O R D E R (ORAL)

        Challenge in this Revision Petition, by Tata AIG General Insurance Co. Ltd. (for short “the Insurance Company”), is to the order dated 5.5.2017, passed by the State Consumer Disputes Redressal Commission, West Bengal at Kolkata (for short “the State Commission”), in First Appeal No.A/582/2015.  By the impugned order, the State Commission has overturned the order dated 21.4.2015, passed by the District Consumer Disputes Redressal Forum, Unit I, Kolkata (for short “the District Forum”) in CDF/Unit-I/Case No.487/2012.  In the first instance, the District Forum had dismissed the Complaint filed by Respondent No.1 herein, alleging deficiency in service on the part of the Insurance Company in rejecting his claim for reimbursement of the amount expended by him on installation of a new pace-maker while travelling abroad, on the ground that since the Complainant had already got a pace-maker fixed at the time of taking the policy, in view of the Exclusion Clause in the Travel Guard Insurance Policy, viz., “this policy does not provide benefits for any loss resulting in whole or in part from, or expenses incurred, directly or indirectly in respect of any pre-existing condition or any complication arising from it”, Insurance Company was not liable to accept the claim in respect of a pre-existing disease and therefore, there was no deficiency on the part of the Insurance Company in repudiating the claim.

2.     Being aggrieved by the said order, the Complainant carried the matter further in Appeal to the State Commission, in which the impugned order has been passed, directing the Insurance Company to reimburse to him a sum equivalent to US$ 15932.24 (US$ 16,032.24 – US$ 100), in Indian currency as per exchange rate applicable at the time of payment along with a sum of ₹50,000/- as compensation.  Hence, the present Revision Petition.

3.     Briefly stated, the material facts, leading to the filing of the Complaint are that while opting for the Mediclaim Policy in the year 2010, in the Proposal Form, the Complainant had disclosed that a pace-maker had been installed on 18.6.2004.  Based on the said information, he obtained from the Insurance Company on 7.5.2010, an Overseas Travel Accident Travel Guard Silver, Gold, Platinum & Annual Multi Trip Insurance Policy.  In the said Policy, pre-existing condition was defined as follows :

“Pre-existing Condition – a condition for which care, treatment or advice was recommended by or received from a Physician or which was first manifested or contracted within two year period preceding the Policy Effective Date of Coverage, or a condition for which hospitalization or surgery was required within a five year period preceding the Policy Effective Date specified in the Schedule”.

4.     It appears that while travelling in Boston, USA the Complainant felt some problem with the pace-maker, installed in 2004.  He consulted a Medical Center at Boston, where a new pace-maker was inserted on 27.5.2010.  For the entire treatment at the Medical Center, the Complainant had to incur an expenditure of US$27,638.48.  On return, he filed the claim with the Insurance Company for the said amount which, as noted above, was repudiated on the afore-noted ground.

5.     We have heard learned Counsel appearing for the parties and perused the documents on record, including the Proposal Form as well as the Policy in question.  Having perused the said documents and the Exclusion Clause, we are of the opinion that the present Revision Petition is bereft of any merit. 

6.     Learned Counsel appearing for the Insurance Company has strenuously urged that since it was made clear even in the Proposal Form itself that no claim under the Policy will be entertained if the proposer is suffering from any pre-existing medical conditions, whether declared or undeclared and further the Complainant being under regular treatment in respect of the pace-maker, the State Commission has committed material irregularity in coming to the conclusion that the case of the Complainant was not covered under the Exclusion clause.

7.     Rejecting the self same contention, the State Commission has observed as follows :

“Pre-existing Condition is defined as under in the insurance policy.

“Pre-existing Condition – a condition for which care, treatment or advice was recommended by or received from a Physician or which was first manifested or contacted within two years period preceding the Policy Effective Date of Coverage, or a condition for which hospitalization  or surgery was required within a five year period preceding the Policy Effective Date specified in the Schedule”.

Going by this stipulation, cooling period for pre-existing diseases has been restricted to two/five years.  Since the Appellant underwent pacemaker implant six years preceding the policy effective date, he certainly did not fall into the exempted category.  Further, although it is alleged by the Respondent that the Appellant was on regular check up related to the pacemaker which was implanted in the year 2004, not a scrap of paper is placed on record from its side to support such contention.  Despite this we find that the Respondent, in a bid to repudiate the claim by hook or by crook, only dished out half-truth and straightway repudiated the claim of the Appellant.  There is no reason to believe that the Respondent was unaware of policy terms and conditions, more precisely, the definition of pre-existing condition as contained in the policy schedule.  Still that the claim of the Appellant was most arbitrarily repudiated only manifests gross deficiency in service on the part of the Respondent.”

8.     On a pointed query with regard to the evidence adduced by the Insurance Company in support of its allegation that right from the year 2004, when the pace-maker was installed, till the year 2010 when it needed replacement, the Complainant was under regular treatment, learned Counsel has relied on the Cardiac Results Report issued by the Medical Center in Boston.  Having perused the said document, we are unable to persuade ourselves to agree with the learned Counsel that the said report clearly suggests that the Complainant was under regular treatment, relating to the pace-maker during the aforesaid period of almost six years.  The said report only records the factum of placement of vitatron pace-maker in June 2004.  It does not even remotely refer to any kind of regular treatment the Complainant was undergoing in respect of the pace-maker.  In the absence of any other evidence in that behalf, no fault can be found with the interpretation of the afore-stated pre-existing condition in the Policy by the State Commission.  Furthermore, when at the time of obtaining the Policy the Complainant had admittedly declared that a pace-maker was placed in his body in the year 2004, and according to the Insurance Company, it was to be treated as a pre-existing disease, we really wonder why in the first instance, the Insurance Company issued the Policy in question in the year 2010.

9.     In view of the aforegoing, we do not find any jurisdictional error in the impugned order, warranting interference in our limited Revisional jurisdiction.

9.     Consequently, the Revision Petition fails and is dismissed accordingly, leaving the parties to bear their own costs.