This Revision Petition No.3265 of 2015 has been filed by the petitioner/complainant – Bhupinder Kumar against the order of the Punjab State Consumer Disputes Redressal Commission, Chandigarh (for Short, ‘State Commission) dated 23.12.2014 in FA No.658/2012 vide which his insurance claim under critical illness cover was denied.
Brief facts relevant for the disposal of this revision petition are as follows.
As per the petitioner/complainant, he has been associated with the respondent opposite party Bajaj Allianz Life Insurance Co. since 2005, first as an insurance consultant and presently as a Sales Manager. He had taken an insurance policy No.0010996742 dt. 28.9.2005 from the respondents/opposite parties. He had suffered a heart-attack on 29.4.2007 and was admitted in Patiala Heart Institute from 30.4.2007 to 2.5.2007. Later, he was shifted to Dayanand Medical College and Hospital, Ludhiana where he remained from 19.6.2007 to 20.6.2007. Angiography was conducted and a stent was fixed. The complainant spent an amount of Rs.2.50 lakh for his treatment. He lodged his claim with the Insurance Company but till date his claim has not been paid, despite e-mail reminders, letters. Therefore, he filed a consumer complaint before the district forum and prayed for the following relief :-
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To pay Rs.1 lakh as compensation on account of mental agony, tension, inconvenience, harassment and humiliation suffered by the complainant.
To pay Rs.15,000/- as litigation expenses.”
The District Forum on consideration of the pleadings before it, allowed the complaint and directed the opposite parties to make payment of Rs.2 lakhs to the complainant within one month with 9% interest p.a. from the date of the order as also Rs.7,500/- as cost of the complaint.
Being aggrieved, the opposite parties – Insurance Company had filed an appeal before the State Commission. The State Commission in its order dt. 23.12.14 allowed the appeal and setaside the order of the District Forum.It held that repudiation of the claim was justified and correct in terms of the critical illness policy provisions, explaining that it was not for the district forum to go beyond what was specifically provided in the policy itself.
Being aggrieved with this order, the petitioner/complainant has filed this revision petition before this Commission.
Heard learned counsel for both parties and perused the records of the case, including the policy covering critical illness.
It is not in dispute that the petitioner did undergo an angiography procedure in which a stent was fixed. The issue for consideration is whether this falls within the policy parameters which define ‘critical illness’.
The District Forum reasoned that even though “balloon angioplasty is excluded from the heart surgery to correct narrowing of blockage of left main coronary artery or three more arteries with by-pass grafts, but it will not be correct to say that coronary angiography (single vessel disease) is not to be treated as a critical illness because the complainant had the history of typical chest pain noted in the discharge card Ex C 10, of Patiala Heart Institute, where the complainant was admitted on 30.4.2007 and discharged on 2.5.2007 and also noted in the discharge summary Ex C 11 that the patient had a history of chest pain, radiating to arms associated with sweating and dysponea on exertion 1 ½ months back.” It went on to conclude that “the repudiation of the claim of the complainants by the ops was made mechanically and without application of mind to the facts and was based on the narrower interpretation of the definition of the critical illness in the life insurance policy Ex C2.”
The State Commission, on an appreciation of the facts of the case, reasoned that “For determining the critical illness, it was not the effect of the treatment so given to the complainant, for the treatment of his ailment, which was to be considered but it was the disease itself, which was to be considered and it was the solemn duty of the District Forum to ascertain whether the said ailment fell under the critical illness as defined in the terms and conditions of the policy. It transgressed its powers by itself coining different definition of the critical illness so as to confer the benefit upon the complainant.”
Having heard the arguments of both the counsels and having perused the records, I am inclined to agree with the State Commission. It appears to me that the petitioner complainant, having been involved with the insurance business, ought to have been fully conversant with the policy and procedures governing life insurance and the added cover of critical illness. Critical Illness Benefit has been elaborately defined and its terms and conditions specifically prescribed. Of relevance to the case in hand are two critical illnesses covered under the policy which for ease of reference and understanding are reproduced below:
First Heart Attack:
The death of a portion of heart muscle as a result of inadequate blood supply to the relevant area. The diagnosis should be based on the following:
A historyof typical chest pain, if any
New and recent electrocardiographic changes indicating myocardial infarction
Elevation of cardiac enzymes
Diagnosis based on the elevation of Tropnin T Test, alone shall not be considered diagnostic of a heart attack,
Angina or chest pain are especially excluded.
Coronary Artery Disease Requiring Surgery
The undergoing of heart surgery to correct narrowing of blockage of left main coronary artery or three or more coronary arteries with bypass grafts in persons with limiting angina symptoms and compromise of blood supply supported by investigation but excluding non-surgical techniques such as balloon angioplasty, laser relief of an obstruction or other forms of coronary artery clearing through catheters or similar devices. Narrowing of the affected artery should be more than 75%(seventy five percent).
A close look at the two discharge summary reports is in order. Patiala Heart Institute records admission of the complainant as a 44 year old male without significant past history for chest pain radiating to left arm. It then records that the patient was diagnosed and managed as a case of CAD (coronary artery disease), ACS (acute coronary syndrome), USA ( unstable artery), and responded well to the treatment. It further records that there were no complications during hospital stay and the patient was discharged in satisfactory condition and advised follow up with the Doctor.It is clear from this discharge summary that there was no advice given to the petitioner for angiography, contrary to what has been claimed in the complaint. Only a follow up with the Doctor was suggested. Clearly, nothing under “critical illness” so far.
A look at the discharge summary of Dayanand Medical College &Hospital reveals that the petitioner was admitted for evaluation of coronary artery status. It records a history of chest pain 1½ months back. It further records no history of palpitations, cough, fever or syncope. Its final diagnosis is CAD-single vessel disease and its recommendation PTCA with stenting to LAD which was carried out. It is clear from this that the petitioner complainant had not been shifted to DMCH as claimed in his complaint; rather, he had gone there for an evaluation of his coronary artery status. There is a significant difference in ‘being shifted’ and ‘going for an evaluation’. As it turned out, the evaluation led to PTCE with stenting.
Thus, when the contents of the discharge summaries are seen against the requirements of what constitutes a CRITICAL ILLNESS under the policy, it becomes quite clear that the petitioner complainant’scase cannot be called a case of critical illness. This does not mean that his illness or treatment was not real or not important. It only means that his claim under critical illness category cannot be sustained.
In view of the foregoing discussion, I see no infirmity in the well-reasoned orderof the State Commission. Accordingly, the revision petition is dismissed. No order as to costs.
