Chandigarh

DF-II

CC/610/2016

Sahesh Karan Pathak - Complainant(s)

Versus

TATA AIG Life Insurance Company Limited - Opp.Party(s)

Vikas Jain Adv. & Ankur Bali Adv.

22 Nov 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Consumer Complaint  No	:	610 of 2016
Date  of  Institution	:	17.08.2016
Date   of   Decision	:	22.11.2017

 

 

 

 

Sahesh Karan Pathak son of Sh.Nathu R.Pathak, aged 55 years, resident of House No.80, Wadhawa Nagar, Village Dhakoli, Ziakpur, District Mohali, Punjab      

             …..Complainant

Versus

1]  TATA AIG Life Insurance Company Limited through its Managing Director, Corporate/Regd. Office 5^th & 6^th Floor, Peninsula Towers, Peninsula Corporate Park, Ganpat Rao Kadam Marg, Lower Parel, Mumbai, Maharashtra (400013).

2]  TATA AIG Life Insurance Company Limited through its Managing Director, having its Registered & Corporate Office at 14^th Floor, Tower-A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai, Maharashtra (400013).

3]  TATA AIG Life Insurance Company Limited through its Branch Manager having its Branch Office at 2^nd Floor, SCO No.232-234, Sector 34, Chandigarh

4]  TATA AIG Life Insurance Company Limited through Branch Manager having its Branch Office at SCO No.107-08, Second Floor, Sector 43, Chandigarh.

             ….. Opposite Parties

 

BEFORE:  SH.RAJAN DEWAN            PRESIDENT

                                MRS.PRITI MALHOTRA        MEMBER

                                SH.RAVINDER SINGH         MEMBER 

 

For complainant      : Sh.Ankur Bali, Advocate

For OPs              : Sh.Nitin Thatai, Advocate

 

 

PER RAVINDER SINGH, MEMBER

 

          The facts in issue are that the complainant purchased a policy called Tata AIG Life Health Protector-5 Year Guaranteed Renewable Accident & Health Product Policy No.C100544673 from OPs effective from 9.6.2007 for a total period of 18 years with maturity date 9.6.2025 where under the OPs were bound to provide benefits as per the insurance policy and type of coverage as assured was Health Protector, Accidental Death & Dismemberment Long Scale (Individual), Accidental Hospitalization Income, Total Permanent Disability, Term Benefits and Critical Illness including other benefits (Ann.C-2 & C-3).  It is averred that the complainant paid all the requisite premiums as required under the policy from time to time without any default.

         It is stated that the complainant in July/August, 2014 felt unrest and shortening of breath and as such, had gone to the Hospital for check-up where the doctor had advised for ECHO TMT as well as other test, the result of which showed Concentric LV Hypertrophy and that complainant’s heart was only 65% effective and thus, the doctor advised Coronary Angiography (Ann.C-5 & C-6).  Later on, the complainant got admitted in PGIMER, Chandigarh for Coronary Angiography on 13.9.2014 and discharged therefrom on 14.9.2014 after the treatment of Coronary Angiography.  It is also stated that the complainant incurred the expenses of Rs.1,18,629/- on the said treatment (Ann.C-7 colly) and made the payment from his own pocket.  It is further stated that thereafter, a claim was lodged with the OPs, but they repudiated the same vide letter dated 9.10.2014 on flimsy ground stating that it did not fall under the Critical Illness claim under the said insurance policy.  Alleging the said repudiation of claim as illegal and deficiency in service on the part of OPs, hence this complaint has been filed.

 

2]       The OPs have filed joint reply and while admitting the factual matrix of the case, stated that the medical record as placed on record by the complainant does not suggests that he had suffered “Heart Attack”.  It is stated that though the doctor had advised the complainant to undergo Coronary Angiography but the treatment which was taken by the complainant was not covered under the terms & conditions of the policy. It is also stated that the complainant was admitted in PGI, Chandigarh on 13.9.2014 and discharged on 14.9.2014 and underwent Coronary Angiography treatment, but since the said treatment taken by the complainant, was not covered under the terms & conditions of the policy, therefore, the claim of the complainant was repudiated vide letter dated 9.10.2014. Pleading no deficiency in service and denying rest of the allegations, the OPs have prayed for dismissal of the complaint.

3]       The complainant has also filed rejoinder reiterating the contentions as raised in the complaint.

 

4]       Parties led evidence in support of their contentions.

 

5]       We have heard the ld.Counsel for the parties and have carefully examined the facts and pleadings along with entire evidence on record.

 

6]       The complainant took Tata AIG Life Health Protector-5 Year Guaranteed Renewable Accident & Health Product Policy bearing No.C100544673 from OPs effective from 9.6.2007.  The policy was valid for total period of 18 years i.e. upto 9.6.2025 and covers critical health insurance of Rs.2.00 lacs. The complainant was regularly paying the annual premiums of the said insurance policy.

 

7]       The complainant on 29.8.2014 suffered from Cardiac Arrest and he was treated in Emm Enn Hospital, Panchkula wherein his Echo TMT and other tests were conducted.  The complainant further treated at PGIMER, Chandigarh on 13.9.2014 where Coronary Angiography leading to intra Coronary Stenting, was done. The complainant was admitted in PGIMER, Chandigarh on 13.9.2014 for the said treatment and later on discharged on 14.9.2014 after the treatment. The complainant has spent total amount of Rs.1,18,629/- on the said treatment which includes the cost of Stent, Launcher Meditronic, Maverick Monorial Balloon Bosten, RS Angioplasty Kit, Inflation Devic, Coronary Angiography, Intra Coronary Stenting, Coronary Angiography-HC, Clopivas, Insulin Syringe etc..

 

8]       The medical claim of the complainant has been rejected by the Opposite Parties on the ground that the disease of the complainant for which he was treated in PGIMER, Chandigarh is not an acute myocardial infarction (Heart Attack) and as such, is comes under the exclusion clause of the terms & conditions applicable under the policy taken by the complainant.

 

9]       The OPs has stated that Acute Myocardial Infarction contains the following conditions:-  

1. A history of typical chest pain,
2. The occurrence of typical new acute infarction changes on the electrocardiograph progressing to the development of new pathological Q waves; and
3. Elevation of Cardiac Troponin   (T or I) to at least 3 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.

 

10]      The Opposite Parties have stated that the disease suffered by the complainant is not tantamounts to a Heart Attack, hence not entitled for any claim as alleged in the complaint.

 

11]      Myocardial Infarction (MI) or acute myocardial infarction (AMI), commonly known as a heart attack, occurs when blood flow stops to a part of the heart causing damage to the heart muscle. The most common symptom is chest pain or discomfort which may travel into the shoulder, arm, back, neck, or jaw. Often it is in the center or left side of the chest and lasts for more than a few minutes. Symptoms may vary and include shortness of breath, nausea, feeling faint, a cold sweat, or feeling tired. Most MIs occur due to coronary artery disease.  A number of test like Electrocardiograms (ECGs), blood test and coronary angiography proves useful to diagnose myocardial infraction.  Electrocardiograms using blood enzyme tests or at autopsy may also help to go to the root cause of myocardial infraction (Heart Attack). Many of the factors for myocardial infraction are modifiable and are preventable.

 

12]      The complainant on the face of the record i.e. produced on file in this matter, definitely leads to the conclusion that he had suffered myocardial infraction (heart attack) but that was handled by the doctors by timely preventive action of angioplasty and by doing stenting.  Had the complainant not gone under the treatment in PGI, Chandigarh at the right time, he could have suffered most acute cardiovascular myocardial infraction, which may cause his death. 

 

13]      The contentions raised by the Opposite Parties to differentiate the Heart Attack from Angioplasty with stenting, is nothing but mere a fantasy.  The Insurance Companies cannot be permitted to exploit the innocent people/consumers and to play with their sentiments by collecting premiums, but turn down their claims on flimsy grounds.

 

14]      The documents containing exclusion clauses, has now putforth by the OPs in their defence for the purpose of defending their stand, was never explained or supplied to the complainant at the time of inception of the policy.  The Insurance Plan (Ann.C-1) Page 22 to 30 duly signed by the insured/complainant and insurance officials contain details about Exclusions for Health Protector.  The said details in the insurance policy (Ann.C-1) nowhere had any clause wherein the angioplasty and stenting is excluded from insurance cover.  The OPs cannot induct or import any hypothetical superfluous conditions only after lodging a claim by the complainant when he fell sick in 2014 after a passage of 7 years from the time he took insurance policy i.e. 2007.

 

15]      The claim of the complainant is tenable, legal and valid as per the terms & conditions applicable thereto.  The OPs suffered deficiency in service in failing to consider the claim of the complainant in right perspective.

 

16]      Keeping into consideration, the above facts & circumstances of the case, the OPs are found to be deficient in their services, as such, the complaint is allowed with directions to Opposite Parties to reimburse an amount of Rs.1,18,629/- to the complainant along with interest @6% per annum from the date of filing of the claim i.e. 26.9.2014 till payment and litigation cost of Rs.7000/-, within a period of 30 days from the date of receipt of certified copy of this order.

         In case the OPs failed to comply with the order within the stipulated period, then it shall also be liable to pay additional compensatory cost of Rs.10,000/- to the complainant apart from the above relief.

         Certified copy of this order be communicated to the parties, free of charge. After compliance, file be consigned to record room.

Announced

22^nd November, 2017                                                   

                                                                                      Sd/-  

                                                                   (RAJAN DEWAN)

PRESIDENT

 

 

Sd/-

 (PRITI MALHOTRA)

MEMBER

 

Sd/-

(RAVINDER SINGH)

MEMBER