NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION, NEW DELHI
AVM J. Rajendra, AVSM VSM (Retd.),
Presiding Member
Zonal Manager, Life Insurance
Corporation of India and Anr. – Petitioners
versus
Sunil Kumar and Anr. – Respondents
Revision Petition No.1838 of 2019
(Against the Order dated 03/05/2019 in Appeal No. 397/2018 of the State Commission Uttar Pradesh)
Decided on 7.5.2024
Consumer Protection Act, 1986 – Section 21(b) [Consumer Protection Act, 2019 – Section 58(1)(b)] “Revision – Services – Insurance – Repudiation of claim – Para 10(a)(ii) of the terms and conditions reveal that the maximum aggregate limit of assurance under all policies taken under the plan on the same life to which benefits under Disability for Life Assured shall not in any event exceed Rs.5,00,000/- – Thus, the only policy that has been taken by the Complainant is for maximum of Rs.2,00,000/- as assured limit. He has no other declared policy. The maximum limit of Rs.5,00,000/- is with respect to situations where the beneficiary has multiple policies for the same life assured and in those circumstances, as per the policy terms, the sum payable under Disability for the Life Assured shall not in any event exceed Rs.5,00,000/-” Therefore, as the Complainant had held only one policy the maximum sum assured payable is Rs.2,00,000/-. Thus, the order of the District Forum and State Commission adding Rs.2,00,000/- as the maximum sum assured and further 5,00,000/- at accidental benefit is beyond the scope of terms and conditions of the insurance. Incidentally, even in the complaint dated 31.10.2017, the Complainant had not brought out as under which provision of the terms and conditions of the insurance policy, he was entitled for benefit of Rs.5,00,000/- other than merely stating as accidental benefit claim – Petition allowed in part. [Paras 10 to 17].
Result: Petition allowed in part.
ORDER
This Revision Petition No.1838 of 2019 challenges the impugned order of the learned UP State Consumer Disputes Redressal Commission, Lucknow (‘the State Commission’) dated 03.05.2019. Vide this order, the State Commission had dismissed Appeal No.397 of 2018 and affirmed the order of the District Consumer Disputes Redressal Forum, Auraiya (‘the District Forum’) dated 24.01.2018.
2. As per office report, there is one day delay in filing of the present Revision Petition and the same is condoned.
3. Brief facts of the case, as per the
Complainant, are that he purchased LIC
Jivan Anand With Profits (With Accident
Benefit) policy from Petitioners-LIC No.265127388 dated 28.05.2010 with sum assured of Rs.2,00,000/-. The date of policy maturity was 28.11.2030. He paid the first
half yearly premium of Rs.5,112/- to Opposite Parties (OPs) on 19.06.2010. At the time of purchase of the insurance policy, he was
medically examined and all requisite forms were duly got filled up from him by the OPs.
On being found medically fit, OPs issued the said policy. On 21.06.2010, the Complainant had met with an accident and he suffered 100% permanent disability. The FIR was also filed. He filed claim for sum assured with the OPs. However, the claim was repudiated on the ground of suppression of pre-existing disease.
4. In reply before the District Forum, OP-1 & 2 contended that the complainant suppressed the pre-existing disease while filling proposal form, which is violation of the terms and conditions of the Policy in question. Therefore, the OP1 and 2 was justified in repudiating the claim of the complainant. He sought to dismiss the complaint.
5. The learned District Forum vide order dated 24.01.2008, allowed the complaint and directed the Petitioners/OPs No.1&2 as under:
“Order
The complaint case for the recovery of Rs.7,02,000/- against opposite party No.1 and 2 is allowed. The opposite party shall also be liable to make the payment of interest @ 7% per annum on this amount from the date of institution of complaint case and till the exact date of realization of amount. The Opposite Party No.1 and 2 is hereby directed that in view of the above they may make the payment within the period of one month from the date of decision.” (Extracted from translated copy)
6. Being aggrieved by the impugned order, the Petitioners filed an Appeal before the State Commission. The learned State Commission, vide order dated 24.01.2018 directed as follows:
“I had considered the contentions/arguments of both the parties.
In accordance to medical report dated 19.07.2017 of D.M.R. Dr. Rajeev Mangal M.D. prior to 18.06.2010 the date of submission of proposal for obtaining insurance policy the respondent/complainant was suffering with spinal bone disease. The report of D.M.R. dated 13.03.2010 is based on the documents prepared in free camp of Life Line Neuro spine clinic. The name of patient as Sunil Kumar is mentioned in this document and the disease of spinal bone is mentioned therein, but this document did not bears signature or thumb impression or sign of identification of respondent/complainant and for considering this fact there is no proper ground that this document is concerning to respondent/complainant and was prepared in the Free Camp. The address of respondent/ complainant is also not mentioned on this document. Alongwith this it is pertinent to mention that by producing affidavit by the scriber of this document (doctor) it has not been proved that this document is concerning to respondent/complainant Sunil Kumar. Therefore on the ground of this document it cannot be said that prior to filling of proposal form of insurance policy in question the respondent/complainant was suffering from spinal cord. In addition to this document, any evidence in regard to disease of respondent/ complainant could not be produced by appellant/opposite parties. The onus to prove this fact is on appellant/opposite parties that prior to filling of proposal form of
United India Insurance Co. Ltd. vs. Harchand Rai Chandan Lal
Suraj Mal Ram Niwas Oil Mills Pvt. Ltd. vs. United India Insurance Co. Ltd.
Even if there is ambiguity, Consumer Protection Act being a beneficial legislation, it must be interpreted in favour of consumer.
There should be nexus with pre-existing disease & disease for which claim has been made.
Insurance Policy – Ambiguity in coverage clauses of disease – Repudiation of claim not justified.
Insurance Policy must be read holistically so as to give effect to reasonable expectations of all parties including insured & beneficiaries.
Insurance claims must strictly adhere to policy terms; no liberal interpretations allowed.
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