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2013 Supreme(Pat) 688
IN THE HIGH COURT OF JUDICATURE AT PATNA
S.N. HUSSAIN and AHSANUDDIN AMANULLAH, JJ.
Shahab Ahmad - Petitioner-Appellant.
Versus
Senior Divisional Manager, Life Insurance Corporation of India, Muzaffarpur Division, Muzaffarpur & Ors. - Respondents-Respondents.
Letters Patent Appeal No.1185 of 2005 IN Civil Writ Jurisdiction Case No. 4273 of 2003
Decided On : 03-07-2013
For the Appellant :Mr. Fakhruddin Ali Ahmad, M/s. Gautam Kumar Yadav and Anjum Parween, Advocates.
For the Respondents:Mr. Rajeev Ranjan Prasad, M/s. Rajendra Kumar & Manoj Kumar, Advocates.
The main legal point established in the judgment is the interpretation of the policy clause 11(b) (i) and its application to the specific circumstances of the case.
Headnote:
Insurance - Life Insurance Policy - Clause 11(b) (i) - [Asha Deep Policy] - [11(b) (i)] - The court discussed the interpretation of the clause 11(b) (i) of the Asha Deep Policy, which covers Open Heart By-Pass Surgery on narrowed/occluded coronary arteries to restore adequate blood supply to the heart. The court analyzed the nature of the surgery undergone by the petitioner and the specific conditions mentioned in the clause, ultimately concluding that the surgery performed on the petitioner was covered under the policy.
Fact of the Case:
The appellant filed a writ petition challenging the dismissal of his claim for benefits under the Asha Deep Policy after undergoing Open Heart By-Pass Surgery for Aortic Valve Replacement. The court analyzed the nature of the surgery and the interpretation of the policy clause.
Finding of the Court:
The court found that the surgery performed on the petitioner was covered under the Asha Deep Policy, as it fulfilled the conditions specified in clause 11(b) (i). The court disagreed with the findings of the Single Judge and allowed the appellant's claim.
Issues: Interpretation of the policy clause 11(b) (i) and determination of whether the surgery undergone by the petitioner was covered under the Asha Deep Policy.
Ratio Decidendi: The court's decision was based on the interpretation of the policy clause and the specific conditions mentioned therein, as well as the nature of the surgery performed on the petitioner.
Final Decision: The Letters Patent Appeal was allowed, and the appellant's claim under the Asha Deep Policy was upheld. The respondents were directed to pay the sum assured and other consequential benefits to the petitioner.
This Letters Patent Appeal has been filed by the writ petitioner-appellant challenging order dated 20.09.2005 by which a learned Single Judge of this Court dismissed CWJC No.4273 of 2003 which was filed by the writ petitioner for the following reliefs:-
(i) For the issuance of a writ in the nature of mandamus or any other appropriate writ/ writs, order /orders, direction/ directions for quashing the official letter dated 11.1.2001 issued under the signature of Manager Claim, Life Insurance Corporation of India, Division Office, Muzaffarpur.
(ii) For the issuance of a writ in the nature of mandamus or any other appropriate writ / writs, order / orders, direction/ directions, commanding the respondents to pay 50% (fifty per cent) of the sum assured to the petitioner immediately as clearly mentioned in Para II, b. J. of Akash Deep Policy of Life Insurance Corporation of India.
(iii) For the issuance of a writ in the nature of mandamus or any other appropriate writ / writs, order / orders, direction/ directions commanding the respondents to pay the interest on 50% of the sum assured along with 50% of the sum assured (i.e. Rs.1,50,000) to the petitioner and other consequential benefits to the petitioner for which he is entitled.
(iv) Any other relief or reliefs to which the petitioner is entitled under the facts and circumstances of this case.
2. The impugned order was passed by the learned Single Judge after arriving at the following findings:-
“4. In my view, the contention is based on a complete mis-interpretation of the clause, and a mis-conception about the two kinds of heart surgery that have come up for consideration during the course of the present proceedings. Whereas the aforesaid clause covers a case of Open Heart By-Pass Surgery which is due to narrowing of the Coronary artery, the petitioner had undergone “Aortic Valve Replacement” by an open heart procedure. In other words, it is a case of valve replacement by Open Heart Surgery. This position is borne out of the discharge summary of respondent no.4 marked Annexure-2 to the writ petition as well as the affidavit sworn by Dr. P. Venugopal, the Director of A.I.I.M.S., New Delhi. The petitioner is overlooking the basic fact that all cases of Open Heart Surgery are not covered by the aforesaid clause. Cases of Open Heart Coronary Artery by-Pass Surgery is alone covered by the aforesaid clause. The clause does not cover a case of valve replacement by open heart surgery. I am convinced of the position on a plain reading of the aforesaid clause read with the discharge summary of the A. I. I. M. S. (Annexure-2), the affidavit sworn by Dr. P. Venugopal, Director of the concerned Department of the A. I .I. M. S., as well as the medical report dated 1.9.2005 (Annexure-A) of the Specialist Doctors of the respondent Corporation.” 3. According to the claim of the appellant, he purchased Life Insurance Policy, namely ‘Asha Deep Policy’ for the assured sum of Rs.1,50,000.00 vide policy no. 530523635 on 28.11.1993 which matured after 15 years on 28.11.2008. In the meantime, in the month of May, 1999 the petitioner suffered heart problem due to which the local doctor referred him to AIIMS, Delhi, where he underwent Open Heart By-Pass Surgery for Aortic Valve Replacement (AVR) on 01.07.1999.
4. Learned counsel for the appellant stated that Aortic Valve was obstructing flow of blood supply to his heart and hence after the required process of angiography, the aforesaid operation was performed which restored regular blood supply to the petitioner’s heart. This fact is fully supported by the affidavit sworn by the famous Cardiac Surgeon Dr. P. Venugopal, Director, AIIMS, Delhi who was respondent no.4 in the writ petition and had filed the said affidavit in that capacity only after the direction of the learned Single Judge vide order dated 04.05.2005.
5. Learned counsel for the appellant averred that the aforesaid operation was not done on the narrowed/occluded coronary arteries and
