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

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Complt.  Case No:1179 of 2009

Date of Institution:   19.08.2009

Date of Decision  :   21.09.2010

Renu Nanda wife of Sh.K.K.Nanda, R/o H.No.266, Sector 21, Panchkula, through her G.P.A.Sh.K.K.Nanda

……Complainant

V E R S U S

The Royal Sundaram Alliance Insurance Company Ltd., SCO No.11, 1^st Floor, Sector 26, Chandigarh through its Branch Head.

.…..Opposite Party

CORAM:          SH.LAKSHMAN SHARMA                         PRESIDENT

                    SH.ASHOK RAJ BHANDARI            MEMBER

                    MRS.MADHU MUTNEJA                        MEMBER

PRESENT:     Sh.Vikas Sagar, Adv. for the complainant.

Sh.Arun Dogra, Adv. for the OP.

PER MADHU MUTNEJA, MEMBER

                The instant complainant has been filed by Smt.Renu Nanda against Royal Sundaram Alliance Insurance Company.  

1]             The facts of the case are as under:-

                The complainant had taken an insurance policy called Health forever Insurance Policy from the OP effective from 22.1.2009 to 21.1.2010.  The sum assured under the policy was Rs.5.00 lacs.

                It is relevant to mention that as per terms and conditions of the policy,  the OP had not taken or demanded any proposal form nor sought any medical certificate from the complainant at the time of issuance of policy.    A copy of the certificate of insurance along with terms & conditions supplied to the complainant have been placed at Ann.C-3 & C-4.

                Unfortunately, on 8.5.2009 the complainant suffered chest pain and was admitted to Silver Oaks Cardiac Care Centre Hospital on 10.5.2009 where she was diagnosed with “Unstable Angina”.  On 11.5.2009 Coronary angiography and angioplasty was performed on the patient with stunting by adopting procedure of Coronary Arteriography and under all Septic and Antiseptic Precaution, RFA Cannulated VIA 6F sheath.  After treatment, the complainant was discharged from the hospital on 12.5.2009.  The complainant paid Rs.1,71,418/- to the hospital towards all expenses incurred on the treatment.

                Thereafter as per the rules of insurance policy, the complainant filed a claim of Rs.1,71,418/- with the OP against medical expenditure incurred on the medical treatment of the complainant.  All these details have been placed at Ann.C-7.  The complainant was surprised that instead of releasing the claim amount, the OP repudiated the claim by taking the plea of “Pre-Existing Disease” (Ann.C-8).  No personal hearing was given to the complainant and no consideration was given to the medical documents submitted to the OP by the complainant. 

                The complainant has submitted that she has no signs or symptoms of disease on or before 8.5.2009 and took treatment for the disease for the first time on this date.  A discharge summary given by the Silver Oak Hospital also specifically certifies that the disease was not pre-existing.  The complainant thus served a legal notice dated 2.7.2009 on the OP.  The OP neither replied to this notice nor settled the claim.  The complainant has thus filed the instant complaint against the OP for settlement of her claim.

2]             After admission of the complaint, notice was sent to the OP.

              The OP in their reply have submitted that insurance cover is subject to specific terms & conditions stipulated in the policy.  The terms and conditions have been placed at Exhibits 1 & 2. 

                Mrs.Renu Nanda i.e. insured was admitted for treatment of Coronary Artery Disease along with pre-existing diabetes type-II in M/s. Silver Oaks Cardiac Care Centre from 10.5.2009 to 12.5.2009.  This fact was also mentioned in the Discharge Summary and claim form submitted by the complainant to the OP. 

                The OP has submitted that the ‘insurance’ is a contract between the ‘insurer’ and ‘insured’ and the same insured in this instant policy has agreed for the contract of the insurance and therefore terms and conditions are binding on the respective parties to this instant contract.  The exclusion clause of the policy states:-

“The Company shall not be liable under this policy for any claim in connection with or in respect of:-

a…..

b.  Any heart, kidney and circulatory disorders in respect of insured person suffering from pre-existing Hypertension/Diabetes.”

                It is submitted that the insurance policy conditions binds both the insured and insure therefore the insured cannot claim anything more than what is mentioned under the said terms.

                The OP has placed reliance on Oriental Insurance Co. Ltd. Vs. Sony Cherian (II 1999 CPJ 13 SC) where it is held that the insured cannot claim anything more than what is covered by the insurance policy. 

                The OP has stated that the present complaint is not admissible as the complainant had taken medical treatment due to a pre-existing disease and therefore, was not liable for the claim. They have therefore prayed for dismissal of the complaint.

3]             We have heard the ld.Counsel for the parties and have also perused the evidence and documents placed on record by the parties. 

4]             As per the facts of the case, the complainant had taken an insurance policy from the OP.  There were certain exclusion clauses under which the complainant was not eligible for any claim.  The complainant was admitted in Silver Oak Cardiac Care Centre with angina pain. Angina pain refers to pain in the heart.  This problem can not be classified under the heading of pre-existing disease.  Heart problem may occur to anyone at any time.  It is definitely not a pre-existing disease.  True the complainant is a patient of Diabetes-II but this ailment was not the cause for angina or heart disease due to which the complainant had to undergo Coronary angiography and angioplasty with stunting.  As per hospital records, the procedure done is as under:-

“CORONARY ARTERIOGRAPHY AND UNDER ALL SEPTIC AND ANTISEPTIC PRECAUTION, RFA CANNUNALTED VIA 6F SHETH.”

5]             We do not agree with the contention of the OP that the claim should be repudiated on the ground of pre-existing disease.  The patient being Diabetic was not the cause of the heart ailment, nor did it have any affect on the diagnosis.  The repudiation in this ground is illegal, unjustified and unsustainable.  The complainant has got herself insured and needs to be indemnified.  The disease is not pre-existing.  Even otherwise, the perusal of the Discharge Summary of the Silver Oak Hospital shows that the disease is not pre-existing. 

6]             In view of the above findings, we allow this complaint and direct the OP as under:-

i)         OP shall pay Rs.1,71,418/- to the complainant being the expenditure amount spent by her on treatment.    

ii)        OP shall also pay Rs.10,000/- as compensation to the complainant.

iii)       OP shall also pay Rs.5000/- as cost of litigation.

                The aforesaid amounts shall be paid by the OP within 30 days from the date of receipt of certified copy of this order, failing which they shall pay the amount of Rs.1,81,418/- along with interest @12% per annum, from the date of the order till its actual payment to the complainant, besides the cost of litigation.

7]             Certified copies of the order be supplied to the parties free of any charge. The file be consigned to the record room after compliance.    

Announced

21^st Sept., 2010                                                            Sd/-

(LAKSHMAN SHARMA)

PRESIDENT

                                                                   Sd/-

                                       (ASHOK RAJ BHANDARI)

MEMBER

                                                                                                Sd/-

                                                    (MADHU MUTNEJA)

MEMBER

“om”