NEW INDIA ASSURANCE CO LTD Vs. SUKHDEV SINGH

JUDGEMENT

(1.) The complainant/respondent obtained a mediclaim policy (hospitalization benefit policy) from the petitioner-insurance company for the period from 14-10-2011 to 13-10-2012. At the time of taking the policy the complainant was subjected to pre-acceptance health checkup. In the said document, while replying to question No.4 under the heading 'cardio-vascular system', whereby he was required to disclose any medication along with name and doses, he disclosed that he was taking tablet Amlopres 5 mg once a day. The policy contained a waiting period for the certain specified diseases/ailments and in terms of the said waiting period the benefits of the policy was not available for a period of two years in respect of hypertension. The policy was later renewed for the period from 14-10-2012 to 13-10-2013. The complainant was admitted to Ace Heart & Vascular Institute on 01-04-2013 and was discharged from the said hospital on 04-04-2013. A perusal of his discharge summary would show that he was under the treatment of one Dr. Puneet Kumar Verma during his stay in the hospital. On examination of the complainant in the hospital it was found that he had hypertension (stage one and recent onset) unstable angina (ICD 120) and single vessel disease (ICD 134.137). The complainant was subjected to eco-cardiography on 01-04-2013, followed by angiography as well as angioplasty on the same day. The discharge summary also shows at the time of admission in the hospital the complainant had a complaint of retrosternal chest pain, radiating to back and shoulder for three days and he had mildly elevated blood pressure at the time of examination. However, he was not on a prior medicine for hypertension nor did he give any history of long standing hypertension.

(2.) The claim of the complainant for reimbursement in terms of the mediclaim policy taken by him was repudiated by the petitioner on the ground that he had misrepresented to the hospital at the time of hospitalization by claiming that his hypertension was a recent one. Taking the view that hypertension was most prominent cause and risk factor of coronary artery disease, added force against the artery walls resulting into damage to the artery and making them vulnerable to the narrowing and plaque built up associated with atherosclerosis, the claim was rejected.

(3.) Being aggrieved form the rejection of his claim the complainant approached the Chandigarh District Consumer Disputes Redressal Forum (for short, the District Forum) praying the following reliefs: