IMPORTANT POINT
When a particular illness is not covered in the terms of the policy, no amount can be claimed and repudiation of such claims cannot be interfered.

V.K. Jain, Presiding Member.—The complainant/petitioner took an insurance policy namely Home Suraksha Plus from respondent no.2 HDFC Ergo General Insurance Co. Ltd. The said policy bearing no. 2918200635-739900000, besides covering the building for purchase of which a loan had been taken by the petitioner/complainant from respondent no.1 HDFC Bank, also covered illnesses as per the standard terms and conditions of the said policy.

2. The petitioner/complainant suffered a heart attack and Angioplasty + stent of LAD was performed at Apollo BSR Hospital. He submitted a claim for payment of the policy amount which according to him, was payable on account of the heart attack suffered by him. The claim however, was rejected vide letter dated 21.04.2016, which, to the extent it is relevant, reads as under:

As per the Case Summary received; Mr. Venkar Reddy was admitted for treatment of Myocardial Infraction, we further note from the documents that the troponin level were in normal range at the time of incidence. Also we note from the ECG that this is a Non-ST segment elevation Myocardial Infraction.

Please refer to policy wording which is quoted as under:

Section 3 : Major Medical Illness

The Policy covers Myocardial Infraction provided the diagnosis.

• A history of typical clinical symptoms consistent with the diagnosis of Acute Myocardial Infraction (for e.g. typical chest pain).

• New characteristic electrocardiogram changes.

• Elevation of infarction specific enzymes, Troponins or other biochemical marker.

In this particular case there is no elevation of Troponin levels.

Also the policy has below mentioned exclusions:

• Non-ST-segment elevation Myocardial Infraction (NSTEMI) with only elevation of Troponin I or T.

• Other acute Coronary Syndromes.

• Any type of angina pectoris.

In this particular case the Myocardial Infraction is (NSTEMI) type which is not covered under policy. Hence as per the above mentioned reasons, the claim is not admissible under the policy.

3. The District Forum having allowed the complaint, the insurer approached the State Commission by way of an appeal. The State Commission having allowed the appeal and having dismissed the complaint, the complainant is before this Commission by way of this Revision Petition.

4. The certificate issued by Dr. Dilip Ratnani of Apollo BSR Hospitals to the complainant, to the extent is relevant, reads as under:

“This is to certify that Mr. Venkat Reddy, Age-35 years/Male is presented with Acute chest pain with perspiration admitted in CCU, as there were Dynamic ST-T changes in anterior leads. There was classical wellen’s sign (Biphasic T in V3 T V4-V6 acute fresh changes) on 06.05.2016 (This is classical life threatening emergency). Single Troponin level may be normal in setting of Acute Myocardial Infraction. Even with ST elevation MI we have seen normal Troponin levels (Single Reading). His coronary angiogram further reveals critical 90% stenosis of LAD and Hence he needed Angioplasty + stent of LAD as life-saving procedure.”

It would thus be seen that the complainant had 90% stenosis of LAD and therefore, required Angioplasty as well as implant of stent of LAD as life-saving procedure. As pointed out in the repudiation letter itself, the complainant was hospitalized for treatment of Myocardial Infraction but his troponin levels were in normal range at that time. It was also found from his ECG that this was a Non-ST-segment elevation Myocardial Infraction (NSTEMI).

5. Section 3 of the standard terms and conditions of Home Suraksha Plus policy to the extent it is relevant, reads as under:

Section 3. Major Medical Illness & Procedures

Insured event: For the purposes of this Section and the determination of the Company’s liability under it, the insured Event in relation to the insured, shall mean any illness, medical event or surgical procedure as specifically defined below whose signs or symptoms first commence more than 90 days after the commencement of pe