ORDER (ORAL)

V.K. Jain, Presiding Member—The complainant/respondent obtained a mediclaim policy from the petitioner company for the period from 31.01.2011 to 30.01.2012 which was later on renewed for the period from 31.01.2012 to 30.01.2013. The complainant suffered from some heart ailment and was taken to Government Hospital Chandigarh. From there he was shifted to PGI Chandigarh in September 2012. He underwent angioplasty incurring expenses of Rs. 3,44,703/- on his treatment. The claim lodged by him which was repudiated by the letter dated 03.11.2012 written by the TPA to the insurer and filed by the complainant along with the consumer complaint. The said letter, to the extent it is relevant, reads as under:-

“1. PATIENT SUFFERED FROM CORONARY ARTERY DISEASE, HYPER TENSION. AS PER THE MEDICAL RECORDS AVAILABLE, PATIENT IS KNOWN CASE OF HYPERTENSION FROM 5-6 YEARS AND PATIENT ALSO HAS HISTORY OF OLD INFERIOR WALL MYOCARDIAL INFARCTION. POLICY IS IN 2nd YEAR OF INCEPTION. HYPERTENSION IS CAUSE OF CAD. THEREFORE THE CLAIM IS NON PAYABLE AS PER CLAUSE 4.1 (PRE-EXISTING DISEASE).

2. PATIENT HAS SUFFERED FROM HYPERTENSION, CORONERY ARTERY DISEASE, CHOLELITHIASIS, ‘RENAL CONCRETIONS