1.      This Revision Petition No.650 of 2022 challenges the Punjab State Consumer Disputes Redressal Commission, Chandigarh (‘State Commission’) order dated 12.11.2021 vide which the State Commission dismissed FA No.670/2019 filed by the Petitioner/ Complainant and affirmed the District Consumer Disputes Redressal Forum, Jalandhar (‘District Forum’) order dated 18.09.2019 in C.C. No.137 of 2018 wherein the Complaint was dismissed.

2.      As per report of the Registry, there is a delay of 97 days in filing the present Revision Petition.  As the delay occurred during the suspended period of limitation due to Covid-19, the present Revision Petition is treated to have been filed within limitation.

3.      For convenience, the parties are referred to as placed in the original Complaint filed before the District Forum.

4.      Brief facts of the case, as per the complainant, are that he obtained a critical illness insurance policy from the respondent for the period 12.04.2016 to 11.04.2017, with a sum insured of ₹10,00,000 and paid a premium of ₹17,393. On 27.02.2017, the complainant experienced acute chest pain and was was admitted to Dayanand Medical College (DMC), Ludhiana, diagnosed with CAD (Single Vessel Disease), and underwent Coronary Angiography. He was advised PTCA to LAD but was discharged against medical advice (DAMA) on 01.03.2017. He submitted a claim for critical illness coverage, which the respondent repudiated on 10.05.2017. Aggrieved by the denial, the complainant filed a consumer complaint before the District Forum.

5.      In their reply filed before the District Forum, the OPs contested the complaint by taking preliminary objections that the complaint is not maintainable as the claim was already settled. He concealed material facts and did not approach the forum with clean hands. The complainant had already received ₹13,624 on 18.04.2017 (via cheque/ EFT) as full and final settlement of his claim. While admitting the issue of the insurance policy and receipt of the claim, the respondent contested the allegations of deficiency in service. The hospital bill for ₹18,515 (discharge on request) was partly reimbursed as per policy terms and no further liability exists on the respondent.

6.      The District Forum, vide order dated 18.09.2019, dismissed the complaint with the following reasons:

“6. We bestowed our thoughtful consideration to the submissions made by learned counsel for the respective parties and also gone through the case file very minutely.

7.  Precisely, the case set up by the complainant is that he got insurance policy commencing from 12.04.2016 to 11.04.2017 after paying insurance premium of Rs.17,393/- from the OPs. The said health insurance policy covered critical illness as per assurance given by the agent of the OPs. Unfortunately, the complainant was feeling some pain in the chest on 27.02.2017 and accordingly, he got treatment from Dayanand Medical College and Hospital, Ludhiana, where he remained admitted from 27.02.2017 01.03.2017 and after discharge from the hospital, he submitted an insurance claim bill, but the insurance claim bill of the complainant was returned by the OPs with the remarks that the same is not covered under the critical illness benefit of the policy and the said act and conduct of the OPs is clearly deficiency in service and as such, the instant complaint filed by the complainant with the prayer to direct the OPs pay Rs.10,00,000/- with consequential payments and interest thereon @ 18% per annum as well as compensation and litigation expenses.

8.  There is no dispute that the complainant got insurance policy from the OPs after making payment of the premium and it is also not denied by the OPs that an insurance claim was submitted by the complainant, but the version of the OPs is that the complainant got only angiography from Dayanand Medical College and Hospital, Ludhiana, where he remained admitted from 27.02.2017 to 01.03.2017 and copy of the discharge slip placed on the file and the total amount paid by the complainant to the said hospital was Rs.18,515/- and out of that amount, the OPs has paid a sum of Rs.13,624/- as full and final settled amount to the complainant and as such, the insurance claim of the complainant has been already stands settled and question does not arise to make any harassment to the complainant or deficiency in service.

9.  We find that the complainant has concealed the factum in regard to receiving a full and final settlement amount of Rs.13,624/-.  Even the complainant had not mentioned in the complaint that how much amount he incurred of her treatment, which was paid to the hospital or for any purchase of medicine, no bill produced on the file by the complainant rather a bill has been produced on the file by the OPs, issued by the Dayanand Medical College and Hospital, Ludhiana, copy of the same is available on the file Ex.O-4 and as per bill Ex.O-4, the total amount calculated in the said bill is Rs.18,515/-, but how and under what circumstances, the complainant is claiming Rs.10,0000/- for treatment from the Dayanand Medical College and Hospital, Ludhiana. There is no nexus of 10,00,000/- with the treatment of the complainant rather the complainant has got only angiography from the said hospital and this fact is absolutely established from the discharge report Ex.O-1, wherein on the 2^nd page in the last stanza, it is categorically mentioned that patient was admitted with some vessel disease, Coronary angiography was done on 28.02.2017, which showed Single Vessel Disease. Patient has been advised PTCA, but patient and his attendants refused it and was discharged on his request. So, from the discharge report, it is clear that the complainant has not got any treatment except got conducted angiography and the amount settled by the OPs is according to the terms and conditions of the insurance policy and the same has been disbursed to the complainant, vide settlement letter Ex.0-7. If the complainant has accepted the full and final settlement amount, then he has no right to re-agitate the same later on. So, with these observation, we we do not find any force in the argument put forth by the learned counsel for the complainant, therefore, we find no merits in the complaint of the complainant, thus the same is dismissed with no order of cost. Parties will bear their own costs. This complaint could not be decided within stipulated time frame due to rush of work.”

7.      Being aggrieved, the Complainant filed First Appeal No. 670 of 2019 and the State Commission vide order dated 12.11.2021 dismissed the Appeal with following observations:

 “12.     Now the issue is to decide whether the said disease of the appellant/complainant falls under the critical illness as per terms and conditions of the policy or not? As per terms and conditions of the policy Ex.O-9 at point No.3, under the head Extension HC 8: Critical illness Cover, it is mentioned as under:

"3) First heart attack - of specified severity

First occurrence of myocardial infraction which means the death of a portion of the heart muscle as a result of inadequate blood supply to the relevant area. The diagnosis for this will be evidenced by all the following criteria:

i. a history of typical clinical symptoms consistent with the diagnosis of Acute Myocardial Infarction (for e.g. typical chest pain)

ii. new characteristic electrocardiogram changes

iii. elevation of infarction specific enzymes, Troponins or other specific biochemical markers.

The following are excluded

i. Non-ST-segment elevation myocardial infarction (NSTEMI) with elevation of Troponin I or T.

ii. Other acute Coronoary Syndromes

iii. Any type of angina pectoris."

13. As per discharge report, Ex.O-1, only angiography was only done on 28.07.2017 and recommended for PTCA. The attendants and the patient refused it, accordingly, the patient was discharged on their request. An expenditure of Rs.18,515/- was incurred on the said treatment as per bill issued by the hospital vide Ex.O-4 which was settled by respondents/ opposite parties for Rs.13,624/- vide settlement letter Ex.0-7. As the appellant/complainant went under Angiography only, which does not fall under critical illness as per terms and conditions of the policy.

14.  The appellant/complainant in the grounds of appeal stated that the terms and conditions of the Insurance Policy were not supplied by the respondents/opposite parties. However, no such on averment was made in the complaint filed by the complainant in the District Commission. The appellant/ complainant has himself placed a policy schedule vide Ex. C-1 wherein under the Important Note, it has been stated that the schedule and the attached policy read together as one contract or any word or expression to which a specific meaning has been attached in any part of this policy or of the schedule shall bear the same meaning wherever it may appear. If the appellant/complainant has received this policy schedule along with this note then how he can say that he had not received the policy terms and conditions and there is no correspondence to evident that the complainant contacted the respondents/ opposite parties to issue the policy terms and conditions as there were not received by him along with policy schedule, therefore, the ground taken in the appeal is not tenable.

15. The District Commission rightly observed that if the complainant has accepted full and final settlement amount then he has no right to re-agitate the same later on.

16. In view of the above discussions, the appeal is dismissed and the order of the District Commission is upheld.”

8.      Being dissatisfied by the Impugned Order dated 12.11.2021 passed by the learned State Commission, the Petitioner/ Complainant filed the instant Revision Petition No.650 of 2022.

9.      In his arguments, the Counsel for the Petitioner/ Complainant reiterated the grounds advanced in the Revision Petition and asserted that the petitioner/complainant is challenging the dismissal of their consumer complaint and appeal by the District Forum and the State Commission arguing that the orders failed to appreciate critical evidence and legal principles. He sought to recover ₹10 lakh as critical illness coverage under the insurance policy, in addition to addressing alleged procedural lapses. The petitioner was diagnosed with Acute Anterior Wall Myocardial Infarction (heart attack), which qualifies as a critical illness under the policy. The OPs wrongly denied the critical illness claim despite its clear coverage under the insurance terms. The insurer failed to decide and pay the claim in a timely manner, causing mental agony and harassment. The reasons for claim repudiation were neither valid nor mutually agreed upon between the parties. Payment of ₹13,624 made by the insurer was solely towards medical expenses and not towards the critical illness benefit of ₹10 lakhs. The petitioner argued that there is no evidence to show that this payment constituted the full and final settlement. The insurance company did not provide the full terms and conditions of the policy, nor did it produce evidence of their dispatch or the petitioner’s acceptance of them. The insurer failed to examine any expert witness or medical professional to support their contention that the petitioner’s condition was not critical. As per Section 13(1) of the Act, the burden of proving that the illness was not critical lies with the insurer. The insurer changed its grounds for repudiation during litigation, which is against principles of fairness and transparency. He relied on the case of Shital International v. United India Insurance Co., asserting that such behaviour renders the repudiation unsustainable.  He sought to set aside the judgments and orders of the District Forum dated 18.09.2019 and the State Commission dated 12.11.2021, allow CC No. 137 of 2018 and direct the insurer to pay a ₹10 lakh critical illness coverage as per the policy terms and compensation for mental agony and litigation costs.

10.    The learned counsel for the OPs presented a detailed version of the case and emphasised the concurrent findings of the lower fora and procedural lapses by the petitioner. He argued that the petitioner claimed to have suffered Acute Anterior Wall Myocardial Infarction (heart attack) but provided contradictory documents, such as the discharge summary and doctor’s certificate, which confirm Coronary Artery Disease (Single Vessel Disease). As per the terms of the policy, Single Vessel Disease is not categorized as a critical illness, and the petitioner is attempting to expand the scope of the insurance coverage beyond the agreed terms. The policy schedule, which the petitioner submitted before the District Forum, explicitly stated that the schedule and attached policy documents form a single contract. The petitioner cannot claim ignorance of the terms when they were communicated through the policy schedule. The petitioner failed to substantiate the claim with credible medical documentation proving the diagnosis of a critical illness. The concurrent findings of both the fora have correctly concluded that his diagnosis does not meet the policy’s definition of a critical illness. The scope of revision petition is limited to cases involving jurisdictional errors, material irregularities, or perversity in orders.  The petitioner approached this Commission with unclean hands, attempted to mislead by submitting incomplete documents,  misrepresenting the facts of the case, suppressing material evidence, including relevant policy documents and medical records. He sought dismissal of the Revision Petition with costs.  He relied upon the following judgments in support of his arguments:

A. United India Insurance Co. Ltd. vs. Harchand Rai Chandal Lal, (2004) 8 SCC 644;

B. Bhupinder Kumar vs. Bajaj Allianz Life Insurance Co. Ltd. & Anr., 2017 SCC OnLine NCDRC 233;

C. Rubi Chandra Dutta Vs. M/s United India Insurance Co. Ltd., (2011) 11 SCC 269;

D. Sunil Kumar Maity Vs State Bank of India & Anr. Civil Appeal No. 432 OF 2022 Order dated 21.01.2022;
E. Rajiv Shukla Vs Gold Rush Sales & Services Ltd.(2022)9 SCC

F. K.D. Sharma V/s Steel Authority of India Ltd. & Ors." [(2008) 12 SCC 481;

G. Primary Cooperative Agriculture And Rural Development Bank Ltd. & Anr. Vs. Anantharamegowda, R.P. No.1055 of 2017 decided on 01.05.2024 by the NCDRC;

H. Akash Hospital & Diagnostics & Ors. Vs. Attam Chand Madhotra & Ors., R.P. No.138 of 2020, decided on 07.02.2024;

11.    I have examined the pleadings and associated documents placed on record, including the orders of both the fora and rendered due consideration to the arguments advanced by both the parties.

12.    The main issue in the present case is, whether the claim of the complainant was settled by the OP as per the terms of insurance contract between the parties?

13.    The concurrent findings of both the District Forum and State Commission establish that the petitioner’s condition of Single Vessel Disease does not qualify as a critical illness under the policy terms.  The petitioner failed to produce evidence to substantiate claims of Acute Anterior Wall Myocardial Infarction or demonstrate any procedural lapses by the insurer. The petitioner’s arguments do not reveal any jurisdictional errors, material irregularities, or perversity in the orders of the lower fora.  The revision petition appears repetitive and lacks merit, focusing on issues already adjudicated.

14.    The learned District Forum addressed all the main issues and rendered a detailed and well-reasoned order based on evidence and arguments advanced. The learned State Commission, duly considered the pleadings and arguments, determined that no intervention is warranted on the District Forum's order. Also, there are no significant grounds are reasons are advanced by the Petitioners/OPs which entail interference with such detailed and well reasoned orders.

15.    It is a well settled position in law that the scope for Revision under Section 21(b) of the Act, 1986 and now under Section 58(1)(b) of the Act, 2019 confers very limited jurisdiction on this Commission. In the present case, there are concurrent findings of the facts and the revisional jurisdiction of this Commission is limited. After due consideration of the entire material, I do not find any illegality, material irregularity or jurisdictional error in the impugned order passed by the learned State Commission warranting our interference in revisional jurisdiction under the Act. I place reliance on the decision of the Hon’ble Supreme Court in ‘Rubi (Chandra) Dutta Vs. M/s United India Insurance Co. Ltd., (2011) 11 SCC 269. In addition, Hon’ble Supreme Court in ‘Sunil Kumar Maity vs. SBI & Anr.  Civil Appeal No. 432 OF 2022 Order dated 21.01.2022 observed as follows:-

“9. It is needless to say that the revisional jurisdiction of the National Commission under Section 21(b) of the said Act is extremely limited. It should be exercised only in case as contemplated within the parameters specified in the said provision, namely when it appears to the National Commission that the State Commission had exercised a jurisdiction not vested in it by law, or had failed to exercise jurisdiction so vested, or had acted in the exercise of its jurisdiction illegally or with material irregularity. In the instant case, the National Commission itself had exceeded its revisional jurisdiction by calling for the report from the respondent-bank and solely relying upon such report, had come to the conclusion that the two fora below had erred in not undertaking the requisite in-depth appraisal of the case that was required. .....”

16.    Similarly, the Hon'ble Supreme Court in Rajiv Shukla Vs. Gold Rush Sales and Services Ltd. (2022) 9 SCC 31 has held that:- 

As per Section 21(b) the National Commission shall have jurisdiction to call for the records and pass appropriate orders in any consumer dispute which is pending before or has been decided by any State Commission where it appears to the National Commission that such State Commission has exercised its jurisdiction not vested in it by law, or has failed to exercise a jurisdiction so vested, or has acted in the exercise of its jurisdiction illegally or with material irregularity. Thus, the powers of the National Commission are very limited. Only in a case where it is found that the State Commission has exercised its jurisdiction not vested in it by law, or has failed to exercise the jurisdiction so vested illegally or with material irregularity, the National Commission would be justified in exercising the revisional jurisdiction. In exercising of revisional jurisdiction the National Commission has no jurisdiction to interfere with the concurrent findings recorded by the District Forum and the State Commission which are on appreciation of evidence on record.

17.  In view of the aforesaid deliberations, the detailed and well- reasoned Order of the learned State Commission dated 12.11.2021 does not suffer from any illegality or impropriety. In fact, the order is just and fair. Therefore, no intervention is considered warranted. The Revision Petition No. 650 of 2022 is, therefore, dismissed.

18.    Considering the facts and circumstances of the case, there shall be no order as to costs. All pending Applications, if any, stand disposed of accordingly.