IMPORTANT POINT
Insurance Company cannot apply a hard and fast rule to presume that complainant was suffering for long duration before taking policy.

Dr. S.M. Kantikar, Member —The present Revision Petition has been filed before this Commission under Section 21(b) of the Consumer Protection Act, 1986 against the impugned order dated 27.03.2014 in Appeal No. 96 of 2014 passed by the State Consumer Disputes Redressal Commission (in short, ‘State Commission’). The State Commission dismissed the appeal which was filed against the orders passed by the District Consumer Disputes Redressal Forum, (in short, ‘District Forum’) in Complaint No. 210/2013, whereby the complaint was allowed.

2. The facts in brief are that the complainant took Mediclaim Policy 2007 (Hospital Benefit Policy) from New India Assurance Company Limited, the OP/Petitioner for total cover of Rs.11 lacs. It was in force from 31.05.2011 to 30.05.2012, thereafter renewed again, which was effective from 31.05.2012 to 30.05.2013. During subsistence of policy the Complainant suffered severe chest pain on 19.10.2012 and got admitted in Mukat Hospital, Chandigarh. On the same day an angiography was performed in the same hospital, thereafter, he took further treatment at Delhi Heart & Lung Institute, New Delhi where he was operated as Coronary Artery Bypass Graft/surgery on 23.10.2012 and discharged on 31.10.2012. The Complainant filed the claim form along with Raksha TPA on 15.11.2012. After scrutiny the Petitioner/OP repudiated the claim on the basis of exclusion clause 4.3 of the terms and conditions of the policy, stating that Complainant was suffering from pre-existing disease Hypertension, Diabetes Mellitus, which are the known risk factors of Coronary Artery Disease. Thus the compliant filed a complaint before the District Forum alleging the deficiency in service by OP in repudiating his genuine claim and prayed for total compensation of Rs.3,34,929/-.

3. The District Forum allowed the complaint with the directions to the OP to reimburse the medi-claim amount of the Complainant to a tune of Rs.2,24,929/- and to pay Rs.50,000/- as compensation for mental agony and harassment and Rs.7,000/- as cost litigation charge with interest @ 18% p.a.

4. The OP/Petitioner Company being aggrieved with the order of the District Forum preferred the First Appeal No. 96 of 2014 before the State Commission, Chandigarh, which was again dismissed.

5. Aggrieved by the order of State Commission this revision petition has been filed.

6. We have heard the Counsel for the petitioner at admission stage. He stressed upon the fact that the complainant concealed his preexisting disease; he was suffering from Diabetes and Hypertension. He brought our attention to the hospital records like Lama Summery of Mukat Hospital, Chandigarh and Discharge Summery of Delhi Heart & Lung Institute, Delhi. On perusal of both records we find there is a mention of Essential Hypertension and Diabetes Mellitus. But, it is quite surprising that, no where it was stated that, the duration of diabetes/hypertension that how long the complaint was suffering. Therefore, it appears to be a just vague , which did not carry any evidentiary value. Even also, the OP did not produce any evidence to prove that which medication and for how long the complainant was taking for diabetes/hypertension. The counsel vehemently argued that, diabetes and hypertension are chronic diseases, having long duration, but as per the complainant it was diagnosed after 19 months of taking the policy. It is known that, many times the healthy persons are unaware of such silent aliments of diabetes and hypertension, which come to their knowledge first time during health checkup camps or in any emergent situation. Thus, OP can not apply a hard and fast rule to presume that, the complainant was suffering for long duration i.e. before taking the policy. Therefore, we are not convinced with this argument. No doubt the medical literature states that, the Hypertension and Diabetes are risk factors for Coronary Artery Disease, but the OP failed to prove that those diseases were pre-existing in this case.