IMPORTANT POINT
Insurance claim cannot be allowed beyond terms of insurance cover.

Ajit Bharihoke, Presiding Member—This revision is directed against the order of the State Commission, Punjab, Chandigarh dated 27.12.2004 by which the State Commission dismissed the appeal preferred by the petitioner / opposite party with cost of Rs.5000/- against the order of the District Forum to the following effect:

“So in view of the above noted facts, the present complaint is allowed and the opposite party is directed to pay to the complainant the sum assured i.e. Rs.1,00,000/- (Rupees one lac only) alongwith interest at the rate of 6% per annum from the date of complaint i.e. 24.06.2009 till realization. The opposite party is further directed to pay to the complainant a sum of Rs.1000/- (Rupees One Thousand only) as litigation expenses. Orders be complied within a period of thirty days from the date of receipt of a copy of this order. File be consigned to record room”.

2. The relevant facts for the disposal of this revision petition are that complainant / respondent Ashwani Kumar filed a consumer complaint under 12 of the Consumer Protection Act, 1986 against the petitioner alleging that he obtained SBI Life Insurance Policy from the petitioner commencing from 08.11.2004. The date of the maturity was 08.11.2019. As per the terms and conditions of the policy, the respondent / complainant was provided basic life cover for Rs.1.00 lac besides the critical illness rider and accidental death and accident total disability rider for Rs.1.00 each. The critical illness rider also included the risk benefit from heart attack. It is alleged that the respondent suffered a heart attack in January 2009 and angiography was done on 05.01.2009 which confirmed 95 % & 50% blockage in Left Axis Deviation (LAD) and Left Circumflex Artery (LCX). Thus, on the advice of the doctors, the respondent underwent coronary angioplasty on 09.01.2009. He spent a sum of Rs.3.00 lac on the treatment. The respondent filed the claim for Rs.1.00 lac under critical illness clause of the insurance policy. The claim was repudiated by the petitioner on the ground that angioplasty and / or any other intra-arterial procedures were excluded from the insurance cover. Claiming the repudiation to be deficient in service, the petitioner approached the District Forum.

3. The petitioner in its written reply claimed that there was no deficiency in service and insurance claim of the respondent / complainant was rightly repudiated.

4. The District Forum on consideration of evidence took the view that angioplasty treatment taken by the respondent / complainant was covered under the critical illness clause of the insurance policy. As such, holding the petitioner to be deficient in service, allowed the complaint and passed the above noted order.

5. Being aggrieved of the order of the District Forum, the petitioner preferred an appeal before the State Commission Chandigarh. The State Commission concurred with the order of the District Forum and dismissed the appeal with the following observations:

“We have considered this submission also, but we are not in agreement with the argument of the learned counsel for the appellant, because critical illness rider was obtained by the respondent vide proposal Ex.C-5 and at the time of accepting the proposal, no such condition was mentioned in the proposal and the District Forum has rightly observed that the critical illness of heart attack and other diseases are covered and not the procedure. The procedure to be adopted to cure a particular disease is the judgment of the doctor and not of the patient or the assured. The Coronary Artery Bypass Surgery is also one of the methods to remove the blockage and Angioplasty is also one of the methods to remove the blockage by introducing the stent. A prudent man will not understand the medical procedures to be followed by the doctor at the time of taking the policy, but the policy is taken to cover critical illness which as per the policy, included kidney problems, cancer etc., including the h