- (1.) THE complainant opted for mediclaim and has been enrolling himself as a member of the medical policy from 1994 onwards. It was periodically renewed. The last renewal was on 9.3.1998. While so, on 5.7.1998, the complainant has some discomfort in the chest. He was admitted in the Harvey Heart Hospitals, Nungambakkam, Chennai, where angiogram was taken and that it was found that he was having blocks. Therefore, on the advice of a doctor, he underwent Angioplasty on 19.8.1998 at Apollo Hospital. The complainant made a claim to the opposite party in a sum of Rs. 2,91,160/ - for reimbursement of the expenses incurred by him. The opposite party repudiated the same and hence the complaint.
(2.) THE sum and substance of the objection of the opposite party is that it was a pre -existing disease and, therefore, the complainant cannot seek reimbursement.
(3.) WE are of the view that this stand taken by the opposite party is really horrendous. It is not disputed that the complainant has been covered under mediclaim policy from the year 1994 onwards. It was periodically renewed of course there was no break in the year 1998 and the renewal was on 9.3.1998. Therefore, it is not the first time, the complainant has taken a mediclaim policy. Therefore, the motive of the complainant cannot be suspected nor the contention that it was a pre -existing disease can be accepted as valid condition. The complainant has stated that only on 5.7.1998 he was feeling discomfort in the chest and, therefore, he went to Harvey Hospital. The discharge summary from the Harvey Hospital which is marked as Ex. A5 dated 6.7.1998 is as follows: "64 year old male was admitted with complaints of chest discomfort since 3 days, relieved by .......He is a known diabetic since 8 years on regular oral hypoglycemic agents previous earlier revealed gallstones asymptomatic. General and systemic examination was normal. Investigations revealed interior wall infarction with antero -septal ischaemia with elevation of cardiac enzymes. On 8.7.1998, coronary angiogram done revealed 2 vessel disease with normal LV function (EF : 70%). Mild posterior lateral hypokinesia. There was an AV malformation connecting LAD to PA and RCA to PA. Post catheterization stay in hospital. Uneventful patient observed for 72 hours post -angio and discharged with FCG ischaemic changes had settled and cardiac enzymes had come to normal." Advice on Discharge: Advised angioplasty to RCA lesion." The opposite party have not produced any medical parties to have examined any expert to show that blocks in such heart ailment suggest blocks cannot occur suddenly and that it would take time to exhibit symptoms. For all we know that after the insurance cover in the month of March, 1998, he would have developed this heart problem. There is no material to show that it was a dormant one and that the complainant was aware of the same and that its symptoms came to the surface only in the month of July, 1998.;