On 31.7.2008, complainant Kuldeep Kumar, applied for taking Tata AIG insurance policy, bearing product name ‘Invest Assure Gold-5 years’ from the opposite parties for insured amount of Rs.5,00,000/-. Its premium of Rs.50,400/- was payable six monthly. The insurance policy was issued, effective from 28.8.2008. On 28.9.2008, the complainant fell ill and was admitted in Sukhda Hospital, Hisar. He was discharged from the hospital on 4.10.2009. He was diagnosed for suffering from ‘Pulmonary Embolism’. For it complainant received, medical treatment from number of hospitals, including from Sir Ganga Ram Hospital, New Delhi, Complainant filed his medi claim with the opposite parties, which was repudiated, vide letter dated 27.1.2010 on the ground that his claim does not fall within the terms and conditions of the insurance policy, as his illness cannot be termed as ‘critical illness’. Averring the repudiation of his claim, as deficiency of service, on the part of the opposite parties, complainant has filed, this complaint, on 16.4.2010, for a direction to the opposite parties for payment of insured amount of Rs.5,00,000/-, with up to date interest, besides compensation for his harassment and litigation expenses.
2. Opposite parties, in their joint reply, have pleaded for the legality and validity of filing of the claim of the complainant. It is pleaded that Pulmonary Embolism is not ‘critical illness’ as per terms and conditions of the insurance policy. It is also pleaded that symptoms of said disease, to the complainant, had started appearing even 2-3 months prior to July,2009 and as such, the case of the complainant, falls in exclusive clause of the insurance policy and so there is no deficiency of service on the part of the opposite parties.
3. Both the parties to the complaint have placed on record copies of various documents, to prove aforesaid undisputed material facts, including copy of insurance form, terms and conditions of the insurance and medical treatment record of the complainant.
4. We have gone through the record of the case carefully and have heard learned counsel for the parties. We are of the considered opinion that there is no merit in this complaint and so it deserves dismissal.
5. Simple question before this forum is as to whether or not ‘Pulmonary Embolism,’ disease is ‘critical illness’ as per terms and conditions of Insurance policy, covered in the insurance policy ? ‘ Critical illness’ has been defined in the policy as under:-
“Critical illnesses” means illnesses, the signs or symptoms of which, first commence more than 180 days, following the Issue Date or Commencement Date or the date of any reinstatement of this supplementary contract, whichever is the latest and shall include either the first diagnosis of any of the following illnesses or first performance of any of the covered surgeries stated below:-
- Cancer
- Stroke
- Heart Atack
- Coronary Bypass Graft Surgery
- Kidney Failure
- Major Organ Transplant”
6. Further as per medical literature on record ‘Pulmonary Embolism’ has been described as under :-
“Pulmonary Embolism(PE) is a blockage of the main artery of the lung or one of its branches by a substance that has travelled from elsewhere in the body through the bloodstream (embolism). Usually this is due to embolism of a thrombus(blood clot) from the deep veins in the legs, a process termed venous thromboembolism. A small proportion is due to the embolization of air, fat, talc in drugs of intravenous drug abusers or amniotic fluid. The obstruction of the blood flow through the lungs and the resultant pressure on the right ventricle of the heart leads to the symptoms and signs of PE. The risk of PE is increased in various situations, such as cancer or prolonged bed rest.
Symptoms of pulmonary embolism include difficult breathing, chest pain on inspiration, and palpitations. Clinical signs include low blood oxygen saturation and cyanosis, rapid breathing, and a rapid heart rate.
Severe cases of PE can lead to collapse, abnormally low blood pressure, and sudden death”.
7. Therefore, ‘Pulmonary Embolism’ has nothing to do with aforesaid six diseases of critical illness namely Cancer, Stroke, Heart Atack, Coronary Bypass Graft Surgery, Kidney Failure, Major Organ Transplant. Pulmonary Embolism is not even directly or indirectly related to these six diseases and therefore it cannot be said that complainant was suffering from any ‘critical illness’ as per terms and conditions of the insurance policy. Therefore his claim was not entertainable by the opposite parties.
8. Learned counsel for the opposite parties, has also contended that even symptoms of pulmonary embolism, had appeared to the complainant 2-3 months prior to his admission in that hospital, so his claim is also time barred. We have considered the contention, but find no merit in it. Of course as per medical record,(page A-56), the complainant was having, passed history of chest trauma 2-3 months back prior to his admission in that hospital on 20.9.2008. Therefrom at the most, it can be said that symptoms had appeared 2-3 months prior to his admission dated 28.9.2009, meaning thereby symptoms appeared , in the month of June or July,2009. But the insurance policy, came into operation only from 28.8.2008 onwards. Therefore, symptoms of pulmonary embolism, had appeared certainly after said period of 180 days from the date of commencement of the policy. Therefore, it cannot be said that claim of the complainant is time barred or is not covered, because of appearance of the symptoms of the deceased on that date. Moreover in the case in hand, pulmonary embolism, was diagnosed, not on said symptoms, but on the basis of subsequent medical tests much after his admission in the hospital.
9. Learned counsel for the complainant, has also cited ‘ L.I.C. of India & Another Versus Kailash Chandra Kar. I,(2009),CPJ,373’. We have gone through this ruling, but find that it has no bearing, on the facts of the case in hand as in hat case, complainant had undergone open heart surgery for change of the valve and his claim was being denied, on the ground that said surgery was not covered under said chronic bypass graft surgery. The contention was repealed. It is held that said surgery, was covered in that bypass graft surgery and so claim was entertainable. On the other hand, in the case in hand, as above discussed and found ‘ Pulmonary Embolism’ is not at all covered, in any of aforesaid six diseases. It is not even remotely related to any one of them and so claim of the complainant is not entertainable by the Insurance Company. Therefore repudiating the claim of the complainant, cannot be said as unjustified or deficiency of service on the part of the opposite parties.
Resultantly, this complaint is hereby dismissed, but with no order as to costs.
Announced. President
Dated:05.03.2015 District Consumer Disputes
Redressal Forum, Hisar
Member/05.03.2015
