Manivasagam vs The Branch Manager, National Insurance Company Ltd. and The Chief Executive Officer/The Authorized Officer, Medi Assist India Private Ltd.

R. Sudhakar, J.—This writ appeal has been filed as against the order dated 01.08.2011 passed in W.P.(MD) No. 5254 of 2008, wherein the petitioner has sought for a Writ of Certiorarified Mandamus to quash the impugned order passed by the second respondent in his proceedings dated 25.04.2008 and consequently, direct the respondents to pay a sum of Rs. 1,41,406/- (Rupees One Lakh Forty One Thousand Four Hundred and Six only) as per the Medi Claim Policy. The case of the appellant/writ petitioner is that he was insured under the scheme of Medical Claim Policy in the year 2001 and the same was renewed regularly. It was in force from 01.12.2008 to 30.01.2009. He felt chest pain on 03.08.2007 and on advise from his family Doctor, he underwent a test of Coronary Angiogram and thereafter, he was advised to undergo a bye-pass surgery.

After the surgery, he filed the claim with the respondent Insurance Company. On denial of the same, he filed W.P(MD) No. 8331 of 2007, wherein the petitioner was directed to submit his claim by supporting documents to the Insurance Company which shall be considered in terms of the Medical Claim Policy taken out by the appellant/writ petitioner. Accordingly, the appellant/writ petitioner filed the claim. By the impugned order, the claim of the appellant/writ petitioner came to be rejected. Challenging the same, the appellant/writ petitioner filed the present writ petition.

The learned Single Judge dismissed the writ petition on the ground that the disputed question of facts cannot be gone into in the writ petition as the remedy available to the petitioner is to take out appropriate proceedings before the Consumer Court regarding deficiency in service or appropriate civil remedy in accordance with law. Aggrieved over the order passed by the learned Single Judge, the present writ appeal has been filed.

Heard the learned Counsel for the appellant/writ petitioner and the learned Counsel for the first respondent Insurance Company. However, there is no representation on behalf of the second respondent.

Clause 4.1 of the policy reads as follows:

Clause

Description

4.1 All diseases/injuries which are pre-existing when the cover incepts for the first time. For the purpose of applying this condition, the date of inception of the initial mediclaim policy taken from any of the Indian insurance companies shall be taken, provided the renewals have been continuous and without any break.

A perusal of the Clause 4.1 of the terms and conditions of the policy, would show that it provides for exclusion in respect of pre-existing diseases.

It is the admitted case of the petitioner that he is suffering from hypertension and diabetes. If the treatment is relating to hypertension and diabetics, then it is pre-existing disease and no claim can be made. However, in the report, it is stated that the petitioner was suffering from Coronary Artery Disease and surgery was done. Coronary Artery Disease is not a pre-existing disease at the time when the policy was issued. Therefore, the claim apparently is rejected on the misconception. The authority cannot read something more into the terms and conditions of the policy and come to the inference that one disease is relatable to other disease and therefore, medi claim is rejected.

If the treatment to the appellant/writ petitioner is relating to diabetes or hypertension, then it is a pre-existing disease and he is not entitled to reimbursement in terms of the medi claim policy. Since the nature of the treatment is for Coronary Artery Disease, which is not a pre-existing disease even as per the records, the Insurance Company cannot dispute the claim by giving another interpretation on the nature of the disease. There may be many reasons for a pre-existing disease or ailment and it is for the Doctors to identify the disease or ailment and provide the treatment. Under the terms of the medi claim policy, interpretation of a particular disease is not permissible. They are strictly bound by the disease or ailment specified in the policy as pre-existing disease. No addition or deletion by way of interpretation can be done, which is what has happened in the present case.

If the disease for which the appellant/writ petitioner was treated, is not stated as pre-existing disease in the policy and there are no supporting documents to show that it was a pre-existing disease on the date of issuance of the policy, the Insurance Company is bound to honour the policy. In this case, we have no difficulty to accept the plea of the appellant/writ petitioner that Coronary Artery Disease was not a pre-existing disease when the policy was issued and that fact is not disputed by the respondent Insurance Company. The pre-existing diseases in this case are hypertension and diabetes and only those diseases/ailments can be excluded.

There is no dispute of fact on a reading of the policy and the document under which the claim is made by the appellant/writ petitioner. The dispute arose out of misinterpretation by the Insurance Company. The learned Single Judge was not right in declining to interfere in this case on a plea of disputed fact, which we find, does not exist. We do not see reason as to why we send the appellant/writ petitioner to the Consumer Court after this long period of time when there is no serious dispute on facts. Accordingly, the writ appeal is allowed and the impugned order passed by the second respondent is quashed. The respondents are directed to pay the amount due to the appellant/writ petitioner under the above said Medical Claim Policy as per law. No costs.