National Consumer Disputes Redressal
New India Assurance Co. Ltd. vs Dr. S. S. Kansal on 29 October, 2015
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI REVISION PETITION NO. 2669 OF 2015 (Against the Order dated 03/07/2015 in Appeal No. 171/2014 of the State Commission Uttar Pradesh) 1. NEW INDIA ASSURANCE CO. LTD. THROUGH ITS MANAGER, R.G. CITY CENTRE, 2ND FLOOR, LSC, BLOCK-B, LAWRENCE ROAD, NEW DELHI-110035 ...........Petitioner(s) Versus 1. DR. S. S. KANSAL S/O SHRI K.C. KANSAL R/O INFRONT OF HYDEL OFFICE, PRABHAT NAGAR, JAIL CHUNGI MEERUT ...........Respondent(s)
BEFORE: HON'BLE MR. JUSTICE AJIT BHARIHOKE, PRESIDING MEMBER HON'BLE MRS. REKHA GUPTA, MEMBER For the Petitioner : MS. SHUCHI SINGH For the Respondent :
Dated : 29 Oct 2015 ORDER
1. This revision is directed against the order of the State Commission Uttar Pradesh dated 03.07.2015 in Appeal No. 171 of 2014 arising out of the order of the District Forum Meerut in CC No. 1457 of 1998.
2. Briefly stated facts relevant for the disposal of the revision petition are that the respondent complainant filed a consumer complaint in the District Forum Meerut alleging that he obtained the mediclaim insurance policy for Rs.2.00 lacs from the petitioner opposite party. The policy was valid for the period w.e.f.28.05.1998 to 27.05.1999. During the subsistence of mediclaim policy, the complainant developed some problem for which he was referred to Apollo Hospital. In the Apollo Hospital, the complainant was attended to and treated by Dr. S K Gupta, Cardiologist, who after angiography found that it was a case of annulo aortic ectasia with severe AR and complainant was advised surgery. The complainant underwent open heart surgery as an in patient for which he incurred expenses to the tune of Rs.2,56,022/-. The complainant submitted his medi claim which was repudiated by the petitioner insurance company vide letter dated 27.10.1998 which reads as under:
"Your claim file was referred to our panel doctor for his technical opinion. As per our panel doctor the disease suffered by you is a manifestation of congenital disease which is not covered as per exclusion no. 4.3 of the policy conditions. The competent authority has accordingly repudiated your claim which please note.
The inconvenience caused is regretted."
3. Being aggrieved of the repudiation of mediclaim, the complainant raised a consumer dispute. The petitioner on being served with the notice filed written statement and pleaded that mediclaim of complainant was rightly repudiated because the disease suffered by him was congenital disease, which is not covered for indemnification as per Exclusion Clause 4.3 of the policy condition.
4. The District Forum on consideration of the pleadings of the parties and evidence allowed the claim and directed the petitioner insurance company to pay to the complainant a sum of Rs.2.00 lacs with interest @ 12% p.a. from the date of representation besides Rs.5000/- as damages and Rs.2000/- as litigation cost.
5. Being aggrieved of the order of the District Forum, the petitioner insurance company preferred an appeal and the State Commission vide impugned order concurred with the order of the District Forum and dismissed the appeal. This led to filing of revision petition.
6. Ms. Shuchi Singh, Advocate for the petitioner has contended that impugned order of the foras below are not sustainable because both the foras below have failed to appreciate that the disease for which the mediclaim was filed was a congenital disease and in view of Exclusion Clause 4.3 of the insurance contract, the insurance company was not liable to reimburse the expenses incurred on the treatment of the said disease. In support of this contention, learned counsel for the petitioner has taken us through the medical literature particularly page 139. Relevant medical literature is reproduced herein below:
"Causes of an Enlarged Heart The most common causes of an enlarged heart are blockages in the heart's blood supply ( coronary artery disease) and high blood pressure. An enlarged heart can have many other causes, including:
Viral infection of the heart Abnormal heart valve Pregnancy, with enlarged heart developing around the time of delivery ( peripartum cardiomyopathy) Kidney disease requiring dialysis Alcohol or cocaine abuse HIV infection Genetic and inherited conditions Frequently no cause for an enlarged heart is identified.This is known as idiopathic dilated cardiomyopathy."
7. In order to succeed in this argument, counsel for the petitioner is required to show that the treatment for which the mediclaim was filed was the manifestation of a congenital disease. On reading of the medical literature cited above, it is clear that there are so many causes which may cause enlarged heart and one of those cause is genetic and inherited condition. Counsel for the petitioner has failed to point out any evidence which may show the exact cause of the disease suffered by the complainant for which he had to undergo surgery. In absence of conclusive evidence that the surgery for which the mediclaim was filed was the manifestation of the congenital disease, the concurrent finding of fact returned by foras below cannot be faulted.
8. In view of the above, we find no reason to interfere with the impugned order in exercise of revisional jurisdiction. Revision petition is, therefore, dismissed.
......................J AJIT BHARIHOKE PRESIDING MEMBER ...................... REKHA GUPTA MEMBER