ORDER
B.K. Taimni, Member
1. Heard learned Counsel for the petitioners.
2. Learned Counsel for the petitioners submits that firstly the Life Insurance Corporation of India is not liable to pay any amount in terms of the policy; secondly in view of the medical certificate it is established that there was suppression of material facts and thirdly the entire amount could not have been paid in terms of the policy.
3. It will be useful to refer the Clause 11(b)(i) of the policy, which reads as under:
“(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 proved to be necessary by means of coronary angiography. All other operations (e.g., Angioplasty and Thrombolysis by coronary artery catheerization) are specifically excluded.”
4. Learned Counsel for the petitioner placed reliance on medical opinion of Dr. Pradeep Mathur. The question is whether the operation in question was open, heart by-pass surgery performed on significantly narrowed/occluded coronary arteries to restore adequate blood supply to heart. The clause as mentioned herein above supports the case of the complainant respondent. Mr. Mangat Ram Chawla was operated at Indraprastha Apollo Hospital on 27.3.2002 for severe aortic regurgitation secondary to bicuspid aortic valve. He had symptoms of breathlessness on exertion and occasional palpitation for 5-10 days. However he also mentioned in the certificate/opinion that “Bicuspid aortic valve is a congenital abnormality of heart present right from birth”. Surgery is an open heart surgery and requires valve replacement of original aortic valve by prosthetic valve 270N-X. This surgery does not involve bypassing of coronary arteries and hence it is different from coronary bypass surgery. Dr. Pradeep Kumar has not filed any affidavit. He had not treated the patient in Appollo Hospital as per discharge summary. He was not made available for cross-examination. For these reasons, we cannot act upon his opinion.
5. No doubt, it is also mentioned that this surgery did not involve bypassing of coronary arteries, yet it was an open heart surgery but it would not make difference in view of the main purpose rule of interpretation. In case, main purpose rule of interpretation of policies like the present one is applied, the policy would cover the risk. Consequently we are not inclined to accept this contention.
However, there is lot of force in the submission of learned Counsel insofar as the second submission is concerned. For the Benefit ‘B’ under the policy is to be given in terms of following conditions.
6. Benefit (B)-If any one of, the contingencies given in para 11(b), subject however to the conditions mentioned in paras 11(a) and 11(c) of the “Conditions and Privileges” when referred to occurs during the term of the policy then the following benefits will be available:
(i) Immediate payment of 50% of the sum assured.
(ii) Payment of balance 50% of the sum assured along with vested bonus, if any, in the event of the life assured surviving the stipulated date of maturity or at his death, whichever is earlier.
(iii) 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.
(iv) Waiver of premiums, if any, (including accident premium) due from the policy anniversary falling on or immediately after the date of eligibility for Benefit (B).
7. The policy was taken on 28.11.1993 for a period of 20 years and, therefore, out of total amount, which was payable to the complainant, only 50% of the amount could have been given and insofar as rest 50% of the amount, it may be paid at the maturity of the policy itself or at his death, whichever is earlier.
It is not a case of death of the life assured. Consequently insofar as 50% of the amount is concerned, the complainant respondent is not entitled at this stage and if he is hot entitled to recover the amount, the question of interest on 50% of the amount of policy would not arise.
8. In view of the above foregoing reasons, 50% of the amount is required to be paid to the complainant.
9. As regards interest learned Counsel submits that interest had been awarded by the District Forum @ 15%, which has been confirmed by the State Commission. We find some force in this revision petition. Accordingly we reduce the interest from 15% to 12%.
10. Next submission of the learned Counsel for the petitioner is that compensation of Rs. 9,000/- has been awarded and he submits that compensation of Rs. 9,000/- was unreasonable and should not have been awarded. We think that in the circumstances when interest @ 12% has been awarded, the complainant should not have been awarded compensation of Rs. 9,000/-. Accordingly, the petitioner is directed to pay Rs. 25,000/- and interest @ 12% and cost of Rs. 1,500/- as awarded by the State Commission. Rest of the amount shall be paid at the time of maturity. Amount of Rs. 25,000/- with interest @ 12% has already been deposited. It is submitted that Rs. 74,823/- has already been deposited. The respondent may withdraw Rs. 25,000/- with 12% interest from the date of operation till payment along with cost of Rs. 1,500/-. Rest of the amount shall be paid back to the petitioner for it is said that he has deposited the entire amount of Rs. 74,823/- in terms of the order of the District Forum.
The revision petition is disposed of accordingly.