The central legal point established is the interpretation of critical illness under the insurance policy and the validity of the insurance claim in relation to the defined terms and conditions.

JUDGMENT :

Mr. Justice Gurdev Singh, President-The appellants/opposite parties have preferred this appeal against the order dated 5.3.2012 passed by District Consumer Disputes Redressal Forum, Patiala (in short, “District Forum”), vide which the complaint filed by the respondent/complainant, Bhupinder Kumar, under Section 12 of the Consumer Protection Act, 1986, was allowed with Rs.7,500/-, as costs and the opposite parties were directed to pay him a sum of Rs.2,00,000/- within one month of the receipt of the certified copy of the order and failing that to pay interest at the rate of 9% per annum from the date of the order.

2. The complainant alleged, in his complaint, that he was working with the opposite parties and had taken the insurance policy dated 28.9.2005 from them, which was still continuing on the date of filing of the complaint. On 29.4.2007 he suffered heart attack for which he was admitted in Patiala Heart Institute at Patiala and remained admitted for his treatment from 30.4.2007 to 2.5.2007. The doctors of the Hospital preferred for angiography and he was shifted to Dayanand Medical College & Hospital, Unit Hero DMC Heart Institute, Ludhiana (in short, “DMC”) where he remained admitted from 19.6.2007 to 20.6.2007. At that place angiography was conducted by Dr. Naved Aslam and a stent was fixed. After his treatment, he lodged his claim with the opposite parties. On that treatment, he had spent Rs.2,50,000/- from his own pocket and mentioned that amount in his claim. His genuine claim was wrongly declined by them without properly considering the same. He sent number of e-mails, reminders and letters to the opposite parties to reconsider his genuine claim and to allow the same but they refused to do so. All these facts and circumstances show that there was clear-cut deficiency in service on the part of the opposite parties, who indulged in mal-practice and unfair trade practices. As a result thereof, he suffered mental agony, tension, inconvenience, harassment and humiliation and for the same he is entitled to Rs.1,00,000/-, as compensation, besides the claim amount of Rs.2,50,000/- and Rs.15,000/-, as litigation costs. He prayed for the issuance of directions accordingly to the opposite parties.

3. The complaint was contested by the opposite parties, who filed joint written reply before the District Forum. In their reply they admitted that the complainant was working with them and had obtained the Policy in question and that he submitted his claim for Rs.2,50,000/- under that Policy, which was disallowed. While denying the other allegations made in the complaint, they pleaded that the complainant had opted for critical illness benefit of Rs.2,00,000/-, which was payable under the diagnosis of any of the critical illness, which was covered under the Policy. It was mentioned in the Discharge Card of Patiala Heart Institute itself that there were no complications during the stay of the complainant in the Hospital and was being discharged in satisfactory condition. Heart attack has been defined in the Policy terms and conditions and it means the death of a portion of heart muscle as a result of inadequate blood supply to the relevant area. The basis of diagnosis of heart attack is also mentioned in the Policy terms. None of the medical document provided by the complainant indicated that he suffered the heart attack. Even his diagnosis does not fall under the definition of Coronary Artery Disease' requiring surgery as defined in the Policy. As per the terms of that Policy, P.T.C.A. with stenting is not covered under any of the critical illness. Therefore, the claim of the complainant was rightly rejected/repudiated by them, vide letter dated 1.9.2007 and he is not entitled to any such amount of Rs.2,50,000/- alleged to have been spent on his treatment. It cannot be said that there was any deficiency in service, mal-practice or unfair trade practice on its part and, as such, the complainant is not entitled to any compensa