New India Assurance Co. Ltd. vs Surinder Singh

The complainant/respondent obtained a mediclaim policy from the petitioner company for the period from 31.01.2011 to 30.01.2012 which was later on renewed for the period from 31.01.2012 to 30.01.2013. The complainant suffered from some heart ailment and was taken to Government Hospital Chandigarh. From there he was shifted to PGI Chandigarh in September 2012. He underwent angioplasty incurring expenses of Rs. 3,44,703/- on his treatment. The claim lodged by him which was repudiated by the letter dated 03.11.2012 written by the TPA to the insurer and filed by the complainant along with the consumer complaint. The said letter, to the extent it is relevant, reads as under:-

"1. PATIENT SUFFERED FROM CORONARY ARTERY DISEASE, HYPER TENSION. AS PER THE MEDICAL RECORDS AVAILABLE, PATIENT IS KNOWN CASE OF HYPERTENSION FROM 5-6 YEARS AND PATIENT ALSO HAS HISTORY OF OLD INFERIOR WALL MYOCARDIAL INFARCTION. POLICY IS IN 2nd YEAR OF INCEPTION. HYPERTENSION IS CAUSE OF CAD. THEREFORE THE CLAIM IS NON PAYABLE AS PER CLAUSE 4.1 (PRE-EXISTING DISEASE).

PATIENT HAS SUFFERED FROM HYPERTENSION, CORONERY ARTERY DISEASE, CHOLELITHIASIS, 'RENAL CONCRETIONS. BOTH HYPERTENSION AND STONE DISEASE ARE EXCLUDED FROM THE 1st 2 YEARS OF THE POLICY. THEREFORE CLAIM IS NON PAYABLE AS PER CLAUSE 4.3 OF THE POLICY. CORONERY ARTERY DISEASE,HYPERTENSION CLAIM NON PAYABLE."

Aggrieved from the repudiation, the complainant approached the District Forum by way of consumer complaint. The complaint was resisted by the petitioner primarily on the ground with which the claim had been repudiated by the TPA.

The District Forum having dismissed the consumer complaint the petitioner approached the concerned State Commission by way of an appeal. Vide impugned order dated 16.01.2014 the State Commission set aside the order passed by the District Forum and allowed the consumer complaint directing the petitioner to pay a sum of Rs. 3,37,228/- along with compensation quantified at Rs. 25,000/- and the cost of litigation quantified at Rs. 15,000/-. The said amount was to carry interest at the rate of 9% p a. in case the payment was not made within 45 days of the receipt of the copy of the order. Being aggrieved from the order passed by the State Commission the insurer is before this Commission.

It would be seen that the entire case of the insurer is based upon class 4.1 and 4.3 of the terms and conditions attached to the mediclaim policy. Though the case of the complainant is that the said terms and conditions were never supplied to him I am unable to accept this part of the stand taken by him. It is clearly stated in the policy document itself that it is subject to "Mediclaim Policies (2000) Clause as attached." Had the clauses as applicable to the policy not been attahced the complainant in the ordinary course of human conduct would have written to the insurer asking for those clauses the same having been specifically referred in the policy document. There is no evidence or even an allegation in the complaint having sought those clauses/terms from the insurer. The submission of the Ld. counsel for the complainant is that the complainant had sought the terms and conditions from the agent but since the agent was not impleaded as a party to the consumer complaint the plea taken by the complainant in this regard cannot be verified. Therefore I am unable to accept the contention that the terms and conditions attached to the Policy was not supplied to the complainant.

Clauses 4.1 and 4.3 of the policy have been reproduced in the written version to the consumer complaint and read as under:-

"Clause No 4.1

4.1 Pre-existing diseases/condition: All diseases/ injuries/conditions, which are pre-existing when the cover incepts for the first time (except as shown hereunder). Any complication arising from pre existing disease/ ailment/injury will be considered as a part of preexisting condition. This exclusion will be deleted after four consecutive claim free policy years provided there was no hospitalization for the pre-existing disease/ ailment/condition/injuiy during the said four years of insurance with our Company.

Clause No 4.3

4.3 Waiting period for specified diseases/ ailments/conditions:

From the time of inception of the cover, the policy will not cover the following diseases/ailments/conditions for the duration shown below. This exclusion will be deleted after the duration shown, provided the policy has been continuously renewed with our Company without any break."

A perusal of the discharge summary of the complainant would show that he was hospitalized for the treatment of a coronary disease and his angioplasty was done at PGI Chandigarh. Therefore the reimbursement which he sought from the insurer was for the expenses which he incurred on his angioplasty. As per the discharge summary this was an old case of hypertension and inferior wall myocardial infraction. The said summary does not show how old the coronary ailment was. There is no evidence to prove that the complainant was suffering from any coronary ailment at the time the insurance policy was taken by him. No evidence was produced by the insurer to prove that the complainant was suffering from coronary ailment at the time the policy was initially taken by him in the year 2011. The possibility of the coronary ailment having been discovered by the complainant after taking the policy but before his admission in the hospital therefore cannot be ruled out. Hence, it is not proved to be a pre existing disease at the time the insurance policy was taken. Though, there is evidence to prove that the complainant was suffering from hypertension 4/5 years before taking the policy, the reimbursement he sought was not for treatment of hypertension but was for the angioplasty which was done in PGI Chandigarh. No evidence was led by insurer to prove that that the blood pressure of the complainant was uncontrolled and had led to the coronary ailment for removal of which angioplasty had to be done by at PGI Chandigarh. No doubt hypertension may be one or more causes of someone developing a coronary artery disease if the hypertension is not under control but it is not necessary that even a controlled hypertension would lead to the patient to a coronary artery disease. Therefore, I am unable to accept the contention that the disease of complainant was covered under clause 4.1 of the terms and condition attached to the policy. As far as class 4.3 is concerned coronary artery disease is not one of the ailments for which cooling off period of 2 years is prescribed in the insurance policy. Therefore, the case is also not covered under class 4.3 of the policy. It is true that hypertension has been concealed by the complainant while obtaining the insurance policy, he having replied in negative when asked whether he was suffering from hypertension. But, a perusal of the repudiation letter would show that the aforesaid concealment was not a ground for repudiation of the claim. As held by the Hon'ble Supreme Court in GALADA POWER AND TELECOMMUNICATION LTD Vs. UNITED INDIA INSURANCE CO. LTD. AND ANOTHER IV (2016) CPJ 5 (SC) the insurer cannot be allowed to travel beyond the ground taken in the repudiation letter issued by it while rejecting the claim. Therefore, the aforesaid concealment cannot be a ground for dismissing the complaint, the same not being one of the grounds for repudiating the claim.

For the reasons stated hereinabove, I find no justification to interfere with the order passed by the State Commission. The revision petition is, therefore, dismissed, with no order as to cost.