Page 110 - Suri’s - NCDRC ON LIFE INSURANCE 2017 V1.3

Suri’s - NCDRC ON LIFE INSURANCE 2017 110

The District Forum reasoned that even though “balloon angioplasty is excluded
from the heart surgery to correct narrowing of blockage of left main coronary artery
or three more arteries with by-pass grafts, but it will not be correct to say that coro-
nary angiography (single vessel disease) is not to be treated as a critical illness be-
cause the complainant had the history of typical chest pain noted in the discharge
card Ex C 10, of Patiala Heart Institute, where the complainant was admitted on
30.4.2007 and discharged on 2.5.2007 and also noted in the discharge summary Ex C
11 that the patient had a history of chest pain, radiating to arms associated with
sweating and dysponea on exertion 1 ½ months back.” It went on to conclude
that “the repudiation of the claim of the complainants by the ops was made mechani-
cally and without application of mind to the facts and was based on the narrower in-
terpretation of the definition of the critical illness in the life insurance policy Ex C2.”
The State Commission, on an appreciation of the facts of the case, reasoned
that “For determining the critical illness, it was not the effect of the treatment so
given to the complainant, for the treatment of his ailment, which was to be considered
but it was the disease itself, which was to be considered and it was the solemn duty of
the District Forum to ascertain whether the said ailment fell under the critical illness
as defined in the terms and conditions of the policy. It transgressed its powers by it-
self coining different definition of the critical illness so as to confer the benefit upon
the complainant.”
Having heard the arguments of both the counsels and having perused the records, I
am inclined to agree with the State Commission. It appears to me that the petitioner
complainant, having been involved with the insurance business, ought to have been
fully conversant with the policy and procedures governing life insurance and the
added cover of critical illness. Critical Illness Benefit has been elaborately defined
and its terms and conditions specifically prescribed. Of relevance to the case in hand
are two critical illnesses covered under the policy which for ease of reference and
understanding are reproduced below:
First Heart Attack:
The death of a portion of heart muscle as a result of inadequate blood supply
to the relevant area. The diagnosis should be based on the following:
A historyof typical chest pain, if any
New and recent electrocardiographic changes indicating myocardial infarc-
tion
Elevation of cardiac enzymes
Diagnosis based on the elevation of Tropnin T Test, alone shall not be consid-
ered diagnostic of a heart attack,
Angina or chest pain are especially excluded.
Coronary Artery Disease Requiring Surgery
The undergoing of heart surgery to correct narrowing of blockage of left
main coronary artery or three or more coronary arteries with bypass grafts in
persons with limiting angina symptoms and compromise of blood supply
supported by investigation but excluding non-surgical techniques such as
balloon angioplasty, laser relief of an obstruction or other forms of coronary
artery clearing through catheters or similar devices. Narrowing of the affected
artery should be more than 75%(seventy five percent).

INDEX