Life Insurance Corporation Of India vs Anita Loona

This revision petition has been filed by the petitioner Life Insurance Corporation of India against the order dated 20.03.2017 of the State Consumer Disputes Redressal Commission, Punjab, (in short 'the State Commission') passed in Appeal No.74 of 2013.

Brief facts of the case are that the respondent/complainant had taken Ashadeep policy on 28.04.1998 which was valid from 28.04.1998 to 28.04.2018. The complainant submitted a claim stating that in July, 2011 she underwent cancer treatment at Medanta, the Medicity Hospital, Gurgaon. The claim was repudiated on 19.12.2011 on the ground that this cancer was localised and non-invasive and the same was not covered under the policy. Aggrieved with the repudiation letter, the complainant filed a consumer complaint No.360 of 2012 before the District Consumer Disputes Redressal Forum, Ferozepur, (in short 'the District Forum'), which partly allowed the complaint as under:-

"6. In view of the above discussion, this complaint is accepted with Rs.5000/- as compensation and Rs.2000/- as litigation expenses and the opposite parties are directed to pay Rs.50,000/- i.e. 50% of the sum assured of Rs.1,00,000/- along with interest at the rate of 9% per annum from the date of repudiation of the claim till realization. However, the opposite parties will be bound to provide the remaining benefits under the policy to the complainant as per policy schedule. This order is directed to be complied with within a period of thirty days from the date of receipt of a copy of this order. File be consigned to the record room."

Aggrieved by the order of the District Forum, the opposite parties preferred an appeal bearing No.74 of 2013 before the State Commission, which was dismissed by the order dated 20.03.2017 of the State Commission and the order of the District Forum was upheld.

Hence the present revision petition.

Heard the learned counsel for the petitioner at the admission stage and perused the record. Learned counsel argued that though cancer of all types are covered, however, there is an exclusion that the localized and non-invasive cancer is not covered. In the claim form submitted by the complainant, it has been clearly stated by the concerned doctor that the nature of the cancer was localized and non-invasive cancer. Hence, it is a clear case of exclusion and both the fora below have erred in allowing the claim of the complainant. As per the condition 11 (b), Benefit (b) of the policy schedule shall be available on the occurrence of any of the following contingencies:

(i) the life assured undergoes open Heart By-Pass surgery performed on significantly narrowed/occluded coronary arteries to restore adequate blood supply to heart and the surgery must have been proven to be necessary by means of coronary angiography. All other operations (e.g. angioplasty and Thrombolysis by coronary Artery CA theterization) are specifically excluded.

OR

(II) The Life Assured undergoes Renal Dialysis as a result of an end stage Renal Failure presented as chronic irreversible failure of both kidneys to function.

OR

(iii) the Life Assured suffers from Cancer (Malignant) (That is, the presence of uncontrolled growth and spread of cancer cells which destroy the tissues in which they arise with a potential for invading adjacent structures and capable of spreading to distant organs). This includes leukaermia, Hodgkin's Disease and invasive malignant melanoma of skin but excludes Carcinoma in situtumours associated with HIV infections, non-invasive localized cancers and all other skin cancers."

Thus, the case of the complainant is factually covered under the exclusion clause given in clause 11(b)(iii). In support of his argument, learned counsel for the petitioner referred to judgment of this Commission in RP No.167 of 2016, Life Insurance Corporation of India & Anr. Vs. Madan Gopal, decided on 18.03.2016 (NC), wherein this Commission has held that the consumer forum cannot go behind the terms of the contract of insurance policy. Similarly, the learned counsel further referred to the judgement of Hon'ble Supreme Court in United India Insurance Co. Limited Vs. Harchand Rai Chandan Lal, 2004 AIR (SC) 4794, wherein the Hon'ble Apex Court held as under:-

"6. ....The terms of the policy have to be construed as it is and we cannot add or subtract something: Howsoever liberally we may construe the policy but we cannot take liberalism to the extent of substituting the words which are not intended.

...It is settled law that terms of the policy shall govern the contract between the parties, they have to abide by the definition given therein and all those expressions appearing in the policy should be interpreted with reference to the terms of policy and not with reference to the definition given in other laws. It is a matter of contract and in terms of the contract the relation of the parties shall abide and it is presumed that when the parties have entered into a contract of insurance with their eyes wide open, they cannot rely on definition given in other enactment.

Therefore, it is settled law that the terms of the contract has to be strictly read and natural meaning be given to it. No outside aid should be sought unless the meaning is ambiguous."

I have given a thoughtful consideration to the arguments of the learned counsel for the petitioner and have examined the material on record. Both the fora below have allowed the claim of the respondent/complainant. As both the fora below have given concurrent finding of fact and have not found the cancer in the present case as covered under the exclusion clause of the policy, the scope under the revision petition becomes very limited as held by the Hon'ble Supreme Court in Lourdes Society Snehanjali Girls Hostel and Ors. Vs. H&R Johnson (India) Ltd. and others, (2016) 8 Supreme Court Cases 286, wherein, the Hon'ble Supreme Court has held the following:

"23. The National Commission has to exercise the jurisdiction vested in it only if the State Commission or the District Forum has either failed to exercise their jurisdiction or exercised when the same was not vested in them or exceeded their jurisdiction by acting illegally or with material irregularity. In the instant case, the National Commission has certainly exceeded its jurisdiction by setting aside the concurrent finding of fact recorded in the order passed by the State Commission which is based upon valid and cogent reasons."

Relying on the above judgment of the Hon'ble Supreme Court, the facts cannot be reassessed by this Commission against the concurrent finding of fact given by the fora below. Moreover, it is seen that the policy was taken in the year 1998 and the claim was preferred only in the year 2012 when the complainant suffered from the cancer and the same was treated. As per clause 11 (b)(iii). Cancer is covered as contingency for the benefit (b) of the policy. However, there is some exclusion mentioned in the clause itself. Exclusion of non-invasive and localised cancer is not mentioned in the general exclusion clause and it has been inserted in the column where the cancer has been allowed as a contingency. For a common man, who takes the policy, it is very difficult to first of all imagine that exclusion may be embedded in the list of inclusions and that out of several types of cancer, one or two types would not be allowed. The claim form has been so designed that a specific answer is to be given whether the cancer is localised and non-invasive. Localised or non-invasive is only an artificial division of different types of cancers but all types of cancer are dangerous and life threatening. Moreover, a report filed by a U.S. National Cancer Institute Staff published on August 26, 2015 reads as under:-

"A new study suggests that women who are diagnosed with abnormal cells in the lining of a breast duct- a noninvasive condition called ductal carcinoma in situ, or DCIS- generally have a low risk of dying from breast cancer. In addition, treating these lesions may help prevent a recurrence in the breast but does not appear to decrease the already-low risk of dying from the disease, even after 20 years of follow-up.

The findings from an observational study involving more than 100,000 women, were published August 20 in JAMA Oncology. Stevan A. Narod, M.D., of the Women's College Hospital, Toronto, and his colleagues used data from NCI's Surveillance, Epidemiology and End Results (SEER) program to estimate the death rate from breast cancer among women diagnosed with DCIS.

DCIS refers to abnormal cells in the breast duct that form characteristic patterns detectable on mammography. In some case, DCIS may become invasive cancer and spread to other tissues. At this time, because of concerns that a small proportion of the lesions could become invasive, nearly all women diagnosed with DCIS currently receive some form of treatment."

From the above report, it is brought out that latest study show that even some of the non-invasive cancers can become invasive and therefore, distinction drawn in the policy becomes blurred. Thus, the exclusion of localised and non-invasive cancer cannot remain exclusion because this type of cancer can also become invasive, which will be included as a cancer allowed under the policy.

The report of Oncologist in the claim form, though states that cancer is localised and non-invasive, but in the last column it also suggests "regular follow up". If the caner was totally localised and non-invasive, the regular follow up may not be required. As no time limit is mentioned for this follow up, so it is perhaps not for treatment of the wound. Therefore, this seems to be the advice of follow-up for the main disease of cancer, obviously to watch for its spread to other nearby tissues or its recurrence. Therefore, the report itself seems to be contradicting the finding of localised and non-invasive cancer. It is true that the Hon'ble Supreme Court in United India Insurance Co. Limited Vs. Harchand Rai Chandan Lal (supra) has ruled that terms of the policy are to be interpreted in its natural meaning, and no outside help should be sought unless the meaning is ambiguous. In the present case, it is seen that words localised and non-invasive have not been defined in the policy. So outside interpretations are needed. First of all, the Oncologist report in the claim form is self-contradictory in itself as seen above and then the recent study shows that a non-invasive cancer can sometimes develop into an invasive cancer leading one to conclude that the case of the complainant may not be truly localised and non-invasive and consequently not covered under the exclusion.

Based on the above discussion, I find no illegality, material irregularity or jurisdictional error in the order dated 20.03.2017 of the State Commission which calls for any interference from this Commission in the facts and circumstances of the case. Accordingly, the revision petition No.2720 of 2017 is dismissed at the admission stage.