Aman Kapoor v. National Insurance Co. Ltd.

of the District Forum awarding a medical insurance claim to the petitioner/complainant was set aside.

The petitioner complainant had purchased the impugned Medical Insurance Policy of floater sum covering his family for an insured amount of Rs.5 lakh from the respondent/opposite parties- insurance company. In fact, he had held a medical insurance policy since 2007, renewing the same regularly. The impugned policy was valid for the period 13.6.2014 to 12.6.2015. In November, 2013, he was blessed with a son, Parth. He got Parth endorsed on the policy on 20.02.2014.

2.

In September, 2014, Parth was hospitalized in Narayana Institute of Cardiac Sciences for 'heart Ventricular Septal Defect', for the period 4.9.2014 to 13.9.2014. A sum of Rs.1,81,160/- was spent. Since Parth was covered under the policy, an insurance claim, supported by all relevant documents, was filed. The same was however repudiated, on the ground that it fell under the exclusion clause 4.3 of the terms & conditions of the policy.This led to a complaint before the District Forum.

3.

The respondents/opposite parties contested the complaint before the District Forum, substantively taking the plea that clause 4.3 of the terms and conditions of the policy was fully applicable to the facts of the present case. They argued that the son of the petitioner was hospitalized from 4.9.2014 to 13.9.2014 with diagnosis Levocardia, and that this being a congenital disease, was not covered for the first twelve months from the date of inception of the cover.

4.

The District Forum allowed the complaint and directed the opposite parties No.1 and 2 to reimburse the mediclaim to the tune of Rs.1,81,160/- in favour of the petitioner/complainant along with 9% interest from the date of filing of the claim until full and final recovery and Rs.2,000 as litigation cost.

5.

Being dissatisfied, the respondents/opposite party nos.1 and 2filed an appeal before the State Commission. The State Commission accepted the appeal and dismissed the complaint of the petitioner/complainant as being not maintainable as the treatment taken by the insured was covered under the Exclusion Clause No.4.3 of the policy terms and conditions and the claim was rightly repudiated by the OPs.

6.

Not satisfied with the order of the State Commission, the petitioner/ complainant has filed the present revision petition and prayed the following relief :-

7.

"Allow the revision petition.8. Set aside the impugned order dated 29.12.2016 in FA No.600/2016 passed by the State Consumer Disputes Redressal Commission.

9.

Pass such other and further order(s) as it may deem fit and proper in the facts and circumstances of the case."

10.

We have heard the counsel for the petitioner and gone through the records.11.

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The facts of the case are not much in dispute.It is not at all in dispute that the petitioner had been availing medical insurance policy from the respondents since 2007 and that he did include the new born in the policy w.e.f. 20.02.2014. As such, Parth, the son was covered under the impugned policy in force.What is contentious is whether the treatment and hospitalization that his son underwent at Narayana Institute of Cardiac Sciences, Bangalore is covered under the insurance policy or not.The District Forum found merit in the complaint of the petitioner and therefore, allowed reimbursement of the total amount spent to the tune of Rs.1,81,160/- alongwith 9% interest and some litigation cost.The State Commission, on are-appreciation of the same facts and evidences on record, accepted the appeal by the respondents/opposite parties, and found merit in the avermentthatthe complaint was not maintainable as it attracted the exclusion clause 4.3 of the terms and conditions of the policy.

12.

The crux of the matter therefore is whether or not the case fell under section 4.3 of the policy. First, the section itselfis reproduced below for ease of reference :-

"4.3 : During the period of twelve months from the date of inception of the policy, the expenses on treatment of diseases such as cataract, Benign Prostati Hypertrophy and Hysterectomy for Hemorrhagic or Fibromyoma, Hernia, Hydrocele, congenital internal disease, Fistula in anus, Piles, Sinusitis and related disorders are not payable. These diseases, if pre-existing, will be covered only as per provisions of 4.1 above."

13.

A plain reading of this clause would suggest that any "congenital internal disease"

would not be covered for a period of 12 months from the date of inception of the policy.As noted earlier, Master Parth was included in the policy from 20.02.2014. His admission and treatment, in September 2014, thereforetook place within the period of 12 months from the date of inception i.e. 20.02.2014. The next issue for consideration therefore, is whether Master Parth had a congenital heart disease or not.

14.

The State Commission concluded, based on discharge summary of the Narayana Institute of Cardiac Sciences that the condition was indeed congenital. The discharge summary clearly states under diagnosis that Master Parth suffered from {S,D,D}, Levocardia, DORV (TFA physiology), Ventricular Septal Defect, Sever Pulomonary Stenosis, Good biventricular function.It then prescribed the procedure that was followed and recorded its impression as under :-

15.

Congenital heart disease - Double outlet right ventricle16. Severe pulmonary infundibular/RVOT narrowing with confluent branch pulmonary artery (Mc Goon's ration 1.2) Small sized LPA.

17.

Artial and ventricular septal defects.18. Right sided aortic arch with mirron image branching pattern.19. Mediastinal aortopulmonary collaterals as described above.20.

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Thereafter, the Commission has also relied on the definition of Levocardia and Ventricular Septal defect as gathered from the internet and concluded that as Master Parth was suffering from congenital internal disease, the claim was not payable within the first 12 months from the date of inception of the policy and therefore, the order passed by the District Forum was liable to be set aside.

21.

In fact, the District Forum also found that the condition of Master Parth was congenital. Hereafter however, the Forum took the view that what Master Parth suffered from was congenital defect, and that 'defect' as contrasted with 'disease' were not excluded under section 4.3.This aspect has been considered and addressed by the State Commission in its order wherein it observed as below:-

"The District Forum while interpreting the congenital heart defect or congenital heart disease has not distinguished the words congenital heart defect and the disease nor given any specific findings what is the difference between congenital heart disease and defect."

22.

We are inclined to agree with the state commission. It is not possible to meaningfully distinguish between congenital heart defect and congenital heart disease. A defect at birth would manifest itself sooner or later. To say that the manifestation is a disease and therefore quite distinct from defect is to be trite. Moreover, even if this specious reasoning is undertaken, it would not come to the rescue of the petitioner/ complainant in the instant case. This is so because the moment it is claimed that Master Parth was born with a defect which later on became a disease, non-disclosure clause of pre-existing conditions would be attracted. The burden of proof would then have to be on the petitioner to show that he was not aware of the congenital heart defect. As no such claim has been advanced in the complaint nor any relevant evidence put forth in this regard such as a discharge certificate after birth, the claim would qualify for repudiation. Equally, if the plea is taken, as it has been, that it was a case of congenital heart disease, then the claim fails, attracting section 4.3.

23.

Another plea has been taken by the petitioner/complainant that he was not aware of the terms and conditions of the policy as the same had never been supplied to him.This too has been taken into account by the State Commission which has found itself unable to accept this plea on the ground that there seems to have been no effort on the part of the petitioner/complainant to obtain a copy of the terms and conditions. We are inclined to also agree with this view.We further contend that it is incumbent upon the consumer to be an informed and responsible consumer in order to be able to avail of relief under the Consumer Protection Act, 1986. Ignorance of terms and conditions of the policy is no excuse and provides no shelter to the petitioner complainant.

24.

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In view of the discussion above, we find no reason to interfere with the well-reasoned order of the State Commission. This revision petition is accordingly dismissed and the order of the State Commission is upheld. No order as to cost.

25.

......................J

AJIT BHARIHOKE

PRESIDING MEMBER

......................

ANUP K THAKUR

MEMBER

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