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15. The issue for adjudication before us as to whether the OPs No.1&2 had rightly repudiated the Insurance Claim of the Complainant for the treatment of his son for congenital heart disease or not?

16. Before adjudicating on the aforesaid issue, it is necessary to define Congenital Heart Disease. As per medical literature "Congenital Heart disease" (CHD) is a birth defect affecting the heart's structure, most commonly involving the heart walls, valves, or large blood vessels.

17. Further, to deal with the aforesaid issue, we have gone through the following documents available on record.


   i.   Policy Ex.C-2/Ex.OP1.2/1
  ii.   Bill dated 19.03.2022 Ex.C-3
 iii.   Bills Ex.C-4 (12 pages)
 iv.    Authorization letters Ex.C-5 to Ex.C-9
  v.    Discharge Summary Ex.C-10/Ex.OP1.2/2
 vi.    Legal Notice dated 11.04.2022 Ex.C-11, postal receipts Ex.C-
        12 to Ex.C-15.
vii.    Reply dated 28.04.2022 to legal notice Ex.OP1.2/4

viii. Terms and conditions of the policy Ex.OP1.2/5 On perusal of Discharge Summary (Ex.C-10)/sequence of events shows that the son of the Complainant-Bhunesh Bansal, was born on 02.10.2003. He was suspected to be having Congenital Heart Disease at the age of one year. He had undergone Echo investigation on 05.04.2005 i.e. at the age of 2, there were subsequent Echo tests on 10.08.2006, 24.09.2007, 10.10.2007, 19.03.2008, 12.02.2010, 21.03.2012, 30.12.2013, 28.12.2015, 09.03.2018, 18.02.2019, 06.03.2020, 17.09.2021 and 01.03.2022. In the year 2007, he had undergone Cath and Balloon Aortic Valvotomy on 09.10.2007. Balloon Aortic Valvotomy refers to a procedure which is carried out to widen a narrowed aortic valve. It increases blood flow and relieves symptoms related to heart disease. Meaning thereby the son of Complainant had undergone the said medical procedure at age of approximately 4 years. The Complainant had purchased his first Insurance Policy No.233599/48/2015/234 (Annexure A-3) in the year 2014 when his son was already 11 years of age. The son had his first procedure related to heart disease in the year 2007. Therefore, the Complainant was aware/in knowledge of the medical condition of his son i.e. Congenital Heart Disease. As per Discharge Summary (Ex.C-10), he was suffer from Bicuspid Arotic Valve, Valvular Aortic Stenosis and Trivial Aortic Regurgitation. A bicuspid aortic valve (BAV) is a congenital heart defect where the aortic valve has two leaflets instead of the normal three, which can lead to complications like aortic stenosis (narrowing) or aortic regurgitation (leaking). It is the most common congenital heart defect, affecting about 1-2% of the population, and is present from birth, though it often doesn't cause problems until adulthood. He had undergone regular follow up as mentioned above and was admitted for Aortic Valve replacement on 09.03.2022 (Ex.C-10).

19. Furthermore, we have gone through the Exclusion Clause 4.2 of the terms and conditions wherein under the caption of Heart Ailment at Serial No.4 Congenital Heart Disease and Valvular Heart Disease, whether declared or no declared are permanently excluded. In this context, the learned Counsel for Respondent No.1/Complainant has submitted that no Proposal Form or terms of Exclusion were not provided to him. To verify this factum, we have gone through the contents/averments of the Complaint filed by the Complainant before the District Commission. It has transpired that the Complainant has nowhere mentioned that he had not received Proposal Form/terms and conditions of the policy containing the Exclusion Clause. In fact he himself had enclosed photocopy of the policy (para 3 (a) of the Complaint). Moreover, the Complainant got his policy renewed for eight years consecutively. It is hard to believe that he was unaware of terms and conditions/exclusion clause from the year 2014-2022. Besides, he failed to inform the OPs No.1&2 with regard to factum of Congenital Heart Disease his son was suffering from.

1. Policy since 03.12.2014, 19 year male with congenital heart disease. Admitted due to aortic valve replacement, the member was detected to have congenital heart disease for which he underwent Balloon Aortic Volvotomy in 2007.

Presented with DOE. As per policy-4.2 if the proposer is suffering or has suffered from any of the following diseases at the time of taking the policy, whether declared or not declared, they will be permanently excluded from the policy coverage. Congenital Aortic Valve disease is included in the list provided. Hence, the claim is not payable.