Challenge in this revision petition is to the order dated 25.08.2010 passed by the Karnataka State Consumer Disputes Redressal Commission, Bangalore (‘State Commission’ for short) dismissing the appeal of the petitioner Insurance Co. filed against the order dated 31.10.2009 passed by the District Forum. By its order in question, the District Forum allowed the complaint and directed the OP Insurance Co. to pay Rs.45,000/- along with Rs.1,000/- as costs to the complainant, respondent herein.

 

2.         Briefly stated, the case of the complainant is that he insured his life under Health Plus Policy Plan for a sum of Rs.1,00,000/- w.e.f.18.2.2008 with the OP Insurance Co. While doing fabrication work, he fell down from the first floor due to which he sustained VDP 12-L3 with bilateral Radiculopathes. He took treatment in a hospital at Manipal and spent Rs.45,000/- for this treatment. However, when he preferred a claim with the Insurance Co. to reimburse the amount spent for the treatment, the OP Insurance Co. paid only Rs.1500/- towards bed charges and refused to pay the remaining amount to the complainant. Aggrieved by the response of the OP Insurance Co., the complainant knocked the doors of the consumer fora by lodging a complaint with the District Forum which was accepted. When the petitioner Insurance Co. carried the order of the District Forum before the State Commission in appeal, it did not find favour with the State Commission which dismissed it vide its impugned order while upholding the order of the District Forum and hence the revision petition.

 

3.         We have heard learned counsel for the petitioner and perused the record. It is the contention of the petitioner that the respondent/complainant has undergone disc operation for decompression. According to the petitioner, bilateral radiculopathes suffered by the respondent/complainant is due to pressure of the disc over the nerves and the same is not listed under any of the 9 types of nervous system shown in the policy condition. Since the surgery in question is not covered under the major surgical benefits, the claim of the complainant was repudiated rightly and the petitioner Co. is liable to pay hospital cash benefit of Rs.500/- per day, which has already been paid. The State Commission while dismissing the appeal of the petitioner and upholding the order of the District Forum has given the following reasons in its impugned order:-

 

“We have perused the terms and conditions of the policy. Under 11 major surgical benefit limits:- clause vii reads as follows:-

 

Admittedly, the respondent has produced the opinion of Dr. V.P. Hegade Katti, consultant physician and heart specialist which has been marked as Annexure-‘C’ regarding the Surgery undergone by the respondent, who has opined that since the surgery is done to relieve the compression of the Nerve roots everything from spinal card, which is a major neurological structure. The surgery is undoubtedly a major nervous system surgery. It is usually done by neurosurgeons and specialized orthopedic surgeons.

The opinion of the above doctor, in our view, co-relates to one of the surgeries mentioned under nervous system as shown in the policy condition i.e., repair of cerebral or spinal arterio-venous malformations and cerebral aneurysms. That means the surgery undergone by the respondent/complainant relates to the surgery repair of spinal arterio-venous malformations. Since the surgery is covered under the major surgical benefits, the respondent is entitled to get reimbursement of the amount spent by him for the treatment, from the appellant corporation. Hence, we are of the view that the decision rendered by the DF as per its impugned order is proper and correct. It does not call for any interference. This appeal is liable to be dismissed. “

 

4.         We do not find any infirmity in the finding returned by the fora below. Counsel for the petitioner has contended that the opinion of Dr. V.P. Hegade Katti which has been referred to and relied upon by the fora below could not provide the reliable basis for the view taken by the fora below because admittedly Dr. Katti is a consultant physician and heart specialist who would not be as deeply familiar with the ailment and the operation procedures in question. The counsel also contended that the opinion given by the doctor of the petitioner Co. was bypassed by the District Forum and request for leading the evidence of the doctor of the petitioner Co. and cross-examining Dr. Katti on behalf of the petitioner Co. was also rejected by the District Forum.

 

5.         Having considered the submissions made by the counsel, we do not find any substance in them since these aspects have been duly examined by the fora below and no infirmity has been observed in their findings. Even while challenging the opinion of Dr. V.P. Hegade Katti on the ground that he is simply a consultant physician and heart specialist, in all fairness the counsel has admitted that the field of specialization and the qualifications of the doctor of the petitioner Co. are also not on record. In any case, it is to be noted that the opinion given by Dr. Katti is only in respect of the nature of ailment of insured, relevance of the operative procedure adopted for that ailment and the coverage of that procedure in the list given in the policy document. Taking into consideration these aspects and the entirety of the circumstances of the case, we do not find any justification to interfere with the concurrent findings of the fora below based on appreciation of the evidence adduced before them. The revision petition, therefore, stands dismissed with the parties bearing their own costs.