IMPORTANT POINT
Angiography cannot be called a case of critical illness.

Anup K. Thakur, Presiding Member—This Revision Petition No.3265 of 2015 has been filed by the petitioner/complainant – Bhupinder Kumar against the order of the Punjab State Consumer Disputes Redressal Commission, Chandigarh (for Short, ‘State Commission) dated 23.12.2014 in FA No.658/2012 vide which his insurance claim under critical illness cover was denied.

2. Brief facts relevant for the disposal of this revision petition are as follows.

3. As per the petitioner/complainant, he has been associated with the respondent opposite party Bajaj Allianz Life Insurance Co. since 2005, first as an insurance consultant and presently as a Sales Manager. He had taken an insurance policy No.0010996742 dt. 28.9.2005 from the respondents/opposite parties. He had suffered a heart-attack on 29.4.2007 and was admitted in Patiala Heart Institute from 30.4.2007 to 2.5.2007. Later, he was shifted to Dayanand Medical College and Hospital, Ludhiana where he remained from 19.6.2007 to 20.6.2007. Angiography was conducted and a stent was fixed. The complainant spent an amount of Rs.2.50 lakh for his treatment. He lodged his claim with the Insurance Company but till date his claim has not been paid, despite e-mail reminders, letters. Therefore, he filed a consumer complaint before the district forum and prayed for the following relief:-

4. To pay Rs.1 lakh as compensation on account of mental agony, tension, inconvenience, harassment and humiliation suffered by the complainant.

5. To pay Rs.15,000/- as litigation expenses.”

6. The District Forum on consideration of the pleadings before it, allowed the complaint and directed the opposite parties to make payment of Rs.2 lakhs to the complainant within one month with 9% interest p.a. from the date of the order as also Rs.7,500/- as cost of the complaint.

7. Being aggrieved, the opposite parties – Insurance Company had filed an appeal before the State Commission. The State Commission in its order dt. 23.12.14 allowed the appeal and set aside the order of the District Forum. It held that repudiation of the claim was justified and correct in terms of the critical illness policy provisions, explaining that it was not for the district forum to go beyond what was specifically provided in the policy itself.

8. Being aggrieved with this order, the petitioner/complainant has filed this revision petition before this Commission.

9. Heard learned counsel for both parties and perused the records of the case, including the policy covering critical illness.

10. It is not in dispute that the petitioner did undergo an angiography procedure in which a stenting was fixed. The issue for consideration is whether this falls within the policy parameters which define ‘critical illness’.

11. The District Forum reasoned that even though “balloon angioplasty is excluded from the heart surgery to correct narrowing of blockage of left main coronary artery or three more arteries with by-pass grafts, but it will not be correct to say that coronary angiography (single vessel disease) is not to be treated as a critical illness because the complainant had the history of typical chest pain noted in the discharge card Ex C 10, of Patiala Heart Institute, where the complainant was admitted on 30.4.2007 and discharged on 2.5.2007 and also noted in the discharge summary Ex C 11 that the patient had a history of chest pain, radiating to arms associated with sweating and dysponea on exertion 1 ½ months back.” It went on to conclude that “the repudiation of the claim of the complainants by the ops was made mechanically and without application of mind to the facts and was based on the narrower interpretation of the definition of the critical illness in the life insurance policy Ex C2.”

12. The State Commission, on an appreciation of the facts of the case, reasoned that “For determining the critical illness, it was not the effect of the treatment so given to the complainant, for the treatment of his ailment, which was to be considered but it was the di