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2023 Supreme(Online)(Del) 18182
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION, NEW DELHI
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Tata Aig Life Insurance Co. Ltd. v. Kuldeep Kumar
Revision Petition | First Appeal No. 916 of 2015 | Consumer Complaint No. 190/2010
For the Appellants/Petitioners: [List of names]
For the Respondents: [List of names]
Insurance claims must strictly adhere to policy definitions, preventing claims for conditions not explicitly covered.
Headnote:(A) Consumer Protection Act, 1986 - Revision against State Commission - Insurance policy terms - Claim for Pulmonary Embolism - Distinction between critical illness and general ailments - State Commission misinterpreted policy terms related to stroke and pulmonary embolism, leading to incorrect allowance of complaint - Actual illness not covered under policy despite similar nomenclature in the terminology used. (Paras 4, 5, 16, 20)
(B) Insurance Policy - Terms of cover must be strictly interpreted - Insurers bound only to cover conditions specifically listed in policy - Examination of critical illnesses cannot disregard explicit exclusions within the contract, emphasizing the principle of strict adherence to contract terms. (Paras 10, 13, 19)
Facts of the case:
The Complainant applied for a policy to cover critical illnesses including pulmonary embolism, yet the claim was denied by TATA AIG on the basis that it wasn't covered under their definitions of critical illness. The State Commission initially overturned the lower court's dismissal of the claim.
Findings of Court:
The court found that the critical illness policy did not cover pulmonary embolism, thereby validating the insurance company's repudiation.
Issues: The court considered whether pulmonary embolism qualifies as a critical illness under the terms of the insurance policy in question, as understood within the scope of existing medical definitions and exclusions.
Ratio Decidendi: The court ruled that the specific language and definitions within the insurance policy must always be adhered to strictly, and that the terms cannot be extended or interpreted in a manner inconsistent with their explicit definitions.
Result: The Revision Petition was allowed, setting aside the order passed by the State Commission and restoring the District Forum's decision.
| Table of Content |
|---|
| 1. introduction of the revision petition. (Para 1 , 2) |
| 2. details of the complaint and initial dismissals. (Para 3 , 4 , 5) |
| 3. arguments by the petitioners and distinction of conditions. (Para 6 , 7) |
| 4. court's examination of evidence and definitions of critical illness. (Para 8 , 9 , 10) |
| 5. legal principles guiding insurance interpretation. (Para 11 , 12 , 13) |
| 6. final decision and court's rationale. (Para 16 , 18 , 19) |
1. This Revision Petition has been filed by the Petitioner No. 1 / Opposite Party No. 1 and Petitioner No. 2 / Opposite Party No. 2 against Respondent / Complainant challenging the impugned order dated 10.3.2017 passed by the State Consumer Disputes Redressal Commission, Haryana Panchkula in First Appeal No. 916 of 2015. Vide such Order, the State Commission had allowed the Appeal while setting aside the order dated 5.3.2015 passed by the District Consumer Disputes Redressal Forum, Hisar in Consumer Complaint No. 190/2010.
2. The brief facts of the case are that the Complainant is a policy holder of TATA AIG Insurance Company Ltd. It was submitted by the Complainant that he had applied for an Insurance Plan named "Invest Assure Gold" of Rs.15,00,000 for 5 years with premium fixed at Rs.50,000 which was to be paid semi - annually. It was further submitted that the Complainant had also taken a rider on this plan named "Critical Illness Rider" of Rs.5,00,000. It was also submitted that the Complainant was regularly paying premium of Rs.50,400 (approximately) for the afore stated policy which bore No. 001810865 and was dated 31.7.2008. It was further averred that the Complainant fell ill and was admitted in Sukhda Hospital, Hisar on 28.9.2009 and was subsequently, discharged on 4.10.2009. However, the Complainant had not recovered from his illness and hence, he got himself checked by various hospitals. It was further submitted that the Complainant was informed that he had been suffering from "Pulmonary Embolism" which is a critical illness, and the doctors gave the finding that the Complainant is highly probable for Pulmonary Thro - embolism. It was also submitted that the Complainant subsequently filed a claim and produced all the relevant documents to the TATA AIG Company Ltd. However, the claim was repudiated vide letter dated 21.1.2010 on the ground that "Pulmonary Embolism" is not a qualifying condition under the policy. Hence, the Complaint was filed by the Complainant before the District Forum seeking lumpsum amount of Rs.5,00,000 with interest @18% per annum, Rs.50,000 for harassment and Rs.5,500 as litigation expenses.
3. The Opposite Parties appeared before the District Forum and resisted the Complaint and denied all the allegations thereby denying deficiency in service on their part. It was contended by the Opposite Parties that Pulmonary Embolism is not "critical illness" as per the terms and conditions of the insurance policy. It was further contended that the symptoms of the said disease had started appearing even 2-3 months prior to July, 2009 and the case of the Complainant falls in exclusive clause of the insurance policy. Hence, the Opposite Parties prayed for dismissal of the complaint with costs.
4. The learned District Forum vide its order dated 5.3.2015 dismissed the complaint and held that the repudiation of the claim by the Opposite Parties cannot be said as unjustified or deficiency of service.
5. Aggrieved by the above order, First Appeal bearing No. 916 of 2015 was filed by Appellant / Complainant before the State Consumer Disputes Redressal Commission, Haryana Panchkula.
6. The learned State Commission vide its impugned Order dated 10.3.2017 allowed the Appeal while setting aside the order of the District Forum.
7. Hence, the present Revision Petition has been filed by the Petitioners / Opposite Parties against the above mentioned impugned order of the learned State Commission. It has been submitted by the Opposite Parties that the Complainant applied for the policy on 31.7.2008 whi
