State Consumer Disputes Redressal Commission
Bajaj Allianz Life Insurance Company ... vs Alok Kumar Lunia on 6 March, 2013
CHHATTISGARH STATE
CONSUMER DISPUTES REDRESSAL COMMISSION
PANDRI, RAIPUR(C.G.)
Appeal No.FA/12/631
Instituted on : 05.11.2012
Bajaj Allianz Life Insurance Company Limited,
Through - Branch Manager,
1st Floor, Shyam Shakuntalam Complex, Nehru Nagar
Bhilai, District Durg (C.G.) ... Appellant.
Vs.
Alok Kumar Lunia, S/o Late Shri Jaswant Kumar Lunia,
R/o : S.M. 31, Near Omkeshwar Temple, Padmnabhpur,
Durg, Tehsil and District Durg (C.G.) ... Respondent.
PRESENT: ‐
HON'BLE JUSTICE SHRI S.C. VYAS, PRESIDENT
HON'BLE SMT. VEENA MISRA, MEMBER HON'BLE SHRI V.K.PATIL, MEMBER COUNSEL FOR THE PARTIES: ‐ Shri Manoj Prasad, for appellant.
Shri R.B. Sharma, for respondent.
ORAL ORDER Dated: 06/03/2013 PER: ‐ HON'BLE JUSTICE SHRI S. C. VYAS, PRESIDENT This appeal is directed against order dated 27.07.2012 of District Consumer Disputes Redressal Forum, Durg (C.G.) (hereinafter called "District Forum" for short), in Complaint Case No.51/2012, whereby the appellant/Insurance Company, has been directed to pay Rs.5,00,000/‐ within a period of one month from the date of order to the respondent/complainant and also to pay interest thereon @ 7% p.a. // { PAGE \* MERGEFORMAT } // from the date of filing of the complaint till date of payment. It has further been directed to pay Rs.1,000/‐ as compensation for mental agony and Rs.1,000/‐ as cost of litigation.
2. Undisputedly, respondent/complainant obtained Bajaj Allianz Invest Gain Platinum Insurance Policy from the appellant/Insurance Company under which risk was covered w.e.f. 31.03.2010 and under Critical Illness Rider of the insurance policy, it was agreed that Rs.5,00,000/‐ will be paid to the policy holder in case of first heart attack and some other illness, which have been mentioned in the insurance policy. The case of the respondent/complainant before the District Forum was that on 23.03.2011, he suffered chest pain and when it did not subside, then on 25.03.2011, he attended clinic of a qualified physician. His ECG was taken in the clinic and it was opined that he had suffered first heart attack. Thereafter he was referred to higher medical centre. He took treatment at Jaslok Hospital, Mumbai from 29.03.2011 to 01.04.20112 and was subjected to many tests including Angiography. Ultimately, it was diagnosed that he suffered Ischemic Heart Disease i.e. Acute Coronary Syndrome and treatment was provided for that. Grievance of the complainant is that he preferred a claim before the Insurance Company for payment of Rs.5,00,000/‐ on account of his sufferance of first heart attack, which comes in the // { PAGE \* MERGEFORMAT } // category of Critical Illness Benefit Rider, but the Insurance Company repudiated the claim on the ground that as it was not first heart attack, therefore, the Insurance Company is not liable to pay any amount to the complainant.
3. The case of the appellant/Insurance Company before the District Forum was that in the Certificate, which was received from treating Doctor, ECG has shown ST‐T changes and there is no ST Elevation. It has been averred that ST‐T changes is not cover under Critical Illness mentioned under Policy terms & conditions and claim was repudiated by the Insurance Company, because the respondent/complainant has not suffered any critical illness and there was no such first heart attack.
4. Learned District Forum after having considered the material placed before it by both parties, did not agree with the defence of the appellant/Insurance Company and allowed the complaint by the impugned order.
5. After having heard arguments advanced by both parties and having gone through the record of the District Forum, we are of the view that this appeal does not have any merit, and merely some relief // { PAGE \* MERGEFORMAT } // to the appellant/Insurance Company, can be granted in respect of direction of payment of interest on the awarded amount.
6. Learned counsel for the appellant has placed very heavy reliance upon an affidavit of Dr. Manoj B. Bhise, Chief Medical Officer, Bajaj Allianz Life Insurance Co. Ltd., Head Office, Pune and submitted that this affidavit has not been taken into consideration by the District Forum. He submitted that Dr. Manoj Bhise, in his affidavit has stated that he is a doctor, who has got specialization in Cardiology and he has studied the treatment papers of the respondent/complainant and found that his illness does not fall under the First heart Attack as defined in the Policy terms and conditions, because ECG did not show ST Elevation, left sided ST‐T changes.
7. We find that treatment papers of the respondent/complainant of Jaslok Hospital, as well as Certificate issued by Dr. M.P. Chandrakar, who attended the respondent/complainant on the first occasion, when he suffered chest pain, has been brought on record as Annexure A‐5. Jaslok Hospital, Mumbai after conducting angiography, has certified that there was 100% blockage as large thrombosis in Left artery (main) and there was 30% blockage in another right main artery, which supplies blood to the heart. Thus were two blockages in the main right and left arteries and Coronary Angio Report clearly says that // { PAGE \* MERGEFORMAT } // "ELECTTIVE PTCA TO LAD OF LMWH AND GPIIb/IIIa." The Certificate issued by Dr. Chandrakar (Annexure A‐5), further shows that he was the person, who took ECG after sufferance of chest pain by the respondent/complainant. It has been certified by him that chest pain was suggesting cardiac pain and ECG showed ST/T changes in leads 1, avL and leads V1‐6. When this ECG was compared to the previous ECG of 16/02/2010, which was normal suggesting these changes have been found to be a fresh changes, therefore, he was referred to a higher centre.
8. After going through the entire treatment papers of the respondent/complainant, Certificate of Dr. M.P. Chandrakar and Report of Angiograph, we are convinced that respondent/complainant suffered heart attack in the form of Ischemic pain and there was 100% blockage in one of the main artery, associated with 30% blockage in another main artery, which cannot be termed anything else than heart attack in the form of Ischemic pain. Thus, the respondent/complainant suffered first heart attack, which was properly taken care of by timely treatment and examinations.
9. In the Discharge Ticket of Jaslok Hospital, Mumbai, it has been stated that illness of the respondent/complainant, has been diagnosed as Ischemic Heart Disease (Acute Coronary Syndrome) and this // { PAGE \* MERGEFORMAT } // Discharge Ticket conclusively proves that respondent/complainant had suffered first heart attack. In view of this, learned District Forum has not committed any error in passing award in favour of the respondent/complainant.
10. So far as direction of the District Forum, regarding payment of interest on the amount of award, is concerned, we are of the view that such direction should have been from the date of order of the District Forum and not from the date of filing of the complaint. Considering the facts of the case, the impugned order is modified to the effect that interest @ 7% p.a. on the awarded amount, would payable by the appellant/Insurance Company w.e.f. 27.07.2012 till date of payment. With this slight modification in the impugned order, the appeal is disposed of. No order as to the cost of this appeal, in view of the fact that cost, has already been awarded to the respondent/complainant, while allowing the application for condoantion of delay.
(Justice S.C.Vyas) (Smt.Veena Misra) (V.K. Patil)
President Member Member
/03/2013 /03/2013 /03/2013