Per Shri P.N. Kashalkar, Hon’ble Presiding Judicial Member

1.       We heard appellant in person and Mr.Deepak Sharma, Advocate for the respondents.

2.       We are finding that this appeal has been filed by the original complainant whose complaint was dismissed by the District Consumer Disputes Redressal Forum, South Mumbai by order dated 05/05/2010.

3.       There is delay of 18 days in filing this appeal for which condonation of delay application No.315/2010 has been filed.  Just and sufficient cause has been made out in the condonation of delay application which is supported by the affidavit.  Since, it is the appeal filed by the complainant himself, we do not want to impose cost while allowing the condonation of delay application preferred by the appellant.  We allow the condonation of delay application and condone the delay to decide the appeal on merits.

4.       The appellant had taken medi-claim policy in the year 2001.  He had renewed the medi-claim policy every year.  The assured sum was `1 Lakh.  It was Hospitalization and Domiciliary Hospitalization Benefit Policy.  Besides amount assured, the complainant was to receive cumulative bonus of `25,000/-, if in case he does not claim any medi-claim in any year.  For every year `5,000/- was payable.  The sum assured was `1 Lakh and cumulative bonus was `25,000/- [@ `5,000/- for each year for which he had not claimed any medi-claim].  It so happened that in February 2007 he had approached Dr.Dilip Patil, who took ECG and Dr.Dilip Patil then found some difficult situation and therefore, he suggested that the complainant should get done Echo 2D Test.  Accordingly said test was undergone by the complainant in Wockhardt Hospital, who after conducting the test suggested the complainant to do Angiography.  Accordingly, on 11/06/2007 he got admitted in P.D. Hinduja National Hospital where he had done Angiography at the hands of Dr.Chandrashekhar Ponde.  After discharge from the said hospital, he lodged medi-claim for the amount of `26,148/- with the respondent/Insurance Company.  Respondent/Insurance Company after considering the papers submitted by the appellant repudiated the claim on the ground that the claim was for pre-existing disease.  Respondent informed the appellant that appellant was having Hyper Tension for the last 20 years and therefore, when he purchased medi-claim policy, he was already having disease of Hyper Tension and heart ailment for which he had got done Angiography in P.D. Hinduja Hospital on 12/06/2007.    Angiography of the Coronary vessels of the heart was the known complication of Hyper Tension.  So, it was covered under the caption pre-existing disease as mentioned in exclusion clause 4.1 of the policy.  Not satisfied with the repudiation letter sent by the respondent/Insurance Company he approached the Insurance Ombudsman by filing representation.  Insurance Ombudsman carefully considered the case of the appellant and opined that the claim was rightly repudiated by the Insurance Company since Mr.Kanchan was admittedly having Hyper Tension since last 20 years and it was under control by medicine and he had not disclosed this fact while taking this policy first time in the year 2001.  The Learned Ombudsman also mentioned in his order that –

“It was well established in Medical Science that hypertension is a risk factor for cardiac diseases and coronary diseases are more frequent in those who have BP than in those who are normal.  As per the policy condition Insurer shall not extend to pay any expenses incurred relating to the pre-existing diseases and for consequences attributable thereto or accelerated thereby or arising therefrom.  In view of this the Company has rejected the claim.”

So, the Ombudsman came to the conclusion that the complainant’s case is covered under the exclusion clause No.4.1 and therefore, the insurance claim preferred was not tenable in law and he confirmed the repudiation passed by the Insurance Company. 

5.       Not satisfied with the Ombudsman’s order, the complainant approached the District Consumer Forum by filing consumer complaint and District Consumer Forum on considering the facts and circumstances of the case, in its reasoned order held that the complainant was having pre-existing disease of Hyper Tension for last 20 years and therefore, the Insurance Company was within its right not to honour the insurance claim on the ground of pre-existing disease i.e. Hyper Tension for which the appellant was under medication for last 20 years though he had taken medi-claim policy for the first time in the year 2001.

6.       In the course of hearing before us, we also asked the appellant, whether he had taken medicine for Hypertension, he answered in the affirmative which would clearly go to show that the appellant is a person having Hyper Tension for last 20 years i.e. even before he had purchased medi-claim policy in the year 2001.  This is being so, his case squarely attracted exclusion clause No.4.1 of the Insurance Policy.  In the circumstances, we are of the view that the District Consumer Forum rightly dismissed the complaint upholding the repudiation made by the Insurance Company or its Agent.  We are finding no substance in the appeal preferred by the org. complainant.  In the circumstances, appeal is liable to be dismissed.  Hence, we pass the following order :-

                             -: ORDER :-

1.       Misc. Appl. No.315/2010 for condonation of delay is allowed.  Delay is condoned.

2.       Appeal No.610/2010 stands dismissed.

3.       Parties are left to bear their own costs.

4.       Copies of the order be furnished to the parties.