JUSTICE V.K. JAIN, PRESIDING MEMBER (ORAL)

1.      The complainant/respondent obtained a mediclaim policy (hospitalization benefit policy) from the petitioner-insurance company for the period from 14-10-2011 to 13-10-2012. At the time of taking the policy the complainant was subjected to pre-acceptance health checkup. In the said document, while replying to question No.4 under the heading ‘cardio-vascular system’, whereby he was required to disclose any medication along with name and doses, he disclosed that he was taking tablet Amlopres 5 mg once a day. The policy contained a waiting period for the certain specified diseases/ailments and in terms of the said waiting period the benefits of the policy was not available for a period of two years in respect of hypertension. The policy was later renewed for the period from 14-10-2012 to 13-10-2013. The complainant was admitted to Ace Heart & Vascular Institute on 01-04-2013 and was discharged from the said hospital on 04-04-2013. A perusal of his discharge summary would show that he was under the treatment of one Dr. Puneet Kumar Verma during his stay in the hospital. On examination of the complainant in the hospital it was found that he had hypertension (stage one and recent onset) unstable angina (ICD 120) and single vessel disease (ICD 134.137). The complainant was subjected to eco-cardiography on 01-04-2013, followed by angiography as well as angioplasty on the same day. The discharge summary also shows at the time of admission in the hospital the complainant had a complaint of retrosternal chest pain, radiating to back and shoulder for three days and he had mildly elevated blood pressure at the time of examination. However, he was not on a prior medicine for hypertension nor did he give any history of long standing hypertension.

2.      The claim of the complainant for reimbursement in terms of the mediclaim policy taken by him was repudiated by the petitioner on the ground that he had misrepresented to the hospital at the time of hospitalization by claiming that his hypertension was a recent one. Taking the view that hypertension was most prominent cause and risk factor of coronary artery disease, added force against the artery walls resulting into damage to the artery and making them vulnerable to the narrowing and plaque built up associated with atherosclerosis, the claim was rejected.

3.      Being aggrieved form the rejection of his claim the complainant approached the Chandigarh District Consumer Disputes Redressal Forum (for short, the District Forum) praying the following reliefs:

(i)      that the opposite party be directed to release amount of Rs.7,59,670/- along with 18% interest per annum till the date of realization of the amount from the date of filing of the present complaint,

(ii)      that the opposite parties be directed to compensate the complainant within amount of Rs.1,00,000/- as compensation for the mental agony and the harassment the complainant has undergone,

(iii)     Rs.33,000/- be awarded towards legal expenses borne by the complainant and

(iv)    a cost of Rs.1,00,000/- be imposed as penal charges on the opposite parties.

4.      The complaint was resisted by the petitioner on the ground that the claim was covered under exclusion clause contained in the policy since hypertension was not covered within first two years of the policy.

5.      The District Forum, vide its order dated 15-04-2014, directed the petitioner-insurance company to pay a sum of Rs.3,85,235/- to the complainant, along with interest at the rate of 9% per annum from the date of filing of the complaint till realization. The petitioner was also directed to pay Rs.20,000/- towards compensation for mental agony and Rs.11,000/- towards legal expenses.

6.      Being aggrieved from the order of the District Forum the petitioner approached the Chandigarh State Consumer Disputes Redressal Commission by way of an appeal. The said appeal having been dismissed vide impugned order dated 05-06-2014, the insurance company is before us by way of this revision petition.

7.      Having drawn our attention to the pre-acceptance health checkup report dated 13-10-2011 whereby it was disclosed that the complainant was taking one tablet of Amlopres 5 mg per day and the exclusion clause which is clause No.4.3 of the policy the learned counsel for the petitioner submits that since the complainant was suffering from hypertension at the time of pre-acceptance health checkup on 13-10-2011 and he underwent angiography and angioplasty within two years from the said date, the claim was clearly inadmissible, as hypertension was the cause of coronary artery disease which required angioplasty in the hospital.

8.      It can hardly be disputed that at the time the complainant was examined before accepting the proposal for medical coverage, he did have hypertension. It would be difficult for us to say that without suffering from hypertension he was taking Amlopres 5 mg which is a well-known medicine to control hypertension.

9.      In view of the clause 4.3 of the policy, there being a waiting period of two years for certain ailments including hypertension, the petitioner would not be liable to make payment under the policy if the treatment  which the complainant had undergone at the hospital was for a disease caused by hypertension.

10.    Clause 4.1 of the policy reads as under:

          “Pre-existing diseases/condition: All diseases/injuries/conditions, which are pre-existing when the cover incepts for the first time (except as shown hereunder). Any complication arising from pre-existing disease/ailment/injury will be considered as a part of pre-existing condition. This exclusion will be deleted after four consecutive claim free policy years provided there was no hospitalization for the pre-existing disease/ailment/condition/injury during the said four years of insurance with our Company.”

          Thus, neither hypertension which was a pre-existing disease/condition, nor any complication of hypertension would be covered for two years.

11.    If an insurance company wants to repudiate the claim on the ground that it was excluded under the terms of the policy issued by it, the onus would be on the insurance company to prove that the claim rejected by it fell within the purview of the exclusion clause. Therefore, it was for the petitioner-company to establish, before the District Forum that the coronary artery disease from which the complainant was suffering at the time of admission in the hospital was caused by hypertension form which he was suffering. The submission of the learned counsel in this regard is that hypertension is the sole cause of a coronary artery disease and since the complainant admittedly had hypertension at the time he was subjected to pre-acceptance checkup on 13-10-2011 the obvious inference would be that the coronary ailment was directly attributable to the hypertension from which the complainant was suffering. However, no medical literature has been produced before us to show that hypertension can be the only cause for a person developing a coronary artery disease at a later date. No one can dispute that hypertension is one of the conditions which can later cause coronary artery disease (CAD), but in our opinion it would not be correct to say that only hypertension can be the cause of a coronary artery disease. In our view, the coronary artery disease can be caused by several factors which inter alia would include hypertension but it is neither necessary that every person having hypertension would certainly have a coronary artery disease at one stage or the other in his life, nor can it be said that a person who does not have hypertension will never develop a coronary artery disease. Therefore, it was imperative for the petitioner to establish, before the District Forum that it was the hypertension which had caused the coronary artery disease for which the complainant was treated at the hospital between 01-04-2013 to 04-04-2013.

The petitioner has not placed before us all the documents which the parties had filed before the District Forum. Therefore, we do not have the benefit of going through all those documents. However, a perusal of the order of the District Forum would show that vide letter dated 02-04-2013 which was annexure C-7 to the complaint, Dr. Puneet Kumar Verma, Director and Chief Cardiologist, Ace Heart & Vascular Institute had written to Raksha TPA Pvt. Ltd., the third party agent engaged by the petitioner-company, stating therein that there was no evidence of LVH on echo of the patient. It further shows that the CAD of the patient, as determined by the coronary angiography did not seem to have been governed by the recent onset of hypertension. The order of the District Forum also shows that the doctors of Max Hospital where the complainant was earlier hospitalized for treatment of some other ailment did not prescribe any medicine to him for hypertension. In the opinion of Dr. Puneet Kumar Verma, the signs and symptoms of CAD were not likely to have bearing with hypertension. On perusal of the certificate of Dr. Puneet Kumar Verma dated 13-03-2014 (Exhibit C-9), the District Forum noted that the complainant was normotensive (having normal blood pressure) and non-diabetic and he had no history of hospitalization on account of hypertension.

12.    Since the petitioner did not produce any evidence such as opinion of a doctor to prove that the single vessel disease from which the complainant was found to be suffering at the time of admission in the hospital was caused by hypertension, whereas the opinion of the doctor who treated the complainant in Ace Heart & Vascular Institute clearly indicated that hypertension was not the cause of the complainant developing a coronary artery disease, we cannot accept the contention that the ailment of the complainant was covered by the exclusion clause contained in the insurance policy. In any case, the scope of our revisional jurisdiction being extremely limited i.e. to ensure that the order passed by the fora below is not without jurisdiction and does not suffer from any illegality or perversity, we will not be justified in interfering with the concurrent finding of fact recorded by the District Forum and the State Commission with respect to the cause of the ailment for which the complainant was treated in Ace Heart & Vascular Institute. Considering the material available to the District Forum, it cannot be said that no reasonable person, acting on the said material could have recorded the finding which the District Forum recorded and the State Commission accepted in this case.

12.    For the reasons stated hereinabove, we find no merit in this revision petition and the same is hereby dismissed.