PER JUSTICE R.C. JAIN, PRESIDING MEMBER (ORAL)

          Aggrieved by the concurrent findings and order passed by the Consumer Disputes Redressal Forum, Nadia dated 15.07.2010 passed in complaint case No. CC/10/51 and thereafter by the West Bengal State Consumer Disputes Redressal Commission in FA/554 of 2010, the insurance company who was arrayed as opposite party has filed the present petition under Section 21B of the Consumer Protection Act, 1986.

2.      The consumer dispute raised by the complainant was with regard to non-settlement of a claim under the “Invest Gain Economy Policy” taken by the complainant from the opposite party No.2.  The claim being for the reimbursement of expenditure incurred by the complainant in his medical treatment for a heart disease for which he got a permanent pace maker implanted in the heart on 23.01.2010 at a cost of Rs. 1,57,882/-, the petitioner-insurance company repudiated the claim primarily on the ground that the disease with which the complainant suffered and for which he had taken the medical treatment is not a critical disease and does not fall in the list of critical illness entitling the complainant to the reimbursement of the expenses incurred by him.  Reliance was placed

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on the terms and conditions of the policy.  Another plea raised was that the claim was made within six months of the reinstatement of the policy which falls in exclusion clause of the Exclusionary clauses.  Both the fora below have repelled the pleas and contentions of the insurance company by giving cogent reasons and directed the petitioner insurance company to settle the claim of the complainant by paying him a sum of Rs. 1,00,000/- as per the insured sum under the policy although the expenditure incurred by the complainant was to the tune of
Rs. 1,57,882/-.

3.      We have heard Mr. Pankul Nagpal, learned counsel for the petitioner/Insurance Company and have given our due consideration to his submissions.  He has invited our attention to terms and conditions of the policy copy of which appears at pages 55 onwards.  We have carefully perused the same.  The critical illness, relating to the heart disease to be covered under the policy are stated as under:

          “1. First Heart Attack:

          The death of a portion of heart muscle as a result of inadequate blood supply to the relevant area.  The diagnosis should be based on all of the following:

-      A history of typical chest pain, if any

-      New and recent electrocardiographic changes indicating myocardial infarction

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-      Elevation of cardiac enzymes

Diagnosis based on the elevation of Troponin T Test, alone shall not be considered diagnostic of a heart attack.  Angina or chest pain are especially excluded.

2.  Coronary Artery Disease requiring surgery:

The undergoing of heart surgery to correct narrowing of blockage of left main coronary artery or three or more coronary arteries with bypass grafts in persons with limiting angina symptoms and compromise of blood supply supported by investigation but excluding non-surgical techniques such as balloon angioplasty, laser relief of an obstruction or other forms of coronary artery clearing through catheters or similar devices.  Narrowing of the affected artery should be more than 75% (seventy five percent).”

4.     Our attention is then invited to the Exclusionary Clause appearing at internal pages CIB-4, which is to the following effect:

  “ Exclusions:

In the following cases, the Critical Illness Benefit shall not be paid:    

 (a)  Critical illness occurs as a result of the insured person        committing any breach of law

        (b) Critical illness existed at the date of commencement or reinstatement of risk

(c) Critical illness is diagnosed within six months of the date of   commencement or reinstatement

       (d) Critical illness as a result of AIDS related illness or HIV    infection

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(e)Critical illness as a result of self-inflicted injuries whilst sane    or insane

       (f) Critical illness as a result of war, invasion, civil war, rebellion or     riot

(g) Critical illness as a consequence of the insured person being under the influence of alcohol or drugs other than in accordance with the directions of a registered medical practitioner

(h)  Critical illness occurs as a result of the insured person taking part in any naval, military or air force operation                        

(i) Critical illness occurs as a result of the insured person   participating in or training for any dangerous or hazardous sport or competition or riding or driving in any form of race or competition

(j)   Critical illness occurs as a result of aviation, gliding or any form of aerial flight other than as a fare paying passenger of a recognized airline on regular routes and on a schedule timetable

   (k)  Critical illness as a result of failure to seek or follow medical advice.

5.      On an interpretation of the said clauses, we are not persuaded to hold that the heart disease for which the complainant got a pace maker implanted is not covered under the Critical Illness.  It would not be proper to restrict the interpretation of clause only to the situations mentioned therein and it must be extended to any other similar situation where the illness of heart required treatment.  Restricting the scope of the policy to a very minimal and which will go against the very objective

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of taking the insurance.  We are therefore in agreement with the findings recorded by the fora below on this aspect and for these additional reasons.

6.      Learned counsel then contended that the claim was made within six months of the reinstatement of the policy.  This aspect has been fully dealt with the District Forum in its order by observing as under:

          “Learned lawyer for the Ops submit that as per policy norms there is a waiting period of six months for claiming this benefit since the date of insurance, but in this case the complainant was attacked on 23.01.2010 and his policy was renewed on 24.12.2009.  But the fact remains that the original policy was purchased on 28.8.2006 and the date of next premium was fixed by the OPs as 28.8.2009 and thereafter, on 28.8.2010.  So this policy is a continuing one since 28.8.2006 which is valid upto 28.8.2026.  So no question of violating the policy rules on the side of the complainant does arise in claiming the insured money.  Ld. Lawyer for the Ops agitates that as per discharge certificate the complainant is a patient of hypertension which he did not disclose.  But from the annexed documents we find that the complainant disclosed it in para-4 that he was suffering from hypertension and he was treated by local doctor.”

7.      We have no reasons to differ from the said findings which we find it also in consonance with the legal position established over a period.

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8.      In our view the concurrent findings of the fora below are based on correct and proper appreciation of the facts and circumstances of the case and material produced on record.  The findings do not suffer from any illegality, material irregularity much less any jurisdictional error which warrants interference by this Commission.

          The Revision Petition is accordingly dismissed.