As per Shri Atul Alsi, Hon'ble President.

1. The complainant filed the present Consumer case u/s 35 Consumer Protection Act., 2019 against the arbitrary rejection of non-disbursement of medical insurance claim of Rs.29,19,406/- for the reason angioplasty does not cover a critical illness and thereby claiming insurance amount along with compensation and cost.

The story in short is as under :-

2. The complainant serving as a Government employee and availed housing loan of Rs.54,00,000/- for 15 years in the year 2017.  O.P. No.1 and 2 jointly issued insurance HDFC Life Group Credit Protect Plus Insurance Plan bearing no. PP000086 against the premium of Rs.2,98,304/- for the sum assured of Rs.29,19,406/- for the critical ailment cover under the policy.

3. On dated 5.7.2018 the complainant had undergone angioplasty in Spandan Hospital Nagpur and submitted an insurance claim with all bills and documents but O.P. repudiated the medical claim of the complainant.  The complainant issued legal notice through his Advocate Mr. Sawal on dated 13.1.2020 to O.P. but O.P. had not complied therefore the complainant has filed the present complaint.

4. The O.P.No.1.had filed denied all allegations and submitted that the O.P. insured the complainant under a group credit protector insurance plan for the critical illness.  The complainant's insurance claim came to be rejected by issuing a repudiation letter dated 28.2.2019 and 28.5.209 for the reason that angioplasty and skilled procedures are excluded from the insurance coverage. The complainant has not suffered a heart attack as per the medical paper attached to the insurance claim.  The complainant was suffered double-vessel deceased for which the treatment prescribed was angioplasty, therefore rejection of a claim on the ground of exclusion clause as per the condition of policy is not deficiency of service.

5. O.P.No.2 filed their reply and denied all the allegations and submitted that the complaint was treated for heart disease in the month of Jully-2018 and the complaint has been filed on 24.3.2022 beyond the period 2 years from the arising disputing and cause of action. The O.P.No.2 has sanctioned and disbursed a loan amount of Rs.54,87,000/- as per application. The O.P.No.2 has no role in the adjudication of insurance claim. The complainant loan is a contractual and commercial loan, therefore, the complaint is not maintainable and the complainant loan was closed on 20.4.2019 and there is no averment in respect of the loan transaction, the relationship between the complainant and finance company is not debtor, and creditor, and coming within the meaning of consumer. The complainant opted for the insurance policy from O.P.No.1 therefore O.P.No.1 is not a consumer of the complainant for the allegations of not owning the insurance claim therefore the case is liable to be dismissed with cost.

6. Counsel for complainant Mr. A.T. Sawal argued that the complainant has filed an insurance claim with coronary angiography and angioplasty report dated 26.6.2018 along with a discharge summary dated 5.7.2018 with a copy of the insurance cover policy which clearly mentioned heart attack as critical illness at serial No.3 as per the list of document filed by the complainant at serial No.21. with the list of documents dated 21.2.2022, therefore non-disbursement of the sum assured as per policy for the treatment of angioplasty does amount to deficiency service on the part of O.P.

7. The counsel for O.P.No.1 Mr. Badhe argued that as per the terms and conditions of the policy which is delivered to the complainant after inspection of the policy clearly described in column No.5, the angioplasty and any other intra arterial procedures or any key holder laser surgery are excluded the complaint has not filed any medical evidence in respect of the complainant suffered a heart attack. The repudiation of the insurance claim as per the repudiation letter for the exclusion clause as per the terms and conditions of the policy does not amount to a deficiency of service.

8. The counsel for O.P.No.2 has argued that O.P.No.2 is a finance company and no services have been rendered adjudication of the insurance claim for the heart treatment of the complainant, therefore, there is no consumable interest and the complaint is filed beyond the period of limitation and liable to be dismissed with cost.

                                                REASONING

9. The basic dispute in respect of the present complaint is a rejection of an insurance claim for the reason of exclusion clause under the policy of insurance cover. The complainant filed a coronary angiography report of dated 26.6.2018 and an angioplasty report dated 5.7.2018 of Spandan Heart Institute, Nagpur. The complainant has not suffered a heart attack, the heart attack being covered under the policy as a critical illness and in that case the complainant is entitled to claim sum assured but here in this case complainant was suffering from Double Vessal decease for which the treatment of angioplasty was given. The treatment of angiography and angioplasty and any other intra-arterial procedures, any key-hole or laser surgery, are excluded as per terms and conditions No.5 under the policy for the definition of cover under critical illness list and benefit payable therefore repudiation of insurance claim for exclusion clause while issuing letter dated 28.5.2019 and 29.5.2019 does not amount to deficiency of service on the part of O.P. therefore the case is dismissed as per following order.

ORDER

1. Complainant complaint is dismissed
2. No order as to cost.
3. Copy of order be furnished to both the parties, free of cost.