Passed  by  Shri  Atul D. Alsi, Hon’ble President.

1. The complainant filed present complainant against non disbursement of Rs.1,75,000/- for the medical treatment under the Health medical policy and thereby claiming insurance of Rs.1,75,000/- alongwith compensation and cost of litigation.

The  story  in  short.

2. The complainant availed LIC Jeevan Arogya policy table No.904 at his age of 27 years on dated 24.3.2017 bearing policy no.979593879. The complainant suffered ACUTE CORONARY SYNDROME NSTEMI and required to hospitalise at Jupiter Hospital at Pune on dated 3.10.2007 and operated on 6.10.2017 and he was discharged on 8.10.2017.  The ACUTE CORONARY SYNDROME NSTEMI is a condition of sudden reduction or blockage of blood flow to the heart and mostly caused by plague rupture or clot formation in the heart arteries.  The complainant filed insurance health claim on 14.12.2017 of Rs.1,75,000/-  and the same is repudiated for the reason of suppression of pre existing deceased of hyper tension and diabetes.  The hypertension and diabetes is not disease but it is a disorder and having no concern directly with ACUTE CORONARY SYNDROME NSTEMI. Therefore the rejection of Health Insurance claim does amount to deficiency of service and therefore present complaint is filed before Commission.
3. O.P filed reply and denied allegation of complainant. The complainant has failed to disclosed the Hyper tension and diabetes in proposal form therefore as per certificate issued by Dr. Sanket Pendse shows that the complainant was a patient of diabetics and hypertension since 2014 and as per discharge summery issued  by Jupiter  Hospital, Pune shows that patient was a chronic case of Hypertension since 2010 therefore the complainant had obtained the policy by suppressing pre-existing decease therefore  rejection of claim does not amount to deficiency of service.

                                                REASONING.

4. At the time of purchasing of policy the medical of complainant was conducted.  The Hypertension and diabetic are disorder and not deceased.  If some restrictions are imposed without taking medicine the disorder can be excluded.  The opposite party failed to filed the evidence of expert that due to Hypertension and diabetic the complainant suffer  ACUTE CORONARY SYNDROME NSTEMI  there is no evidence of physical condition of complainant and critical stage of Hypertension or Diabetic on  affidavit by the medical expert, therefore suppress of  Hypertension and Diabetic does not amount to suppression of material fact, therefore complaint is allowed and opposite party  is liable to pay Rs.1,750,00/- towards Health Insurance claim as per bill issued by Jupiter Hospital, Pune with compensation of Rs.20,000/- and cost of litigation of Rs.10,000/- as per following order.

                                                ORDER

1. Complaint is party allowed.
2. Opposite party is directed to pay Amount of 1,75,000/- towards Health Insurance Policy as per bill issued by Jupiter Hospital , Pune
3. Opposite party is also directed to pay compensation of Rs.20,000/- towards physical and mental agony and  Rs.10,000/- towards cost of litigation to complainant.
4. Copy of order be furnished to both parties, free of cost.