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NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION, NEW DELHI
Dr. Inder Jit Singh, Presiding Member
National Insurance Co. Ltd. and Anr. – Petitioners
versus
Reena Sharda and Anr. – Respondents
Revision Petition No.1197 of 2018
(Against the Order dated 22/12/2017 in Appeal No. 147/2016 of the State Commission Rajasthan)
Decided on 2.7.2024
Consumer Protection Act, 1986 – Section 21(b) [Consumer Protection Act, 2019 – Section 58(1)(b)] – Revision – Services – Insurance – Repudiation of Claim – Petitioner/Insurance Company placed a wrong document before the District Forum and this Commission. Such an action is not expected from a public sector Insurance Company like the Petitioner herein – Commission directed, direct the Managing Director of Petitioner/Insurance Company (National Insurance Co. Ltd.) to enquire as to under what circumstances a wrong document was filed before the Consumer Commissions at various levels and how two different versions of document for the same scheme are in circulation and take appropriate action against the officials responsible for the same. Registrar, NCDRC will send a copy of this order to the Managing Director of the National Insurance Company at their Head Office address – There is no illegality or material irregularity or jurisdictional error in the order of the State Commission, hence the same is upheld. Accordingly, Revision Petition is dismissed with cost. [Paras 10 to 13]
Result: Petition dismissed.
ORDER
The present Revision Petition (RP) has been filed by the Petitioners against Respondents as detailed above, under section 21(b) of Consumer Protection Act, 1986, against the order dated 22.12.2017 of the State Consumer Disputes Redressal Commission, Rajasthan (hereinafter referred to as the ‘State Commission’), in First Appeal (FA) No. 147/2016 in which order dated 08.07.2016 of District Consumer Disputes Redressal Forum, Jodhpur (hereinafter referred to as District Forum) in Consumer Complaint (CC) No. 512/2015 was challenged, inter alia praying for setting aside the order passed by the State Commission and restoring the order passed by the District Forum.
2. While the Revision Petitioners (hereinafter also referred to as OP/Insurance Company) were Respondents before the State Commission and Opposite Parties before the District Forum and the Respondents (hereinafter also referred to as Complainants) were Appellants before the State Commission in FA/147/2016 and Complainants before the District Forum in Complaint No. 512/2015.
3. Notice was issued to the Respondents on 22.06.2018. Parties filed Written Arguments on 26.06.2020 (Petitioner) and 10.02.2020 and 10.10.2023 (Respondents) respectively.
4. Brief facts of the case, as emerged from the RP, Order of the State Commission, Order of the District Forum and other case records are that: -
Respondent No.1 (daughter-in-law of Respondent-2) had purchased a medi-claim insurance Policy for the period dated 09.04.2014 to 08.04.2014 for a sum of Rs.1.00 lakh by paying a premium of Rs.7647/- in which insurance coverage of Rs.2.00 Lakhs was given separately for critical diseases. On 05.06.2014, Respondent-2 complained of sweating and discomfort and was referred to Dr. Pawan Sharda of ADM Hospital, who advised ECG be conducted. Subsequently, Respondent-2 was admitted to the Hospital on 06.06.2014, where angiography was conducted and due to blockage, he was advised angioplasty surgery. On 13.06.2014, Respondent-2 was discharged from the Hospital. Respondent-1 filed claim of Rs.5,650/- and a second claim was placed when the angioplasty failed and a demand was made to bring ROTA machine so that there may be ease in fixing a stent. The Respodnent-2 was again admitted in the Hospital on 23.06.2014 and was discharged on 02.07.2014. During this period, angioplasty was again performed and stent was placed. Respondent-1 placed a total claim of Rs.3,26,014/- with the Petitioners. After due consideration of the claim, the Petitioner company passed the claim to an amount of Rs.45,508/-. The remaining claim of the Respondent was denied on the ground of non-coverage in terms of the policy. Insurance Policy was subsequently renewed on 08.04.2015 by the Respondents by paying a premium of Rs.6952/- for further period from 09.04.2015 to 08.04.2016. Hence, the complainant filed complaint before the District Forum.
5. Vide Order dated 08.07.2016, in Complaint No.512/2015, the District Forum dismissed the complaint. Aggrieved by the said Order dated 08.07.2016 of District Forum, Complainants / Respondents herein appealed in State Commission and the State Commission vide order dated 22.12.2017 in FA No.147/2016 allowed the appeal and set aside the order passed by the District Forum.
6. Petitioners have challenged the said Order dated 22.121.2017 of the State Commission mainly on following grounds:—
i. The State Commission while passing the impugned order failed to exercise the jurisdiction vested in it by law and in exercise of the same acted illegally and with material irregularity. The medical expenses, which were reimbursable as per the policy coverage, were paid to the Respondents. As angioplasty expenses were not covered under the critical illness section, the same were not paid.
ii. The terms and conditions of an insurance policy are sacrosanct and it governs the rights and obligations of the parties to the contract of insurance. The Hon’ble Apex Court in Deokar Exports (P) Ltd. v. New India
Wrong Document – Petitioner/Insurance Company placed a wrong document before the District Forum and this Commission. Such an action is not expected from a public sector Insurance Company like the Pet....
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 policy terms must be strictly construed to avoid adversely affecting the parties' interests.
Contract of insurance – Since the policy was held/renewed for 5 years, the plea of non-supply of terms and conditions is not tenable; the insured should have agitated this earlier.
There should be nexus with pre-existing disease & disease for which claim has been made.
(1) Insurance – A contract of insurance is one of utmost good faith. (2) Proposer – Proposer who seeks to obtain a policy of life insurance is duty bound to disclose all material facts bearing upon t....
Once there is a valid insurance policy available in favour of appellant, claim made by him for reimbursement of expenses incurred is justifiable and deserves to be paid to him.
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