Haryana

StateCommission

CC/98/2014

Mukesh Kumar - Complainant(s)

Versus

HDFC Std. LIC - Opp.Party(s)

17 Feb 2017

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION, HARYANA, PANCHKULA.

 

                                                Complaint No.98 of 2014

                                                       Date of Institution: 19.09.2014                            Date of Decision: 17.02.2017

 

Mukesh Kumar S/o Sh.Sunder Lal, R/o H.No.C-1/634, Jesico Colony, Jagadhri, District Yamuna Nagar, Haryana 135003.

…..Complainant

 

Versus

 

1.      Housing Development Finance Corporation (HDFC) Limited, SCO 184-185, Ground Floor, Sector 17, Commercial Belt, Near Mini Secretariat, Jagadhri, District Yamuna Nagar 135003, through its Branch Manager.

2.      HDFC ERGO General Insurance Company Limited, 6^th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East), Mumbai-400059, through its Manager (Claims).

          …..Opposite Parties

 

CORAM:             Mr. R.K.Bishnoi, Judicial Member.

                   Mrs.Urvashi Agnihotri, Member.                                    

For the parties:  Mr.Satpal Dhamija proxy counsel for Mr.Ashwani Talwar, Advocate counsel for the complainant.

                             Ms. Rupali Shekhar Verma, Advocate counsel for the opposite party No.1.

                             Mr.Sandeep Suri, Advocate counsel for the opposite party No.2.

 

O R D E R

 

R.K.BISHNOI, JUDICIAL MEMBER :-

It is alleged by complainant that he obtained housing loan from opposite party (O.P.) No.1 and to secure the loan amount he purchased Home Suraksha Plus bearing policy No.2918200551017900000 commencing from 29.07.2013 to 28.07.2018 for Rs.57,29,500/-.  On 02.04.2014 at about 11.00 A.M. when he was coming from Jagadhari he felt uneasiness and pain in left arm. He immediately went to local hospital where he was admitted and managed with anti-platelets, LMWX and other cardio supportive drugs.  Due to serious condition he was discharged on 03.04.2014 to approach some advanced centre.  On that very day he went to Max Super Specialty Hospital, Mohali where it was revealed that he was having CAD DSVD (LAD, LCX)  and PTCA + Stent (DES_ to LAD/LCx.(3.04.14) was done.  This problem was  covered by major medical illness as detailed below:-

“As Per Section 3 of the Policy in question, the following insured events are covered under the head of Major Medical Illness.

1. First Diagnosis of the below-mentioned illnesses more specifically described below:

1. Cancer
2. End Stage Renal Failure
3. Multiple Sclerosis, or
4. Benign Brain tumor
5. Parkinson’s Disease before the age of 50 years
6. Alzheimer’s Disease before the age of 50 years

2. Undergoing for the first time of the following surgical procedures, more specifically described below:

1. Major Organ Transplant
2. Heart Valve Replacement
3. Coronary artery bypass graft
4. Surgery of aorta

3. Occurrence for the first time of the following medical events more specifically described below:

1. Stroke
2. Paralysis
3. Myocardial infarction
4. Major Burns
5. Loss of speech
6. Deafness
7. Coma”

Exclusion clause of 3 (c ) was not applicable in this case.  He submitted claim with O.Ps., but, the same was declined on the ground that  his case was not covered by critical illness as per policy.  O.Ps. be directed to settle claim for Rs.57,29,500/- besides other compensation alongwith interest @ Rs.12% per annum from the date of repudiation of claim i.e. 03.07.2014 as mentioned in relief clause.

2.      O.ps. filed separate replies.  O.P No.1. filed reply admitting the home term loan and the insurance policy, but, it is alleged by O.P.No.2 that present case was not covered by the critical illness mentioned in the policy.  His case was not covered by Myocardial infarction as defined in the policy.   He had simple uneasiness. Even otherwise he was not  operated upon and only angioplasty and stent was done which is covered by exclusion clause, so his claim was rightly repudiated.

3.      Arguments heard. File perused.

4.      Learned counsel for the complainant vehemently argued that from the perusal of the certificate Ex.C-5 issued by Dr. Sudheer Saxena it is clear that it was a case of critical illness  as acute coronary  syndrome (ACS).  It was double vessel disease for which PTCA was done. So he was entitled for the relief as mentioned in Ex.C-7.

5.      In the beginning it is to be seen whether case of complainant is covered by terms  and conditions of insurance policy or not. Qua heart, a person should have the following problem as mentioned in sub-clause b of clause 2  and sub clause c of clause 3, which are as under:-

“b)     Undergoing for the first time of the following surgical procedures, more specifically described below:

2.      Heart Valve Replacement

c)      Occurrence for the first time of the following medical events more specifically described below:

          3.      Myocardial infarction”

Myocardial infarction is also defined as under:-

                   “Myocardial infarction (Heart Attack)

The first occurrence of an acute myocardial infarction 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 occurrence of a typical new acute infarction changes (ST-T elevation) on the electrocardiograph and progressing to development of pathological.”

Further there is exclusion clause about coronary Artery Bypass Graft which is as under:-

                   “Coronary Artery Bypass Graft

                   

The actual undergoing for the first time of an open chest coronary artery bypass surgery to correct narrowing or blockage of one or more coronary arteries with bypass grafts provided it is recommended by cardiologist and supported with coronary angiographic evidence but excluding balloon angioplasty and/or any other intra-arterial procedures or laser relief.”

6.      As per this clause it is clear that if a person has undergone for the first time an open  chest coronary artery bypass surgery only then he is entitled for compensation and not for balloon angioplasty and any other internal  procedure. This clause is specific about the exclusion.  It is well settled preposition of law that the parties are bound by the terms and conditions mentioned in the insurance policy. They cannot get out of the same. The Fora cannot stretch  the terms and conditions to bring the relief of the complainant within the ambit of the policy.  As per insurance policy it was bounden duty of the complainant to show that his case was covered by terms and conditions agreed in between them. These views are also supported by opinion of Hon’ble Supreme Court  expressed in  United India Insurance Co. Ltd. and others Vs.Roshan Lal Oil Mills Ltd. and others (2000) 10 SCC 19, Sikka Papers Ltd. Vs. National Insurance Co. Ltd. and others AIR 2009 SC 2834. 

7.      In the present case complainant did not undergo open chest surgery and only ballon angioplasty was done and stent was put. It is intra-arterial procedure or lesser relief, which is excluded by this policy. In this way when the case of the complainant is not covered by terms and conditions of insurance policy he cannot  ask for compensation. His claim was rightly repudiated by the O.Ps. Resultantly complaint fails and the same is hereby dismissed.

 

February, 17th, 2017

Mrs.Urvashi Agnihotri, Member, Addl.Bench

R.K.Bishnoi, Judicial Member Addl.Bench

 

S.K.