Order dated 05.02.2018 passed by the Maharashtra State Consumer Disputes Redressal Commission (hereinafter referred to as ‘the State Commission’) in First Appeal No.A/15/613, whereby the State Commission while partly allowing the Appeal filed by the Life Insurance Corporation of India (hereinafter referred to as the LIC), modified the Order dated 06.02.2015 passed by the District Consumer Disputes Redressal Forum, Ratnagiri (hereinafter referred to as ‘the District Forum’) by directing the LIC to pay to the Complainant a sum of ₹1,24,900/- in respect of Jeevan Arogya (903) Policy within 6 weeks failing which the amount would carry interest @ 9% p.a. till realisation.

2.            Concisely narrated, the facts leading to the filing of the Complaint are that the wife of the Respondent/Complainant had obtained two Policies, i.e., Medi-claim Policy, i.e., Jeevan Arogya (Plan 903) (Policy No. 948594049) and Jeevan Anand (Policy No. 948594051 for sum assured of ₹2 lakh) from the Petitioner/Opposite Party LIC.  The Respondent/Complainant was the nominee in the said Policies. During the currency of the Policies, the wife of the Respondent fell ill and was admitted in Chirayu Hospital at Ratnagiri on 22.08.2013.  Seeing no improvement, she was shifted to Aster Aadhar Hospital, Kolhapur on 23.08.2013.  However, she breathed her last in Aster Aadhar Hospital, Kolhapur on 26.08.2013.  The Respondent being nominee lodged medi-claim and insurance amount of ₹2,00,000/- in respect of both the Policies from the LIC. The LIC vide letter dated 29.01.2014 without mentioning about the Medi-claim Policy, denied to pay the insured amount of ₹2,00,000/- in respect of Jeevan Anand Policy, on the ground that the deceased made incorrect statement and withheld information of uncontrolled diabetes mellitus from it.  As per the version of Respondent the Policies were issued to the deceased after complete physical examination of her by the panel doctor Smt K S Mehta ( M.D) of the LIC.   Alleging deficiency in service on the part of the LIC, a Consumer Complaint was filed before the District Forum seeking following reliefs:-

“1.          Policy amount of ₹2,00,000( Rs Two Lakh Only) under Jeevan Anand Policy be ordered to be paid to the Complainant .

2.            Expenses for Medical treatment of deceased Dipti& Ambulance expenses totaling to 1,50,000 (One lakh fifty thousand) under JeevanAryogya policy be ordered to be paid by Opponent to the Complainant .

3.            Complainant be given ₹1,25,000/- (Rs One lakh twenty five thousand) for mental and physical agony from the Opponents.

4.            Complainant be granted interest @ 9% pa from the date of death of Dipti, i.e., 26.8.2013 on the allowed amount of compensation till entire amount realized.

5.            Cost of Complaint ₹25000/- (Rs Twenty five thousand) be ordered to be paid by Opponent to the Complainant. ”

3.            The OP LIC resisted the Complaint by filing their written version. It was submitted that they are ready to pay the amount due for hsopitalisation as per rules under the Jeevan Arogya Policy, i.e., ₹4,000/-.  The expenses of Medical Treatment are payable under the Policy only if the surgery stipulated in the schedule is performed.  In the instant case, there is no evidence that surgery was performed on the deceased/insured.  It was further submitted that it was clear from the medical report of the insured that she was suffering from diabetes for 15 years prior to effecting the insurance and this important/material fact was suppressed by her while taking the policy and policy was taken by fraud. The certificate issued by Dr. Ajit Kulkarni is correct and death of the deceased was mainly caused by diabetes.  Therefore, they were right in repudiating the claim and it was incumbent on the Complainant to appeal against it to the Appellate Authority established by Opponent.  In spite of that, the Complainant has filed the present Complaint, hence it is premature and it was prayed that the Complaint be dismissed.

4.            The District Forum, after perusing the pleadings, evidence and hearing the Parties allowed the Consumer Complaint by observing as under:

“……..In answer to this, the Complainant’s Advocate stated in his arguments that the proposal form for Jeevan Anand Policy was filed by Insurance agent herself and deceased Dipti Malekar had sign it without reading. Opponents have not filed the affidavit to the Insurance agent stating that the said proposal form was signed by deceased Dipti Malekar after completely reading it. Opponent had called for Confidential Report of Medical Examiner of Opponent Company to determine whether deceased Dipti Malekar was physically & mentally fit to get the said policy. Accordingly deceased Dipti Malekar was medically examined and the corresponding report was submitted to Opponent Company. Complainant has filed copy of said report at Exh.7/3. It contains mention of pre-existing disease of deceased Dipti Diabetes Mellitus & treatment continuing for the same. Deceased Insured Dipti Malekar has not suppressed her pre-existing illness. Also, at Sr.No.15 of the Questionnaire of Medical Record. Whether deceased Dipti Malekar physically & mentally fit for the policy has been answered as ‘Yes’. Thus it is clear that the opponents had issued the policy to deceased Dipti Malekar only after conducting her Medical Examination. Hence the reason given by the opponents that the insured had given false information of suppressed certain facts while filling the proposal form does not appear proper & just.

12.          Similarly, on perusal of LIC’s certificate of Hospital treatment filed at Exh.7/4, it has mention of deceased Dipti having fever, cough & breathlessness at the time of her admission in the Hospital. Similarly, on perusal of LIC’s Medical Attendant Certificate filed at Exh.7/5, it is mentioned that deceased Dipti’s death resulted from primary cause Respiratory Arrest. From this, it is proved that the death of Complainant’s wife resulted from pneumonia. As a result, this forum arrives at the conclusion that the complainant is entitled to receive the amount of insurance of the insured. Hence, this forum arrives at the conclusion that by denying just insurance claim of the Complainant, the Opponents have given faulty service and caused deficiency in service. Hence this forum answers issue No.2 in the affirmative.

13.          The Complainant is entitled to receive total expenditure of ₹128290/- for medical treatment in accordance with Jeevan Arogya (Plan-903) policy No.948594049 & insurance Benefit amount ₹200000/- in accordance with Jeevan Anand, with profit Policy No.948594051 with interest at the rate of 9% p.a. from date of repudiation of claim i.e. 29/01/2014 till the date of realization of total amount. Similarly, this forum arrives at the conclusion that due to the mental, physical, financial agony caused to the Complainant as a result of repudiation of the claim by the Opponents, the Complainant is entitled to receive an amount of ₹5000/-and also the cost of the complaint ₹3000/-. Hence this forum passes following order:-

ORDER

1.            The Complaint of the Complainant is partly allowed.

2.            Opponent Insurance Company to pay to the Complainant total amount of treatment expenses ₹128290/-(₹One Lakh Twenty-eight Thousand Two Hundred Ninety only) under Jeevan Arogya (Plan-903) Policy No.948594049 with interest @ 9% p.a. from date of repudiation of claim i.e.29/01/2014 till the date of realization.

3.            Opponent Insurance Company to pay to the  Complainant Insurance amount ₹200000/-(₹ Two Lakh only) under Jeevan Anand with Profit Policy No.948594051 with interest @9% p.a. from date of repudiation of claim i.e. 29/01/2014 till the date of realization.

4.            Opponent to pay the Complainant amount of ₹5000/- (₹ Five Thousand only) towards physical & mental agony cause to the Complainant & ₹3000/-(Three thousand only) towards costs of the Complaint.

5.            Opponent should comply with the present order within 45 days, failing which the Complainant will be entitled to claim relief under Section 25 & 27 of the Consumer Protection Act against the Opponents.”

5.            In compliance of the Order passed by the District Forum, the LIC had paid a sum of ₹2 lakh along with interest in respect of Jeevan Anand Policy to the Complainant but challenging the later part of the Order regarding settlement of claim in respect of Jeevan Arogaya Policy, the LIC filed Appeal before the State Commission. 

6.            The State Commission after hearing the Parties and appreciation of the evidence led by the Parties, modified the Order passed by the District Forum in the aforesaid manner by observing as under:-

“......From bare reading of the Policy, hospitalization charges were covered under the Policy and in our view, same cannot be limited to sum of ₹2,000/- only as daily benefit as the policy itself covered the hospitalisation for the necessary medical treatment for indoor patient in the hospital pursuant to the sickness.  That being so, under Jeevan Arogya (Table 903), the insured was entitled to claim hospitalisation expenses while in indoor patient for necessary medical treatment..

.....In our view, contention that the insurance contract has to be construed as restricted in the terms and conditions mentioned in the printed proforma which annexed to the insurance contract, cannot be accepted because as indicated by the Apex Court ruling only when the insurance contract must be established with proof that such printed contract was explained to the insured in the same language of the contract or language of the insured.  In absence of such evidence, the liability of the insured cannot be restricted to sum of ₹2,000/- per day as claimed by the appellant.  Therefore, in our view, bill paid to Chirayu Hospital as well as Aster Adhar Hospital and ambulance charge during the period when patient was admitted and breathed her last ought to be paid to the insured.  In the present case, therefore, respondent is entitled to receive the bill paid to Chirayu Hospital, Ratnagiri in the sum of ₹9,900/- + bill paid to Aster Adhar Hospital, Kolhapur in the sum of ₹1 lakh and ambulance charges in the sum of ₹15,000/-.  We, therefore, modify the order passed by the learned District Forum as below:-

ORDER

1)            The Appellant shall, on account of Jeevan Arogya (903) Policy bearing No. 948594049, pay a sum of ₹1,24,900/- to the Respondent or legal representative of the insured within a period of 6 weeks from the date of this Order

2)            Amount already deposited or paid to the State Commission towards award shall be adjusted accordingly.

3)            If the amount is not paid within the period mentioned above, the amount shall carry interest @9% p.a. till realisation.

4)            Appeal is partly allowed accordingly.

5)            Rest of the findings and award is maintained.”

7.            Being aggrieved by the Order dated 05.02.2018 passed by the State Commission, the Petitioner/Opposite Party LIC had filed the present Revision Petition before us.

8.            Mr. Vishnu Sharma, learned Counsel appearing on behalf of the Petitioner/Opposite Party LIC submitted that the State Commission erred by not considering the decision of the Hon’ble Supreme Court in Export Credit Guarantee Corpn. India Ltd. vs. M/s. Garg Sons International (2014 1 SCC 686) in which it has been held that insurance is contract between the Parties and the insured cannot claim anything more than what is covered by the terms and conditions of the Policy.  It was further submitted that the State Commission while making observation failed to consider that as per IRDA rules and regulations, they have provided full copies of proposal form with policy.  It was the duty and responsibility of the insured to examine all the details of the plan and provision and conditions therein.  There was also cooling period of 15 days for determination of the contract, but the insured did not come forward for any clarification/concern/grievance and had opted to continue with the documents.  It was prayed that the Order passed by the State Commission be set aside and revision petition be allowed.  

9.            We have heard Mr. Vishnu Sharma, learned Counsel for the Petitioner,  perused the Orders passed by the Fora below and have given a thoughtful consideration to the pleas raised by the learned Counsel for the Petitioner.

10.          In the present case there is concurrent finding that the Petitioner/Opposite Party LIC is liable to pay actual hospitalisation charges. We do not find any illegality, material irregularity or jurisdictional error in the Impugned Order dated 05.02.2018 passed by the State Commission warranting our interference in revisional jurisdiction under Section 21(b) of the Consumer Protection Act, 1986. The Revisional Jurisdiction of this Commission is extremely limited as has been held by the Hon’ble Supreme Court in ‘Sunil Kumar Maity vs. State Bank of India & Anr.’ [Civil Appeal No. 432 / 2022 Order dated 21.01.2022]  by observing as under:-

“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. .....”

11.          Respectfully following the principle laid down by the Hon’ble Supreme Court in ‘Sunil Kumar Maity (supra), we do not find any merit in the present Revision Petition and the same is dismissed. Consequently, the Impugned Order dated 05.02.2018 passed by the State Commission is upheld. Keeping in view the facts and circumstances of the present case, there shall be no order as to costs.