Page 35 - Suri’s - NCDRC ON LIFE INSURANCE 2017 V1.3

Suri’s - NCDRC ON LIFE INSURANCE 2017 35

tioner a sum of Rs.2,50,000/- as insurance claim alongwith 6% interest thereon from
the date of repudiation of the claim, besides the compensation of Rs.15,000/- awarded
on account of mental agony and Rs.5,000/- as litigation cost.
5. The respondent insurance company being aggrieved of the order of the Dis-
trict Forum approached the State Commission, Punjab in appeal. The State Commis-
sion, Punjab on re-appreciation of evidence particularly the interpretation of the criti-
cal benefit clause in the insurance policy, came to the conclusion that Angioplasty
was not covered as an additional benefit under the critical illness benefit. The State
Commission accordingly allowed the appeal, set aside the order of the District Forum
and dismissed the complaint.
6. Learned counsel for the petitioner has contended that the impugned order of
the State Commission is not sustainable because it is based upon misleading of the
terms & conditions of the policy relating to critical illness benefit. Learned counsel
for the respondent/opposite party on the contrary has argued in support of the im-
pugned order.
7. I have considered the rival contentions. On perusal of the copy of the insur-
ance policy and its general terms and conditions, I find that the policy issued to the
petitioner essentially is a life insurance policy with additional benefits, namely, dis-
ability benefit and critical illness benefit. Clause (B) of the annexures to the general
terms and conditions detailing supplementary benefits provides as under: -
―Provided the policy in force for the full sum assured, the life assured is diag-
nosed to be suffering from a critical illness (as defined below) after six months
from the date of policy but before the policy anniversary on which he attains the
age of 65 years nearer birthday, or before the expiry of the period for which the
premiums are payable, whichever is earlier, the sum assured under the supplemen-
tary benefit shall fall to be paid together with guaranteed additions and bonuses
vested or such sum assured till then, subject to conditions set below:
………”

8. The term critical illness is defined in Note I A in the clause. The said note
reads as under: -
―Note 1: A ―Critical illness‖ shall mean anyone of the following illnesses as
defined separately hereunder occurring after 6 months from the date of policy:
Cancer: A malignant tumour characterized by uncontrolled growth and spread
of malignant cells and the invasion of tissues. The diagnosis must be histologically
confirmed. The term Cancer includes Leukemia but excludes the following
All tumours which are histologically described as pre-malignant, non-invasive
or carcinoma in situ;
All forms of lymphoma in presence of human immune-deficiency virus;
Kaposi‘s Sarcoma in the presence of any human immune-deficiency virus;
Any skin cancer other than invasive malignant melanoma; and
Early prostate cancer which is histologically described as T 1 (including T 1 a
and T 1b ) or another equivalent or lesser classification.
(b) Coronary Artery By-pass Graft Surgery (CABGS)- the undergoing of
open heart surgery on the advice of a consultant Cardiologist to correct narrowing

INDEX