NATIONAL INSURANCE COMPANY LIMITED vs MUKUNDAN RAMAN

This revision is directed against the order of the West Bengal State Consumer Disputes Redressal Commission, Kolkata (in short, "the State Commission) dated 30 th September, 2015 whereby the State Commission concurred with the order of the District Forum under appeal and dismissed the appeal.

Undisputed facts relevant for the disposal of the revision petition are that the respondent/complainant purchased a medi-claim policy from the petitioner insurance company valid w.e.f. 28.1.2011 to 27.1.2012. The sum insured was Rs.4.5 Lakhs. In August, 2011 the respondent/complainant visited Dr. Partha Sarthi Sen Gupta with the complaint of chest pain. His ECG was done and was referred to AMRI hospital. He was diagnosed as suffering from Acute Coronary Syndrome evolving anterior MI. As a consequence the complainant had undergone PTCA to LAD and to ramus as an inpatient during the period 25 th August, 2011 to 27 th August, 2011. The expenses incurred by the complainant were to the tune of Rs.2,32,977/-. The complainant submitted the insurance claim which was repudiated. Being aggrieved of repudiation of the claim, the complainant raised a consumer dispute by approaching the concerned consumer Fora.

The opposite party in its written statement justified the repudiation on the ground that the insurance claim was not payable in view of exclusion clause 4.3 in the insurance contract.

The District Forum on consideration of pleading sand the evidence, allowed the complaint and directed the petitioner as under: - " Hence, ordered.

That the case is allowed on contest with cost against o.p. nos.1 and 2 and ex parte without cost against o.p. no.3. O.p. Nos. 1 and 2 are jointly and/or severally directed to pay to the claim amount of Rs.2,43,079/- (Rupees two lakhs forty three thousand seventy nine) only to the complainant and are further directed to pay compensation of Rs.10,000/- (Rupees ten thousand) for harassment and mental agony and litigation cost of Rs.5000/- (Rupees five thousand) only within 45 days from the date of communication of this order, i.d. an interest @ 10% p.a. shall accrue over the entire sum due to the credit of the complainant till full realization. Supply certified copy of this order to the parties free of cost.

Being aggrieved of the order of the District Forum, the petitioner approached the State Commission in appeal. The State Commission, West Bengal vide impugned order affirmed the order of the District Forum and dismissed the appeal.

Learned Shri A.K. Prasad, Advocate has taken us through exclusion clause 4.3 of the insurance policy and submitted that the order of the State Commission has been passed in utter disregard of the exclusion clause. It is contended that the State Commission has failed to appreciate that the complainant was diagnosed as suffering from hyper tension within one year of the taking of insurance policy and, therefore, in view of the exclusion clause, repudiation was justified.

In order to appreciate the contention of learned counsel for the petitioner, it would be useful to have a look on clause 4.3 of the insurance policy, which is reproduced as under: -

"4.3 During the first one year of the operation of the policy the expenses on treatment of benign ENT disorders and surgeries like Tonsilectomy/ Adenoidectomy/Mastoidectomy/Tympansoplasty.

Treatment of disease such as Cataract, Benign Prostatic Hyperthropathy, Hysterectomy, Hernia, Hydrocele, Congenital Internal Disease, Fissures/Fistula in anus, piles, Sinusitis and related disorders, Polycystic ovarian diseases, Non infective arthritis, undescended testis, Surgery of gall bladder and bile duct excluding malignancy. Surgery of Genito-urinary system excluding malignancy. Pilonidal Sinus, Gout and Rheumatism, Hypertension, Diabetes, Calculus Disease, surgery for prolapsed intervertebral disc unless arising from accident, surgery of varicose veins are not payable for first two years of operation of the policy. Treatment for joint replacement due to degenerative conditions. Age related osteoarthritis and osteoporosis are not payable for first four years of operation of the policy. If these diseases are pre-existing at the time of proposal, will be covered only after four continues claim free policy years."

On reading of the above, it is clear during first one year of the operation of the policy the expenses on the treatment of the ailments detailed in the clause are not payable. According to learned counsel for the petitioner as per the discharge summary of the complainant, he was diagnosed for hypertension (recently detected), which could be a cause for the coronary disease suffered by the complainant. Therefore, the insurance company was justified in repudiating the claim.

We do not find merit in the above contention. It is well settled that an insurance is in the nature of a contract and it has to be strictly implemented without adding or deleting any words to the agreement arrived at between the parties. Reference be made to the judgment of the Hon?ble Supreme Court in the matters of Vikram Greentech India Limited & Anr. Vs. New India Assurance Company Limited (2009) 5 SCC 599, United India Insurance Co. Ltd. Vs. Harchand Rai Chandan Lal (2004) 8 SCC 644 & Suraj Mal Ram Niwas Oil Mills Private Limited Vs. United India Insurance Company Limited and Anr. (2010) 10 SCC 567.

On reading of exclusion clause 4.3 we find that although hypertension falls within the exclusion clause but the coronary syndrome evolving anterior MI which led to PTCA to LAD and to ramus is not detailed in the list of diseases given in clause 4.3. Therefore by strict application of the insurance contract the expenses incurred on the aforesaid disease by the complainant are covered under the insurance policy. Thus, in our view the repudiation of the insurance claim was not justified.

In view of the discussion above, we do not find any fault with the finding of the Fora below which may call for interference in exercise of revisoinal jurisdiction. Revision petition is dismissed.