State Consumer Disputes Redressal Commission
Hdfc Standard Life Insurance Co.Ltd. ... vs Hukmi Chand Jain S/0 Madan Lal Jain on 14 November, 2017
Daily Order BEFORE THE CONSUMER DISPUTES REDRESSAL COMMISSION,RAJASTHAN,JAIPUR BENCH NO.1 FIRST APPEAL NO: 1255 /2016 HDFC Standard Life Insurance Co. Ltd. through Br.Manager India Square, 2nd floor, India Motor Circle, Kutchery Road, Ajmer & ors. Vs. Sh.Hukami Chand Jain s/o Madanlal Jain r/o House No. 15-16 Veer Lokshah colony, Fatehsagar Road, Ajmer. Date of Order 14.11.2017 Before: Hon'ble Mrs. Justice Nisha Gupta- President Mr. Ramkalyan Sharma counsel for the appellants Mr. Surya Prakash Gandhi counsel for the respondent BY THE STATE COMMISSION ( PER HON'BLE MRS. JUSTICE NISHA GUPTA,PRESIDENT):2
This appeal has been filed against the order passed by the learned DCF Ajmer dated 26.8.2016 whereby the claim is allowed against the appellant.
The contention of the appellant is that the respondent has undergone PTCA with stenting to LAD and RCA which is not covered under the critical illness hence, the claim should have been dismissed.
Per contra the contention of the respondent is that he was suffering from unstable angina which falls under the heart disease and the claim has rightly been allowed.
Heard the counsel for the parties and perused the impugned judgment as well as original record of the case.
There is no dispute about the fact that the respondent diagnosis was unstable angina and he underwent PTCA with stenting to LAD and RCA .
The counsel for the respondent has submitted the article Heart Disease Health Center wherein it has been stated that 3 unstable angina is also a heart disease. He further submits CardioSmart Americal college of cardiology so on which says that unstable angina is also a type of heart attack.
There is no dispute about this preposition but here in the present case as per policy condition which is not in dispute between the parties, heart attack is defined in clause 17 (c) which reads as follows:
"The death of a portion of heart muscle as a result of an inadequate blood supply as evidenced by an episode of typical chest pain new electrocardiographic changes and by elevation of the crdiac enzymes."
The contention of the appellant is that heart attack should be evident from a typical chest pain, new electrocardiographic changes and further raise of cardiac enzymes and his further contention is that here in the present case there is no evidence of raise of cardiac enzymes hence, one condition has not been fulfilled and procedure adopted could not fall under the definition of critical illness.
The counsel for the respondent has also accepts the facts 4 that no test was undertaken for ascertaining the level of cardiac enzymes and the appellant has rightly relied upon the judgment passed by the National Commission in Revision Petition No. 3265/2015 Bhupinder Kumar Vs. Bajaj Allianz Life Insurance wherein it has been held that PTCA with stenting to LAD is not critical illness. In view of the above the contention of the appellant is acceptable.
The respondent has relied upon the judgment passed by Haryana State Commission in First Appeal No. 190/2015 LIC Vs. Madan Gopal where the person was admitted and surgical procedure was done the claim was allowed as per the policy clause whereas in the present matter the policy is specifically for critical illness and the appellant has rightly relied upon AIR 2000 Supreme Court 10 Oriental Insurance Co. Vs. Samayanallur Primary Agricultural Cooperative Bank, II (2009) CPJ 34 (SC) Vikram Greentech Vs. New India Assurance and judgment passed by the National Commission in Revision Petition No. 211/2009 Reliance Life Insurance Co. Vs. Madhavacharya where the courts were of the opinion that the terms have to be strictly construed. Hence, in the light of above when heart attack is specifically defined under the terms 5 it has to be construed in the light of terms of the agreement.
Reliance has further been placed on the judgment passed by the National Commission in Revision Petition No. 1071/2017 Hardeep Singh Vs. ICICI Prudential Life Insurance, Revision Petition No. 167/2016 LIC of India Vs. Madan Gopal and Revision Petition No. 2333/2012 LIC of India Vs. Niwas Bansal where the National Commission was of the opinion that case could not fall under the definition of critical illness. Hence, in view of the above the respondent who is undertaken only PTCA stenting could not fall in the case of critical illness as defined under the policy and the claim should have been dismissed.
In view of the above the appeal is allowed and the order of the Forum below is set aside.
(Nisha Gupta) President nm