LIFE INSURANCE CORPORATION OF INDIA vs Thota Srinivasa Babu

THE respondent/complainant took a policy called ''Ashadeep'' from the petitioner Corporation, for a sum of Rs.1 lac. The aforesaid policy also carried two benefits termed as Benefit A and Benefit B. One of the aforesaid benefits was to be made available to the insured if the policy was to remain in force for the full sum assured, subject to the condition mentioned therein. Either of the benefits was payable only once during the period of the policy. The aforesaid benefits read as under: Benefit (A) The sum assured with vested bonus, if any, is payable, in the event of the life assured surviving the stipulated date of maturity or at his death, if earlier. Benefit (B) If any one of the contingencies given in Para 11(b), subject however to the conditions mentioned in Para 11(a) and 11(c) of the "Conditions and Privileges" within referred to occurs during the term of the policy, then the following benefits will be available.

Immediate payment of 50% of the sum assured. Payment of balance 50% of the sum assured alongwith vested bonus, if any, in the event of the life assured surviving the stipulated date of maturity or at his death, if earlier. Payment of an amount equal to 10% of the sum assured, every year, commencing from the policy anniversary falling on or immediately after the date of eligibility for Benefit (B) and ending with the policy anniversary preceding the stipulated date of maturity or the date of death of the life assured, whichever is earlier.

Waiver of premiums, if any, (including accident premium) due from the policy anniversary falling on or immediately after the date of eligibility of Benefit (B).

BENEFIT A was obviously inapplicable in the case before us since the insured survived the term of the policy. As regards Benefit B, clause 11(b) of the terms and conditions attached to the policy read as under: (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 Cathelerization) are specifically excluded.

OR ii) the Life Assured undergoes Renal Dialysis or Renal Transplantation 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 Leukemia, Hodkin''s Disesase and invasive malignant melanoma of skin but excludes Carcinoma in situ, tumours associated with HIV infections, non -invasive localised cancers and all other skin cancers.

OR iv) the Life Assured suffers from Paralytic stroke, (that is, Cerebrovascular accident or incident producing neurological sequelae lasting more than 24 hours) resulting into complete and permanent disability of two or more limbs persisting for more than three months from the date of acute episode. Specifically excluded are Transient/Ischaemic Attacks and Stroke like syndromes resulting from Head Injury (subdural or extradural haematoma)

Cerebral abscess Pyogenic, tuberculosis, meningococcal meningitis Sub clause (i), (ii) and (iii) were admittedly inapplicable in the case before us. The only question which arises for our consideration in this case is to whether clause (iv) was application to the case of the complainant or not.

THE complainant, by way of a letter, informed the petitioner corporation as under: Dr. Thota Srinivasababu Policy Holder of Ashadeep 671132000 of your Branch have undergone Emergency Surgical Neck Operation Cervical Discectomy removal of intervertebral Disc on 24.09.2011 at Appolo Hospital, Hyderguda, Hyderabad by Dr. R.T.S. Naik, MBBS Mch Neuro Surgeon. Otherwise I would have landed in Quadriplegia i.e. Paralysis of both hands and legs. In this respect I request you to specially consider my condition and pay 50% (fifty percent) of sum assured under Paralysis Option Claim. A perusal of the documents issued by Apollo Hospital, Hyderabad would show that the complainant who was a known case of hypertension came to the hospital with the complaint of neck pain radiating to right upper limb persisting for one month. His problem was diagnosed with PIVD C4/C5 with cord compression. C4 -C5 Anterior Cervical Discectomy was then done under general Anaesthesia.

IT is, thus, evident that the complainant did not suffer any Paralytic Stroke though, but for the procedure undergone by him, he might have suffered Paralysis of both his hands and legs. Three conditions were required to be fulfilled before the complainant could claim Benefit B read with clause 11(b)(i) of the condition of policy (i) the insured should have suffered from Paralytic Stroke (i.e. Cerebrovascular accident or incident producing neurological sequelae lasting more than 24 hours) (ii) The aforesaid stroke should have resulted into complete and permanent disability of two or more limbs and (iii) the aforesaid complete and permanent disability should have persisted for more than three months from the date of acute episode.

IN the case before us, the complainant did not suffer from any Paralytic Stroke. Therefore, the first condition itself did not become applicable in this case. The second and third condition obviously also not have been applicable since he did not suffer disability of two or more limbs. What has to be kept in mind while considering such a complaint is that the policy taken by the complainant was not a mediclaim policy. In the aforesaid policy, only certain additional benefits were available to the insured, subject to the terms and conditions stipulated in the policy. In case the conditions stipulated in the policy were applicable, inter alia half of the sum insured was to be paid to the insured irrespective of whether any expenditure in the treatment was actually incurred by him on his treatment or not and in case any expenditure was incurred, the amount of the said expenditure would also be irrelevant for the purpose of payment of benefits in terms of the aforesaid policy. Therefore, unless the ailment from which the complainant suffered was specifically covered under the benefit clause read with the terms and conditions of the policy, no benefit under the policy was payable to him. A reference in this regard may be made to the decision of the Hon''ble Supreme Court in United India Insurance Co. Ltd. Vs. M/s. Harchand Rai Chandan Lal, 2004 AIR(SC) 4794 where the Hon''ble Supreme Court inter alia observed that the terms of the policy covering the contract between the parties, should 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 the policy and not with reference to the definition given in other laws. It was further observed that in terms of 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 upon any other enactment. A reference was made to an earlier decision in Oriental Insurance Co. Ltd. Vs. Sony Cherian, 1999 6 SCC 451 holding there in that the insurance policy represents a contract between the parties and the terms of the agreement have to be strictly construed to determine the liability of the insurer. It was further held that the insured cannot claim anything more than what is covered by the insurance policy. Reference was also made to another earlier decision in General Assurance Society Ltd. Vs. Chandumull Jain, 1966 3 SCR 500 where a Constitution Bench of the Hon''ble Supreme Court inter alia held that while interpreting a contract insurance, the duty of the court is to interpret the words in which the contract is expressed by the parties because it is not for the court to make a new contract, however, reasonable, if the parties have not made it themselves.

CONSIDERING the specific terms and conditions of the policy issued to the complainant, there is no escape from the conclusion that since the complainant did not actually suffer a Paralytic Stroke, he was not entitled to Benefit B of the policy taken by him. Consequently, the view taken by the forum below cannot be sustained. As a result, the impugned orders are set aside and the complaint is dismissed with no order as to cost.