IMPORTANT POINT
Pre-existing disease cannot be inferred.

This revision is directed against the order of the Punjab State Consumer Disputes Redressal Commission, Chandigarh (in short, “the State Commission”) dated 5.3.2015 in first appeal No.234/2012 whereby the State Commission concurred with the finding of the District Forum, SAS Nagar, Mohali and dismissed the appeal preferred by the petitioner/opposite party.

2. Shorn off unnecessary details, facts relevant for the disposal of the revision petition are that the complainant’s wife had purchased Happy Family Floater Policy covering self and family members, from the petitioner/opposite party. The policy was valid w.e.f. 22.2.2011 to 21.2.2012. On 23.3.2011 complainant suddenly developed some breathing problem. He was, therefore, taken to Medanta Global Health Pvt. Ltd., Sector 38, Gurgaon. On check-up the complainant was diagnosed suffering from heart problem. Complainant was admitted in the hospital where he underwent valve replacement surgery on 17.5.2011. Complainant was discharged from the hospital on 28.5.2011. After discharge, the complainant submitted insurance claim for reimbursement of expense of Rs.4,30,850/- incurred on his treatment. The petitioner/insurance company, however, repudiated the claim on the ground that the claim was not payable in view of clause 4.1 and 4.2.

3. Being aggrieved of the repudiated of the claim, complainant filed a consumer complaint which was resisted.

4. The District Forum on consideration of pleadings and the evidence came to the conclusion that the repudiation of insurance claim was not justified and directed the petitioner/opposite party as under: -

“The complaint is, therefore, allowed against OP No.1, who is directed to reimburse to the complainant medical expenses of Rs.4,41,346/- and to pay him costs of litigation to the tune of Rs.10,000/- out of the aforesaid amount, it should pay interest to the complainant @ 9% per annum on Rs.4,30,850/- w.e.f. 28.5.2011, on Rs.3,500/- w.e.f. 19.8.2011 and on Rs.6,996/- w.e.f. 5.9.2011 till the date of actual payment. Certified copies of this order be furnished to the parties forthwith free of cost and therefore the file be consigned to the record room.”

5. Being aggrieved of the order of the District Forum the petitioner preferred an appeal. State Commission, Punjab, however, did not find merit in the appeal and dismissed the same. This has led to filing of the revision petition.

6. Learned Shri Mohan Babu Agarwal, Advocate for the petitioner has taken us through clause 4.1 of the insurance policy and submitted that the Fora below have passed the impugned order in utter disregard of the aforesaid term of the contract. Expanding on the argument learned counsel submitted that the insurance policy was taken on 22.2.2011 and the husband of the insured, namely, the complainant was taken to the hospital on 23.3.2011 and he underwent valve replacement surgery in May, 2011. It is argued that mere fact that the valve of the heart of the complainant was damaged is a clear indication that the patient was having a pre-existing disease for a long time prior to purchase of insurance policy.

7. We have considered the submissions made on behalf of the petitioner and perused the record. We are not convinced with the submission made by learned counsel for the petitioner because the petitioner has failed to point out any evidence whatsoever to indicate that the complainant who is husband of the insured, underwent any treatment pertaining to heart problem or he was ever diagnosed as the heart patient before the purchase of insurance policy. Merely because the complainant had underwent valve replacement surgery in May, 2011 it cannot be assumed that he was suffering from heart problem which led to valve replacement since prior to the purchase of the insurance policy on 22.2.2011. Thus, we do not find any fault with the concurrent finding of the Fora below which may call for interference in exercise of revisoinal jurisdiction.

8. In view of the discussion above, we do no