Heard learned counsel for the appellants. None appears for the respondents.

2.      This is an appeal filed u/s 15 of the erstwhile Consumer Protection Act, 1986 (hereinafter called the ‘Act’). Parties to this appeal shall be referred to with reference to their respective status before the District Forum.

3.   Learned counsel for the appellants submitted that the complainant alleged that he has purchased the Medi Claim Policy from the OPs for himself and his wife for the period commencing from 24.2.2009 to 24.2.2026 with additional benefit. Complainant alleged inter alia that on 7.11.2016 the beneficiary namely, Gitarani Dash, the wife of the complainant  was admitted in the hospital and she was diagnosed as suffering from CAD-ACS. Complainant alleged that the doctor of the hospital OP No.3 conducted angioplasty surgery and discharged Smt.Dash on 10.11.2016 with an advice to follow up actions. Complainant during course of treatment has spent Rs.2,43,512/- and made claim before the OPs through TPA.OP Nos. 1 and 2 settled the claim by awarding Rs.2,700/- to the complainant. Alleging deficiency in service and unfair trade practice on the part of the OPs, complainant filed the complaint before the learned District Forum.

4.      Learned counsel for the appellants submitted that except OP No.3, OP Nos. 1 and 2 filed joint written version stating that the complainant has purchased the policy for himself and his wife Gitarani Dash. They also admitted that as per the claim Smt. Dash was hospitalized from 7.11.2016 to 10.11.2016.

5.      Learned counsel for the appellants submitted that OPs 1 and 2 further averred that as per policy condition  and privilege of the policy a claim for Rs.2,700/- was settled because the policy bond does not cover the disease undergone by Gitarani. So, there is no question of deficiency of service or unfair trade practice on their part.

6.      Learned counsel for the appellants submitted that OP Nos. 4 filed written version stating that the complainant and his wife have purchased the Medi Claim Policy and the disease as claimed by the complainant is not covered under the policy. So question of settlement of  claim as prayed for in the complaint does not arise. Apart from this, it is averred that the complainant purchased the policy from OP Nos. 1 and 2 and the dispute is between OP Nos. 1 and 2 in one hand and the complainant in other end but  he is no way responsible.

7.      Learned District Forum after hearing both parties passed the following impugned order.

                   “xxx   xxx   xxx

For the reasons aforesaid and under the facts and circumstances we hold that, the complaint petition merits consideration and accordingly it is allowed on contest against the OP No.1 & 2 directing to pay a sum of Rs.2,00,000/- (Rupees two lacks) only as insurance claim with Rs.5,000/- (Rupees five thousand) only as litigation cost to the complainant within 30 days from the date of receiving this order failing which penal interest @ 9% per annum will be applicable.”

8.      Learned counsel for the appellants submitted that the learned District Forum has committed error in law by allowing the complaint without assigning rational reason. Learned District Forum ought to have gone through the written version of the appellants. According to him, when policy condition only allows coronary angioplasty with two stents implanted and Gitarani having been only implanted with one stent under coronary angioplasty she is not entitled to the whole expenditure except the expenditure of hospitalization which has already been paid to her. Learned District Forum  ought to  have at least understood such clause. So he submitted that the learned District Forum without appreciating the materials on record have passed the impugned order which should be set aside.

9.      Considered the submission of learned counsel for   the respective parties and perused the DFR including the impugned order.

10.    It is well settled in law that the complainant has to prove the unfair trade practice and deficiency of service on the part of the OPs.

11.    It is admitted fact that the complainant has purchased Health Plus Plan policy from OP Nos. 1 and 2 through OP No.4. It is not in dispute that during currency of the policy,  Gitarani has got operated at Care Hospital as per the document filed and she has undergone coronary angioplasty with implanation of one stent. Learned counsel for the appellants produced the conditions of the policy. It is mentioned that the coronary angioplasty with stent implanation (two or more coronary arteries must be stented) and there 40% of the sum assured as major surgical benefit (MSB) would be available. The interpretation of the appellants is that since it refers to only two stents but not one stent the case of  Gitarani is excluded. It is clearly  revealed from the clauses that coronary angioplasty with stent implanation is covered. Whether it is two or more artery stented  has to be evident from concerned doctor. It is true that in the instant case, cost of one stent has been paid but the doctor’s report is not available whether two or more coronary artery have been stented. The OPs have not examined such doctor. When OPs have repudiated the claim onus lies on OP Nos. 1 and 2 to prove that exclusion clause applies to the case of the complainant. OPs cannot presume any fact by not adducing any evidence.

12.    When stent implanation with coronary angioplasty is admissible the case of the complainant cannot be said to have been excluded. Even assuming for the sake of argument that one artery is repaired by one stent and for two arteries two stents are required, same should be made clear from the clauses of the policy condition itself. A policy holder is to be made aware as such before purchase of the policy. The insurer is marketing the policies. For that, it should be consumer friendly. Moreover, when there is angioplasty is allowed whether one stent or two the facts remains that consumer goes for major surgery benefit. Even if such clause is to be retained it can be said that such type of clause is unfair trade practice for insurance company.

13.    In view of aforesaid discussion, this Commission is of the view that the contention of learned counsel for the appellants that the complainant is not entitled to any major surgical benefit is incorrect. He is entitled to 40% of the sum assured as per the policy condition. Learned District Forum has not analyzed the fact in this way. However, it has allowed the Medi Claim as per the documents of complainant on the reasons assigned by them. It should have at least gone deep to find out the exclusion clause so that to make proper interpretation of the entitlement to which the complainant is entitled to. Therefore, the impugned order of the learned District Forum when partially agreed to but at the same time, the final order of the learned District Forum requires modification and hence the appeal is allowed in part by modifying the impugned order to the effect that OP Nos. 1 and 2 would pay 40% of the sum assured of Rs.2,00,000/- and rest of the impugned order would remain unaltered.

            DFR be sent back forthwith.

          Supply free copy of this order to the respective parties.