Life Insurance Corporation Of India vs Saroj Bala

The present revision petition has been filed against the order dated 1.8.2018 in first appeal No303/2018 of the petitioner i.e. the Insurance Company (hereinafter called as "Insurance Company) against the order dated 15.1.2018 of the District Forum in Complaint No.264/2016 whereby the complaint of the respondent (hereinafter called as "the complainant"), was allowed and following directions were issued: -

"10. The complainant has placed on the file copies of the bills Ex.C4 to Ex. C10 amounting to Rs.2,33,965/-. On the other hand, the OP has not produced any evidence that these bills are not correct. Hence the complainant is entitled for the amount of these bills. No doubt these bills are the Photostat copies of the original bills but the complainant stated that the original bills were given to the OP at the time of argument.

As a sequel to the foregoing discussion, we accept the present complaint and direct the OP to pay Rs.2,33,965/- to the complainant spent on her treatment. No order as to costs. This order shall be complied with within 30 days from the receipt of copy of this order failing which the complainant shall be entitled interest @ 8% per annum from the date of order till its realization. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance."

Brief facts of the case are that the complainant had purchased an insurance policy, namely, Jeewan Arogya Policy, which was valid for the period 12.12.2015 to 12.12.2054. On 16.4.2016 she slipped and fell down and sustained serious injuries on her right hip joint. She was admitted in the hospital and undergone treatment. She filed a claim for refund of the treatment amount. However, her claim was repudiated on the ground that the claim had since been filed within the specific waiting period of two years and two years had not yet since expired from the date of issuance of the policy, the claimant was not entitled for refund. Parties led their evidences before the District Forum and the District Forum after perusing the evidence on record reached to the conclusion that the admission of the complainant in the hospital was on account of accidental injuries sustained by her and held that repudiation of the claim was unjustified on the ground that her case was not covered under clause 6 of the policy which bars the claim submitted within a period of two years from the date of issuance of the policy.

This order was impugned by the Insurance Company before the State Commission and the similar plea was taken. Both the contentions of the Insurance Company were dismissed.

The impugned order is challenged before us by the Insurance Company on the same grounds that the admission of the complainant in the hospital was not accidental.

We have heard the arguments and perused the relevant record. Hon'ble Supreme Court in the case of in Mrs. Rubi (Chandra) Dutta Vs. M/s United India Insurance Co. Ltd . 2011 (3) Scale 654 has clearly held that this Commission cannot re-appreciate or reassess the evidences and reach to a different conclusion. It is only required to see whether there is any miscarriage of justice done or whether the findings are illegal or perverse. There is concurrent finding of facts based on the evidences on record as mentioned above. Thus, in view of this, the Hon'ble Supreme Court has held as under: -

"Also, it is to be noted that the revisional powers of the National Commission are derived from Section 21 (b) of the Act, under which the said power can be exercised only if there is some prima facie jurisdictional error appearing in the impugned order, and only then, may the same be set aside. In our considered opinion there was no jurisdictional error or miscarriage of justice, which could have warranted the National Commission to have taken a different view than what was taken by the two Forums. The decision of the National Commission rests not on the basis of some legal principle that was ignored by the Courts below, but on a different (and in our opinion, an erroneous) interpretation of the same set of facts. This is not the manner in which revisional powers should be invoked. In this view of the matter, we are of the considered opinion that the jurisdiction conferred on the National Commission under Section 21 (b) of the Act has been transgressed. It was not a case where such a view could have been taken by setting aside the concurrent findings of two fora."

We have two concurrent findings of the fact. First that the admission of the complainant in the hospital and the treatment taken by her was on account of the accidental injuries which she had received and secondly that such a satiation is not covered under clause 6 of the terms and conditions of the policy.

The Fora below have concurred that the admission of the complainant in the hospital was due to accidental injury. Learned counsel for the petitioner has brought to our notice clause 6. She mentions the title "waiting period" under clause 6. However, there is another clause under clause 6 which relates to the general waiting period and this clause reads as under: - benefit shall be payable in the event of hospitalization or surgery, if the said hospitalization or surgery occurs due to sickness.

In terms of clause 6 itself there is no general waiting period where hospitalization is due to accidental bodily injury. The present revision petition, therefore, has no merit and the same is dismissed.

Learned counsel for the respondent/complainant submits that pursuant to direction of this Commission at the time when operation of the impugned order was stayed, the Insurance Company had deposited 50% of the decretal amount with the District Forum which is lying with them and it is prayed that the said amount alongwith interest, if any, accrued on it shall be ordered to be released to the complainant. Not opposed. The said amount shall be released to the complainant/respondent. For the balance amount the complainant can file execution.