This revision is directed against the order of the State Commission, Punjab dated 25.1.2017 vide which the State Commission accepted the appeal preferred by the respondent/insurance company against the order dated 22.1.2016 passed by District Forum Fatehgarh Sahib, set aside the order and dismissed the complaint.

2.       Briefly put, relevant facts emerging from the record are that the petitioner/complainant purchased a life insurance policy from the opposite party. The policy was valid w.e.f. 29.6.2004 to 28.6.2009. As per the terms and conditions of the policy apart from the life insurance the respondent/complainant was provided extended benefit under the medical illness clause. During the currency of the insurance policy the petitioner/complainant developed some problem and he was advised Angioplasty. The petitioner underwent Angioplasty as per the medical advice at the cost of Rs.2,50,000/-. The insurance claim under the critical illness clause was filed but the opposite party repudiated the claim vide letter dated 4.1.2014 claiming that the expenses incurred on Angioplasty were not covered under the critical illness clause of the insurance policy. Being aggrieved of the repudiation of the insurance claim, the petitioner filed consumer complaint in District Forum Fatehgarh Sahib wherein he described the insurance policy purchased by him as a medi-claim policy although as per record it was life insurance policy.

3.       The opposite party on being served with the notice of the complaint filed written statement claiming that a life insurance policy was issued in favour of the complainant which contained the critical illness rider benefit but it did not include Angioplasty.

4.       The District Forum on consideration of pleadings and the evidence allowed the complaint and directed the opposite party insurance company to pay to the petitioner a sum of Rs.2,50,000/- as insurance claim alongwith 6% interest thereon from the date of repudiation of the claim, besides the compensation of Rs.15,000/- awarded on account of mental agony and Rs.5,000/- as litigation cost.

5.       The respondent insurance company being aggrieved of the order of the District Forum approached the State Commission, Punjab in appeal. The State Commission, Punjab on re-appreciation of evidence particularly the interpretation of the critical benefit clause in the insurance policy, came to the conclusion that Angioplasty was not covered as an additional benefit under the critical illness benefit. The State Commission accordingly allowed the appeal, set aside the order of the District Forum and dismissed the complaint.

6.       Learned counsel for the petitioner has contended that the impugned order of the State Commission is not sustainable because it is based upon misleading of the terms & conditions of the policy relating to critical illness benefit. Learned counsel for the respondent/opposite party on the contrary has argued in support of the impugned order.

7.       I have considered the rival contentions. On perusal of the copy of the insurance policy and its general terms and conditions, I find that the policy issued to the petitioner essentially is a life insurance policy with additional benefits, namely, disability benefit and critical illness benefit. Clause (B) of the annexures to the general terms and conditions detailing supplementary benefits provides as under: -

“Provided the policy in force for the full sum assured, the life assured is diagnosed to be suffering from a critical illness (as defined below) after six months from the date of policy but before the policy anniversary on which he attains the age of 65 years nearer birthday, or before the expiry of the period for which the premiums are payable, whichever is earlier, the sum assured under the supplementary benefit shall fall to be paid together with guaranteed additions and bonuses vested or such sum assured till then, subject to conditions set below:

………”

8.       The term critical illness is defined in Note I A in the clause. The said note reads as under: -

“Note 1: A “Critical illness” shall mean anyone of the following illnesses as defined separately hereunder occurring after 6 months from the date of policy:

1. Cancer: A malignant tumour characterized by uncontrolled growth and spread of malignant cells and the invasion of tissues. The diagnosis must be histologically confirmed. The term Cancer includes Leukemia but excludes the following

2. All tumours which are histologically described as pre-malignant, non-invasive or carcinoma in situ;

3. All forms of lymphoma in presence of human immune-deficiency virus;

4. Kaposi’s Sarcoma in the presence of any human immune-deficiency virus;

5. Any skin cancer other than invasive malignant melanoma; and

6. Early prostate cancer which is histologically described as T₁ (including T₁a and T_1b) or another equivalent or lesser classification.

   (b)     Coronary Artery By-pass Graft Surgery (CABGS)- the undergoing of open heart surgery on the advice of a consultant Cardiologist to correct narrowing or blockage of one or more coronary arteries with by-pass grafts;

            Angiographic evidence to support the necessity of the surgery will be required. Balloon angioplasty, laser or any catheter based procedures are not covered.

7. Heart attack-The death of a portion of heart muscle as a result of inadequate blood supply as evidenced by an episode of typical chest pain, new electrocardiographic changes and by elevation of the cardiac enzyme. Diagnosis must be confirmed by a consultant physician.

   (d)       Kidney failure-End stage renal failure presenting as chronic irreversible failure of both Kidneys to function, as a result, of which either regular renal dialysis or renal transplant is undertaken. Evidence of end stage kidney disease must be provided and the requirement of dialysis or transplantation must be confirmed by a consultant physician.

   (e)       Major Organ Transplant- The actual undergoing as a recipient of a transplant of heart, liver, lung, pancreas or bone marrow as a result of chronic irreversible failure. Evidence of end stage disease must be confirmed by a consultant physician.

   (f)        Stroke: A cerebrovascular incident resulting in permanent neurological damage. Transient ischemic attacks are specifically excluded.

    (g)      Paralysis-  Complete and permanent loss of the use of two or more limbs as a result of injury or disease of the brain or spinal cord. To establish permanent paralysis must normally have persisted for at least 6 months.  

   (h)       Aorta-Surgery: The actual undergoing of surgery (including key hole type) for a disease or injury of the aorta nesding excision and surgical replacement of the disease part of the aorta with a graft.

   (i)        Heart valve replacement/surgery: The undergoing of open heart surgery on the advice of a consultant cardiologist, to replace or repair one or more heart valves.”

   8.       On reading of clause (B) of the note defining critical illness, I find that so far as heart ailment is concerned, critical illness benefit has been extended under the policy for critical coronary heart by-pass graft surgery and the clause specifically provides that balloon angioplasty, laser or any catheter based procedures are not covered under the critical illness benefit. The State Commission relying upon the exclusion clause has allowed the appeal and set aside the order of the District Forum. I do not find any fault with the aforesaid interpretation of critical benefit clause by the State Commission, which may call for interference in exercise of the revisional jurisdiction. Revision petition is accordingly dismissed with no order as to cost.