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Judgment
V.K.Jain, J
The complainant obtained an insurance policy from the respondent for the period from 19.12.2012 to 18.12.2017 which interalia covered the major illnesses and procedures specified therein. One of the illnesses covered under the policy was occurrence of Myocardial infarction. The complainant was admitted to BARC Hospital with complaint of chest pain and dizziness and later shifted to Nanavati Hospital, where his Angiography was performed, followed by an open heart surgery. The claim, which the complainant lodged with the insurer, however, came to be rejected vide letter dated 31.01.2014 which, to the extent it is relevant, reads as under:
On examination and verification of the documents submitted, it is understood that the insured suffered from Constrictive Pericarditis with Pericardiactomy done on 8th June 2013 as evident from the discharge summary of Dr. Balabhai Nanavati Hospital Mumbai dated 15th June 2013. The report of CAG dated 6th June 2013 and CT Scan of chest dated 7th June 2013 reveal pericardial calcification suggestive of chronic constrictive pericarditis but clearly indicate no incidence of Myocardial Infraction. Also the discharge summary from BARC Hospital dated 4th July 2013 describes the patient as diagnosed to have pleural effusion with mention of Constrictive Pericarditis with Pericardiectomy done and had not suffered from Myocardial Infraction.
There has been no loss suffered by the insured as per the 9 major medical illnesses and procedures defined and covered under the Policy and there is no evidence of Myocardial Infraction defined under the policy as under. The claim falls outside the purview of policy coverage.
As per SECTION I : MAJOR MEDICAL ILLNESS & PROCEDURES : Myocardial Infraction
The first occurence of an acute Myocardial Infraction leading to the death of a portion of heart muscle (Myocardium) as a result of inadequate blood supply to the relevant area. The diagnosis for the same must be evidenced by all of the following:
An episode of typical chest pain.
The occurence of a typical new acute infarction changes (ST-T elevation) on the electrocardiograph and progressing to development of pathological Q wave.
Elevation of Cardiac Troponin (T or I) to at least 3 times the upper limit of normal reference range or an elevation in CPK-MB to at least 200% of the upper limit of the normal reference range.
But, excluding non-STEMI with elevation of troponin I or T. Other acute coronary syndromes including but not limited to angina or chest pain are excluded from this definition.
In view of the above reason stated we regret our inability to pay our claim. However, we remain committed to you and assure you the best services at all times.
Being aggrieved from the rejection of the claim, the complainant/appellant approached the concerned State Commission by way of a Consumer Complaint.
The complaint was resisted by the respondent interalia on the ground that the illness of the complainant not being a Myocardial infarction, was not covered under the insurance policy.
The State Commission having dismissed the Consumer Complaint vide impugned order dated 25.10.2016, the appellant/complainant is before this Commission.
The only issue involved in this appeal is as to whether the illness from which the complainant/appellant suffered, amounted to Myocardial infarction or not. No expert evidence was led by the complainant/appellant to prove that his illness constituted Myocardial infarction. No evidence to the contrary was led by the insurer. In these circumstances, it becomes necessary to give an opportunity to the parties to lead evidence to prove as to whether the illness of the complainant constituted Myocardial infarction or not. The impugned order is therefore, set aside and the matter is remitted back to the concerned State Commission to decide the complaint afresh after giving an opportunity to the complainant to prove that the illness suffered by him constituted Myocardial infarction. The respondent shall be entitled to lead evidence in rebuttal.
The parties shall appear before the concerned State Commission on 17.10.2019.
The State Commission shall decide the complaint afresh in terms of this order within six months of the parties appearing before it.