NATIONAL INSURANCE COMPANY LIMITED Vs. MUKUNDAN RAMAN

JUDGEMENT

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

(2.) 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 Aug., 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 25th Aug., 2011 to 27th Aug., 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.

(3.) 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.