JUDGEMENT

          Complainantby filing this complaint has submitted thatcomplainant is a World Billiards Champion held in Bangalore, India on 25.08.1990 and complainant is also a Dhyanchand Awardee and is currently the Chief National Cur Sports Coach of India and the complainant has been coaching the National Team since 2003.

          Fact remains that the complainant had purchased a family medical policy from the op wherein the sum insured was Rs. 2 lacs and the said policy was purchased on 05.04.2002 as per proposal form dated 04.05.2011 and same has been renewed from time to time, year after year and all the premiums have been duly paid by the complainant to the op and the said policy was ultimately renewed from 04.05.2011 to 03.05.2012.

          In February, 2011 the complainant had opted for Super Top Up Medicare where the sum insured was Rs. 5 lacs and the complainant has paid the premium accordingly and on 05.09.2011 complainant was ready to board a flight to Myanmar for coaching, suffered a sudden chest pain at the Calcutta International Airport and for which he did not avail of the said flight and complainant was taken to Apollo Hospital at E.M. Bypass and admitted under Dr. P.C. Mondal on 05.09.2011.

          He was discharged from the hospital on 09.09.2011 and the complainant incurred a total treatment cost of Rs.3,46,289/- and so the complainant lodged a claim with the op when a sum of Rs.1,75,000/- was paid as cash less and a sum of Rs.10,042/- was paid on account of cost of medicine of post hospital treatment.

          On 23.09.2011 the complainant raised a claim for the remaining amount of Rs.1,46,289/- for reimbursement under Super Top Up Medicare Policy.  But after repeated persuasions the matter was taken up by the ops, but suddenly on 17.10.2012 complainant found that his bank account was credited with a sum of Rs.30,000/- without having receipt or intimation of payment advice of the complainant by the op.

          Since 02.11.2012 complainant kept constant touch with M/s Heritage Health T.P.A., the agency responsible for disbursement for claims requesting them to inform the complainant as to why only Rs.30,000/- was paid against a total claim of Rs.1,46,289/-.  Thereafter ultimately by an e-mail dated 21.02.2013 the op informed the complainant that claim under Super Top Up Medicare Policy cannot be admitted due to existing disease in terms of clause No. 4.1 of the said policy.

          Complainant has alleged that complainant had no pre-existing disease in September, 2011 and in the year 2004, complainant had suffered a mild chest pain and was admitted in Surakhsa Hospital under Dr. Suresh Choraria and an Angiogram was done which revealed a double vessel disease for which medical management was recommended and since then nearly 7 years had already lapsed andtherefore, clause 4.1 of the STMP cannot be made applicable to the complainant.

          Complainant has submitted further that the Super Top Up Medicare Policy is an in addition to the original policy wherein the sum insured was Rs.2,50,000/- which has been topped up to Rs. 5 lacs and an additional premium of Rs.6,399/- was paid by the complainant to the op.  Further complainant stated that the complainant did not suffer from any ailment or injury or related conditions or had sign or symptom or was diagnosed or received medical advice/treatment within 48 months prior to Super Top Up Medicare Policy with the complainant.

          Since after 2004 the complainant has been accompanying Indian National Team to various sports meets from March, 2005 till July, 2011 to various countries and the details of such trips of the complainant with the Indian Team as National Coach would appear from a schedule annexed with the complaint.

          In the above circumstances, complainant has made allegation about deficiency in service on the part of the op for not paying the balance amount of Rs.1,16,289/- to the complainant.  By reason of inaction of the op, the complainant suffered mental harassment and humiliation, frustration and lost his peace of mind for which the complainant has prayed for redressal and for directing the op to refund of Rs.1,16,289/- as final claim against the op.

          On the other hand op United Insurance Company Ltd. by filing written statement submitted that the entire allegation is baseless and without any foundation.

          Present claim is not maintainable in view of the fact that complainant took individual Health Insurance Policy (Gold) having its inception dated 04.05.2002 covering the risk of reimbursement of hospitalization expenses of himself, his wife and his daughter subject to terms, conditions, exceptions and limitations thereof and thereafter in the year 2007-08, the sum insured value with cumulative bonus stands at Rs. 2,30,000/-  and in the year 2008-09 the sum insured value stands at Rs.2,50,000/- for the complainant/insured and in the process the said policy stands renewed for the relevant period 04.05.2011 to 03.05.2012.

          During such continuation of the earlier policy, the insured took out a Super Top Up Medicare Policy in addition to the existing Individual Health Insurance Policy which was valid for the period from 04.05.2011 to 03.05.2012.  It is further alleged that Individual Health Insurance Policy-2010 bearing Policy No. 030300/48/11/97/00000682 valid for the period from 04.05.2011 to 03.05.2012 (IHIP) was running simultaneously with the Super Top Up Medicare Policy bearing No.030300/48/11/36/00000649 valid for the period from 04.05.2011 to 03.05.2012(STMP) and the said Individual Health Insurance Policy for the year 2011-2012 inter-alia covers the sum insured value of Rs.2,50,000/- for the insured and the said Super Top Up Medicare Policy for the relevant year covers the sum insured value of Rs.5 lacs with threshold limit of Rs.2 lacs.

          The concept of Super Top Up Medicare Policy lies with the fact that it has the relevant Individual Health Insurance Policy as the base policy and the Super Top Up Medicare Policy cover comes into play once the coverage of total sum insured value under the Individual Health Insurance Policy gets saturated.

          In the instant case, the reimbursement of the portion of medical expenses spent during hospitalization together with post hospitalization medical expenses were settled from the said insurance coverage under Individual Health Insurance Policy by the concerned TPA.  It is a matter of record the cashless payment to the extent of Rs.1,75,000/- and cashless reimbursement of medicine post hospitalization to the extent of Rs.10,042/- have been made by the TPA from the coverage of the said Individual Health Insurance Policy.  That apart within the purview of clause 4.1 of the relevant Individual Health Insurance Policy  a further sum of Rs. 30,000/- (portion of sum insured plus cumulative bonus under the said policy above threshold limit of Rs. 2 lacs which appears running from the year 2007, was further granted.  Therefore a total sum of Rs.2,05,000/- for hospitalization and Rs.10,042/- for post hospitalization for medicine were paid to the insured out of his total claim of Rs.3,46,289/-.

          Now the complainant claims for the remaining balance of Rs.1,16,289/- as per content paragraph 8 at page 5 and paragraph 15 at page 7 of the complaint and it is clear therefore the said TPA could not disburse the remainder claim beyond saturation of the threshold limit of the said Individual Health Insurance Policy from the coverage of Super Top Up Medicare Policy.

          It is further submitted that remainder portion of claim for a sum of Rs.1,16,289/- could not have been disbursed under coverage of Super Top Up Medicare Policy for the fact that admittedly the insured has a pre-existing disease of heart which has been described as IHD by the TPA and the fact has been admitted by the complainant at paragraph 9 and at page 5 of complaint and as per exclusion clause 4 and 4.1 of the relevant Super Top Up Medicare Policy conjointly states that the company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of any pre-existing disease as defined in the policy, until 48 months of continuous coverage of such insured person have elapsed, since inception of his/her Super Top Up Medicare Policy with Company and therefore it is crystal clear that at the inception of a new policy (Super Top Up Medicare Policy, the pre-existing disease, condition)in this case known symptoms and disease of double vessel heart disease and the related heart complication for which the insured was treated has been excluded from the coverage of the said Super Top Up Medicare Policy till expiry of 48 months from the date of inception and in the instant case the admission in the hospital was  made on 05.09.2011 i.e. after 4 months from the date of inception of the said policy and as such as per clause 4.1 of the relevant policy, the reimbursement under the said policy could not have been allowed.  Therefore the claim of the complainant has been rightly settled by the said TPA within the purview and scope of the relevant Individual Health Insurance Policy.

          It is further submitted that the insurance policy is a contract between the insured and the insurer and the terms and conditions which embodies the said policy are binding on both the parties to the insurance policy, neither of the parties can depart from the said terms and conditions and in the event if there is a departure, the coverage under the policy including the policy itself ceases to exist.  It is stated that the insured never objected to the terms and conditions as set forth in the said policy (Super Top Up Medicare Policy) and hence no extended meaning can be imposed to the said exclusion clause 4.1 by canvassing a fallacy.

          Further it is specifically submitted that admittedly the complainant had his pre-existing symptoms and/or related ailment of heart disease prior to inception of Super Top Up Medicare Policy, therefore until 48 months have elapsed from the date of inceptions of such policy, i.e. after 03.05.2015, the insured is entitled to have the benefit of coverage of re-imbursement of medical expenses spent on treatment of said pre-existing heart disease and/or symptom and this rational disentitles the insured from coverage of the said Super Top Up Medicare Policy.

          Further it is submitted that when the claim of the complainant has been settled within the four corners and ambit of the relevant Individual Health Insurance Policy the alleged plea of utter negligence and deficiency of service on the part of the op does not arise at all in as much as the complainant is not legally entitled to the balance claim of Rs.1,16,289/- along with interest of Rs.62,797.06/- as calculated by the complainant and also any damages as claimed.  So, the claim of the complainant should be dismissed along with further prayer for cost etc.

          It is specifically averred that the complainant had double vessel heart disease since the year 2004 and the said sign/symptom/disease was there throughout those years until it further aggravated in the year 2011.  It is therefore the Super Top Up Medicare Policy was incepted with the said pre-existing heart disease/symptom/sign and as such any reimbursement of medical expenses could not have been made prior to elapse of 48 months i.e. 4 years from the date of such inception of policy i.e. after 04.05.2015.

          Moreover it is submitted that as because the complainant is a coach of Billiards Team it does not prove that the complainant has not been suffering from any heart ailment or disease.  But it can be said that the said disease was controlled but not cured and he was under medication and therefore accompanying Billiard Team does not prove that the complainant was cured of his heart disease just after the year 2004 till the year 2011 and in the above circumstances, op has prayed for dismissal of this case.

Decision with reasons

After hearing arguments from both the sides at length and on proper consideration of the evidences on record including the material documents that is Super Top Up Medicare Policy No. 030300/48/11/36/00000649 and also Individual Health Insurance Policy No. 030300/48/11/97/00000682.  It is found that the Individual Health Insurance Policy – 2010 was continued since 04.05.2002 and the present particular policy has valid from 04.05.2011 to 03.05.2012 and sum assured was Rs. 2,50,000/- in respect of Manoj Kumar Kothari.  Whereas in respect of STMP being No. 030300/48/11/36/00000649 was valid for the period from 04.05.2011 to 03.05.2012 and it was a fresh policy and sum insured was Rs. 5 lacs whereas threshold sum insured was Rs. 2 lacs and validity period of the policy was from 04.05.2011 to 03.05.2012.

Considering both the policies it is found that STMP is completely a fresh policy which was opened by paying premium of Rs. 5,800/- on 28.04.2011 and the proposal form was also fresh in nature and in the said policy condition, it is specifically mentioned that the disease appears pre-existing disease at the time of opening the policy and no claim is admissible under STMP until 48 months is over.

Admitted fact is that complainant was admitted at hospital on 05.09.2011 and was discharged on 09.09.2011 from Apollo Gleneagles Hospital with a history of chest pain and profuse sweating prior to his admission and he was admitted in Cardiology Units of the said hospital and during final diagnosis it was detected that he was suffering from Acute Antero Septal Wall ST elevated Myocardial Infraction (Thrombolised Occlusion in Proximal LAD) severe triple vessel Coronary Artery disease with total thrombolised occlusion in Proximal LAD and PercutenousTransluminal Coronary Angioplasty with Stenting to LAD was done and Diabetes Mellitus Type II detected after admission.  During treatment Coronary Angiogram was done and percutenousTransluminal Coronary Angioplasty with stenting to LAD was also done. 

So, from the said discharge summary dated 09.09.2011 issued by Apollo Gleneagles Hospital it is found that on 05.09.2011 he was admitted with chest pain and after diagnosis it was detected that it was Acute Antero Septal Wall ST elevated Myocardial Infraction and severe triple vessel Coronary Artery disease with total thrombolised occlusion in Proximal LAD.  Fact remains that STM Policy was started from 04.05.2011 and it was valid up to 03.05.2012 and it is also found that he was admitted with severe heart disease on 05.09.2011 and practically he suffered from Acute Antero Septal Wall ST elevated Myocardial Infraction severe triple vessel Coronary Artery disease with total thrombolised occlusion in Proximal LAD.  So, consulting this discharge summary and this Super Top Up Medicare Policy, it is found that the present complainant was admitted to hospital with severe heart disease within 4 months from the date of opening the fresh policy of STM Policy on 28.04.2011.  No doubt the threshold sum insured was Rs. 2 lacs and sum insured was Rs. 5 lacs in case of one member of family of the complainant if he or she was admitted and wants to get hospitalization benefit and other.

So admitted position is that complainant had his one policy i.e. Individual Health Insurance Policy which was valid from 04.05.2011 to 03.05.2012 and that policy was continuing since 2002 and sum assured was Rs.2.5 lacs with CB was Rs.2,30,000/-.  Fact remains that complainant for his treatment as Apollo Gleneagles Hospital spent Rs. 3,46,289/- that was the hospitalization charge and initially cashless benefit of Rs.1,75,000/- and cashless reimbursement was Rs.10,042/- and subsequently another Rs.30,000/- were released against Individual Health Insurance Policy No.030300/48/11/97/00000682 and it is undisputed fact.

But entire dispute is in respect of non-release of further amount of Rs. 1,46,289/- and in the present case complainant has tried to convince that as because he has his STM policy.  So, he prayed for release of said disputed Rs.1,46,289/- from the sum assured of Rs.5 lacs against that policy.  But it is admitted fact that he has already received of Rs.2,05,300/- against IHI policy.  But as because IHI policy is for sum assured of Rs.2,50,000/- and complainant claimed disputed amount of Rs.1,46,289/- from new policy i.e. STM policy which was opened on 04.05.2011 and it was valid up to 03.05.2012.

But it is undisputed fact that complainant was suffering from Acute Antero Septal Wall ST elevated Myocardial Infraction, failed Thrombolysis and severe triple vessel Coronary Artery disease with total Thrombolised occlusion in Proximal LAD for which Coronary Angiogram and PercutenousTransluminal Coronary Angioplasty with Stenting to LAD were done during the period from 05.09.2011 to 09.09.2011.

It is fact that complainant’s said claim was repudiated on the ground that the complainant had been suffering from pre-existing such disease prior to opening of the STM policy on 04.05.2011 and that was suppressed but before opening the STM policy on 04.05.2011 he had been suffering from heart ailment continuously.  But as because he was under medication so the present acute heart disease and heart dysfunction could not be aggravated but when medication failed it was aggravated and Coronary Angiogram and PercutenousTransluminal Coronary Angioplasty with Stenting to LAD were performed and for which the ops decided the matter after consulting medical papers and repudiated the claim on the ground that he had his pre-existing disease and as per clause 4.1 of the STM Policy, complainant is not entitled to get any hospitalization cost or treatment cost for such treatment of heart ailment as per provision of clause 4.1 of the policy document as he had been suffering from pre-existing disease i.e. acute heart trouble dysfunction of  heart prior to opening of the STM policy on 04.05.2011 and this is the findings of the settlement of claim under STM policy by the ops.

It is the submission of the Ld. Lawyer for the complainant that prior to 04.05.2011(i.e. on the date of purchasing of STM Policy) complainant had not been suffering from any heart disease because he is a world famous Billiard Snookers and he had been leading so many billiard teams all over the world and he was quite okay and the present ailment for which the complainant was admitted to Apollo Gleneagles Hospital on 05.09.2011 was sudden one.  So, the entire repudiation as made by the op is uncalled for and their decision is bias in nature and complainant had never been suffering from any heart ailment prior to opening of this policy and for which the repudiation made by the op is baseless and for which complainant is entitled to get that amount against STM policy.

Whereas Ld. Lawyer for the op submitted that complainant at the time of submitting the proposal form in connection with STM policy, did not disclose his pre-existing disease (acute heart ailment).  So, he has violated the terms and conditions of the policy and further he did not submit any such medical report in respect of his suffering from heart ailment since 2004 and in this regard Ld. Lawyer for the complainant submitted that on earlier occasion he was admitted to Suraksha Institute of Cardiovascular disease on 17.07.2004 with same type of complaint of chest pain and which was radiating to the left arm and jaw when he was 46 years old and at that time Coronary Angiogram was done on 19.07.2004 and CAG shows lesion in posterior descending artery of RCA and OM1 of Cx and at that time he was admitted under Dr. Suresh Choraria and he was advised to follow the advice of Dr. Suresh Choraria as per his prescription.  Complainant has admitted that he was admitted and their prescription is genuine and if the said prescription is taken into account in that it is clear that on 17.07.2004 he was suffering from descending artery of RCA and OM1 of Cx and it was detected after Coronary Angiogram.

Thereafter he was under medication at per advice of Dr. Suresh Choraria of Suraksha Institute of Cardiovascular Disease.  Most interesting factor is that complainant has suppressed that matter in the present complaint.  He has also not produced any subsequent report of Dr. Suresh Choraria or of other doctors that after medication herecovered from such ailment and he had no heart problem.  So, it is clear that since 17.07.2004 complainant has been suffering from acute heart trouble and dysfunction of heart and heart disease for which he was under constant medication.  So, his disease was under control.  But when the medication failed the said heart disease was aggravated and finally at the age of 53 years he was admitted to Apollo Gleneagles Hospital and heart disease was diagnosed and for which Acute Antero Septal Wall ST elevated Myocardial Infraction, failed Thrombolysis and severe triple vessel Coronary Artery disease with total thrombolised occlusion in Proximal LAD were performed.  So, it is clear that he had his pre-existing heart disease prior to purchasing a STM policy on 04.05.2011 that was suppressed.  So, after considering that report of Suraskhadated 21.07.2004 in respect of this complaint and also the present discharge certificate issued by Apollo Gleneagles Hospital on 09.09.2011 it is found that latest hospitalization on 05.09.2011 at Apollo Gleneagles Hospital of the complainant and his heart treatment i.e. Coronary Angiogram and PercutenousTransluminal Coronary Angioplasty with stenting to LAD were done on the ground he had been suffering from Acute Antero Septal Wall ST elevated Myocardial Infraction, failed Thrombosis and severe triple vessel Coronary Artery disease with total thrombolised occlusion in Proximal LAD and that was first detected during his treatment from 17.07.2004 to 21.07.2004 and thereafter he was under the treatment of Dr. Suresh Choraria and that discharge advice of Dr. Suresh Choraria dated 21.07.2004 also speaks that complainant was advised to follow the advice of Dr. S. Choraria and as per his prescription and for which it is proved from the document of the complainant that complainant was continuously suffering from heart disease and dysfunction of heart since July, 2004 and further it was submitted by the Ld. Lawyer for the op Insurance Co. that there is or was no document issued by any hospital authority or any doctor that complainant recovered from such heart ailment after treated by Dr. S. Choraria at any time between July-2004 to 05.09.2011 and practically complainant suppressed all those medical papers only to get the entire benefit of the present hospitalization cost, only to show that he had not been suffering from any pre-existing disease.

Fact remains that as per policy condition if there is any pre-existing disease of heart of any person (insured) at the time of opening or purchasing the policy and after purchasing the policy if any hospitalization cost is claimed by any such insured for his heart treatment, for his heart ailment he is not entitled to get it as pre-existing disease only 48 months of the policy is covered.  But in this case no doubt 48 months has not covered from the date of purchase of the present STM policy on 04.05.2011 and for which subsequent disputed claim was repudiated by informing him in details by a letter and that letter is marked Exhibit-F by the complainant and complainant has also filed his present treatment sheets Exhibit-E and previous treatment sheet of Surakshaof the year 2004 as Exhibit-C.  So, the present complaint must be dismissed on the ground that repudiation was justified legal and valid and as per terms and conditions of the policy.

On over all evaluation of the entire materials on record and arguments as advanced by the Ld. Lawyers of both the parties and also considering the very principle as laid down in several verdict of National Commission and presently as reported in 2013 (4) CPR 165 NC we have gathered that the parties of a policy shall be governed by the policy condition and no exception or relaxation can be made on the ground of equity also.  So, it is clear that in the present case also the complainant and the ops are strictly governed by the present policy terms and conditions and fact remains that present insured is not entitled to get any benefit in respect of any claim of hospitalization cost until the present policy covers 48 months.  But after completion of 48 months from the date of purchase of present STM policy, complainant is entitled to get benefit of the claim of any pre-existing disease.

But the moot question is whether the complainant had been suffering from any pre-existing heart ailment prior to purchase of the present STM policy on 04.05.2011 and in this regard we have gathered through discharge summary of Apollo Gleneagles Hospital dated 09.09.2011 that the doctor finally diagnosed that complainant had been suffering from Acute Antero Septal Wall ST elevated Myocardial Infraction, failed Thrombolysis and severe triple vessel Coronary Artery disease with total thrombolised occlusion in Proximal LADand after considering the medical journal and also the medical authoritative book on Cardiovascular disease, it is found that such a disease is not sudden one.  But such diseases are old in one and it was continuous in nature and it was always pre-existing and due to medication final stage of acute heart dis-function could not be aggravated and if any patient is under continuous treatment for heart disease which is previously detected may be controlled but cannot be cured but same is aggravatedin form of Acute Antero Septal Wall ST elevated Myocardial Infraction, failed Thrombolysis and severe triple vessel Coronary Artery disease with total thrombolised occlusion in Proximal LAD.  So, the discharge summary issued by Apollo Gleneagles Hospital supports that complainant had been suffering from such severe heart disease prior to his admission on 05.09.2011 and such a disease generally does not occur suddenly, but present aggravated position of the heart of the complainant was caused due to his pre-existing heart problem and so considering that theory we have come to know that complainant had been suffering from any heart ailment prior to his admission on 05.09.2011 and in this regard we have gone through the medical discharge summary of past disease issued by Suraksha  Institute of Cardiovascular Disease on 21.07.2004 and we have gathered that complainant at first was a patient of descending artery of RCA and OM1 of Cx and it was detected on 17.07.2004 after Coronary Angiogram.  Thereafter he was under constant advice of Dr. S. Choraria and he was also advised to follow his prescription that means since 19.07.2004 he was under constant medication as per advice and prescription of Dr. Suresh Choraria but no prescription of Dr. Choraria is filed in this case and that has been suppressed.

After studying the particular chapter of Cardiovascular Disease of Indian Institute of Medical Science bulletin it is found that descending artery of RCA and OM1 of Cx means Myocardial Infarction and other artery vessels related dysfunction.  So, it is clear that complainant has been suffering from the present disease Myocardial Infarction and lesion in posterior descending artery disease since July-2004 and it was primary stage of heart disease of the complainant which was detected in the year 2004 in the month of July by Suraksha.  Thereafter complainant was under constant medication of Dr. Suresh Choraria and it was caused at the age of 46 years of the complainant and it was aggravated in the month of Sept. 2011 when he was admitted and ultimately Coronary Angiogram and PercutenousTransluminal Coronary Angioplasty with stenting to LAD was done and after studying the chapter Cardiovascular disease and his treatment etc. we have gathered that the procedure as adopted to give relief to the present complainant in respect of his pre-existing heart disease was the final form of treatment when medication fails and considering the prescription of Suraksha dated 21.07.2004 and particularly the discharge advice of the said prescription and also the discharge summary of Apollo Gleneagles Hospital and after comparative study of the same and nature and character of the supporting point of the disease of the complainant and aggravated from the said disease the treatment as given by the Apollo Gleneagles Hospital was confirmed treatment and it is specifically mentioned in the authoritative books of Cardiovascular disease that initial stage the heart disease may be controlled by medication but no heart ailment can be cured without Coronary Angiogram and PercutenousTransluminal Coronary Angioplasty with Stenting to LAD and other method of treatment  in this regard i.e. placing of stem cells change of bulb etc. and other various procedure as adopted by doctors as per line of treatment as adopted by various doctors of America and England.

But truth is that complainant is a patient of heart dysfunction and ailment since 19.07.2004 and he was under constant medication of Dr. Suresh Choraria and in between 19.07.2004 to 05.09.2011 he never recovered from his heart ailment but by medication it was controlled and after studying the theory of treatment in case of Cardiovascular Disease as we findfrom different books of medical sciences we have gathered that at initial stage heart dysfunction and artery disease by medication can be controlled.  But it is opinion of the world famous doctors that patient cannot recover from such heart ailment without adopting Coronary Angiogram and PercutenousTransluminal Coronary Angioplasty with Stenting to LAD or placing stem cell or by some other procedure adopted by changing balloon etc.  it is also specifically mentioned in those books that medicines can temporarily give relief but it is specifically mentioned by world famous doctors that once heart disease is detected by medication same cannot be fully cured and even after Coronary Angiogram and other adopting process no doubt the heart functioning system can be restored but conditions are there that the patient shall have to maintain certain advises and in the present case we have gathered after consultation with those medical papers and the opinion of the authoritative  doctors particularly one Dr. R.N. Chatterjee (since dead) we have gathered that once heart disease particularly in respect of Coronary Artery dis-function or Myocardial infarction cannot be cured by medication.

So, it is proved beyond any manner of doubt that complainant was a heart patient (dysfunction of heart) with Myocardial infarction and Coronary Angiogram disease since 2004 and at the time of purchasing the present STM policy he was suffering from that disease.  But it was under control only by medication but that has been suppressed at the time of purchasing the policy.  But anyhow the doctor of Apollo Gleneagles Hospital confirmed that complainant had been suffering from Acute Antero Septal Wall ST elevated Myocardial Infraction, failed thrombolysis and severe triple vessel Coronary Artery disease with total thrombolised occlusion in Proximal LAD and the above disease were not sudden in nature but it was continuation of first detected disease posterior descending artery of RCA and OM1 of Cx.  So, it is proved that complainant had been suffering from heart ailment and dysfunction of heart since 2004 and at the time of opening the present policy that was suppressed for which the present disputed amount cannot be released in view of the fact as per provision 4.1 clause of the terms and conditions of the policy and the complainant is not entitled to any claim in respect of hospitalization cost for his pre-existing disease till the policy completes 48 months from the date of inception of that policy.  But in this case just after purchase of the present STM policy by the complainant within 4 months his pre-existing disease and dis-function of heart and artery disease were aggravated and final method of treatment was performed and no doubt his heart is functioning but he is not free from heart disease.

Considering the above fact and materials we are confirmed that complainant cannot go beyond the terms and conditions of the policy and there is no question of showing any equity even if it is proved that he is a world famous billiard champion coach because admitted fact is that the status of the insured cannot be considered by the Consumer Forum.  What the Consumer Forum shall have to consider whether as consumer in any consumer is found deprived from getting any services as per contract of the policy or any document or for unethical purpose,but in this case Insurance Company has given full benefit of his earlier policy Individual Health Insurance Policy which was continuous in nature since 2002 and released Rs.2,05,300/- and fact remains in respect of the said policy i.e. Individual Health Insurance Policy that was highest in nature.

It is to be mentioned in this regard that the Health Individual Insurance Policy is continuous in nature from 2002 to 2012 whereas STM policy started in the year 2011 and it was valid up to 2012.  But it is completely a new policy and there is no legal ground to come to a conclusion that STM policy is continuation of Individual Health Insurance Policy.  But anyhow the complainant’s Ld. Lawyer has tried to show that it is continuation.  But after studying the policy’s terms and conditions and nature and character of the two policies and after evaluation of the said two policies it is found that some areseparate in nature and in respect of STM policy complainant is not entitled to any claim in respect of his pre-existing disease until and unless the policy covers 48 months to complainant’s but claim the present disputed amount is claimed within 6 months from the date of opening of the policy and for which complainant is not entitled to any relief from the op or from this Forum, in view of the fact as per terms and conditions of the policy, the ops rightly repudiated the present claim.  Another factor is also considered after thorough study and evaluation that Insurance Company for giving him relief took all positive steps to give highest amount of the said insurance policy from old Individual Health Insurance Policy covering the entire sum assured including bonus.

So, in this regard it can safely be said that ops rendered their all services as per terms and conditions of the policy by giving highest relief as per terms and conditions of Individual Health Insurance Policy, but repudiation of the STM policy is justified, legal and not any circumstances this Forum cannot show any equity only considering the status of this complainant because status of the consumer should not be considered by any Forumon the ground the spirit of law is that the Forum shall have to consider the grievance of the consumer but not the status of the consumer.  But in the present complaint practically complainant has tried to convince that he is world famous billiard snooker, so he is entitled to that.  Anyhow painfully we are dismissing the complaint on the ground that complainant was suffering from heart ailment at the time of purchasing the Super Top Up Medicare Policy but he suppressed the fact that he had been suffering from such severe heart disease or Coronary heart disease and Myocardial infarction etc.

In the result, the complaint fails.

Hence, it is

ORDERED

That the complaint be and the same is dismissed on contest without any cost against the op.