15-06-2016 Heard Mr. Ashutosh Anand, learned counsel appearing for the O.P.-appellant- (the Insurance Company for short) on the prayer for condoning the delay in filing the appeal as well as on merits.
- The case of the complainant in short was as follows. He had taken Health Insurance Policy from the Insurance Company, effective from 6.12.2012 for 20 years for a sum assured of Rs. 5,00,000/-. When he felt chest pain, he consulted the Doctors and got himself admitted in Apollo Hospital, Ranchi on 13.11.2013 from where he was discharged on 25.11.2013. He paid Rs. 1,99,000/- to the Hospital towards the cost of hospitalization, treatment and medicines. He lodged insurance claim but it was declined wrongly vide letter dated 28.1.2014.
- The case of the Insurance Company in short was as follows. The condition with which the complainant was diagnosed did not and could not in any way be termed as Cardio Arrest / Heart Attack within the realm and definition of medical science, and that the claim was rightly repudiated on the ground that the heart condition suffered by the complainant did not meet the criteria under the Critical Illness benefit of Health Investor Policy as indicated in the letter of repudiation dated 28.01.2014.
- The learned District Forum interaila held as follows;
“Admittedly, complainant was suffering from chest pain. An artery was found blocked and a medicated stent was placed. It was a very serious condition and if in such a heart ailment is not compensable, what other disease, will be required for grant of re-imbursement. The O.P. has imposed conditions, which cannot be fulfilled, and have been placed only to escape payment of compensation. It amounts to defrauding and cheating the policy holder. Though the terms and conditions, it is not open to insurance company to provide such particulars and details of the disease which quite often do not appear and which may provide a ground to the insurance company to avoid payment of compensation. Symptoms appearing in all kinds of heart ailment cannot always be the same and not always be the same and merely because all symptoms are not 100% the same, the insurance company cannot avoid compensation. The ailment suffered by the complainant was highly serious and life threatening and the purpose of the agreement must be such as to provide benefit for such serious heart disease.
Under the circumstances, we find and hold the O.P. deficient in providing service to the complainant and is found guilty of unfair trade practice.
Accordingly, complaint is allowed. O.P. is directed to reimburse the total medical hospitalization and treatment cost of Rs.1,99,000/- (Rs. One lac ninety thousand) only with interest @ 9% per annum from the date of repudiation of the claim dated 28.01.2014 till the date of payment. O.P. is also directed to pay compensation of Rs. 20,000/- towards deficiency in service to the complainant within 45 days from the date of this order.
- Learned counsel for the Insurance Company submitted that the claim did not qualify the policy conditions and therefore it was rightly repudiated. He referred to the letter of repudiation dated 28.01.2014. He also submitted that the complainant was also the agent of the Insurance Company. He lastly submitted that a high rate of interest has been awarded and that too from the date of repudiation of the claim along with high amount of compensation.
- We are surprised to note the peculiar policy condition mentioned in the letter of repudiation dated 28.01.2014 which reads as follows;
“As per the contract, a claim for heart attack qualifies for the benefit under the critical illness on the first occurrence of an
acute myocardial infarction where all the following three conditions are met.”
(i) A history of typical chest pain
(ii) The occurrence of typical new acute infarction changes on the electrocardiograph progressing to the development of new pathological O waves, and
(iii) Elevation of Cardiac Troponin (T or l) at least three times the upper limit of the normal reference range or an elevation in CK MB to at least 200% of the upper limit of the normal reference range”.
- It appears that such conditions were made only to frustrate the insurance claims. It amounts to unfair trade practice. There cannot be mathematical accuracy in the case of Human Body and illness. The complainant proved that he suffered from chest pain. An artery was found blocked, where a medicated stent was placed, in the Hospital, and his life could be saved.
- After hearing Mr. Ashutosh Anand at length and perusing the papers carefully. The award of interest and compensation is reasonable. In our opinion, even if, the delay of about 78 days in filing this appeal is ignored, no grounds are made out for interfering with the impugned order.
Accordingly, this appeal is dismissed.
Issue free copy of this order to all concerned for information and needful.
Ranchi,
Dated:- 15-06-2016
