ORDER

SH. RAKESH KAPOOR, PRESIDENT

In brief, the case of the complainant is that he had purchased a
medical insurance policy for himself, his wife, his daughter and his
two sons namely  Gourav & Rahul Choudhary from the OP company  It is
alleged by the complainant that the said policy was renewed later and
in the year 2009 his policy no was 360501/48/09/8500005567.  It is
further alleged by complainant  that his son Rahul developed medical
problem in the end of year 2009 for which he was admitted in VIMHANS
Hospital from 2.5.2010 to 25.5.2010 and was diagnosed as a case of
Schizophrenia   .  He had spent a sum of Rs. 80,000/- as expenses on
treatment of his son for the hospitalized period.  The complainant had
lodged a claim with the Op but the same was repudiated on the ground
that the treatment taken is not covered under the said policy.  The
complainant had, therefore, approached this forum for redressal of his
grievances.

The OP has contested the complaint and has filed its written
statement. In the written statement  OP has denied  any  deficiency of
service on its part.  It is stated by the OP that the complainant was
having a mediclaim policy bearing no. 360501/48/09/8500005567 valid
from 21.2.2010 to 20.2.2011.  It is stated by the OP that on scrutiny
of the claim of the complainant.  It was observed that his son was
suffering from Paranoid Schizophrenia    i.e. psychotic symptoms. It
is stated by the OP that the claims  lodged by the complainant was not
admissible as per exclusion clause no. 4.8 of the terms and conditions
 of the policy and therefore the claim lodged by the complainant is
repudiated.

            In the evidence the complainant has filed its affidavit
and has corroborated the contents of the complaint.  The complainant
has put on record copy of the insurance policy, copy of the discharge
summary from VIMHANS hospital, copy of the certificate  from
Consultant Psychiatrist VIMHANS hospital, copy of the complainant
bills and copy of letter of repudiation.  The OP has also filed its
evidence by way of affidavit and has reiterated the contents of the
written statement.  The OP has put on record copy of the terms and
conditions of the policy.

         We have heard arguments advanced at the bar and have perused
the record.

            Some of the facts are not in dispute.  The complainant was
holding a valid policy issued by the OP when his son was admitted in
VIMHANS Hospital.  .  On perusal of the discharge summary it is clear
that Her son was admitted diagnosed as a case of paranoid
Schizophrenia.      Now the sole question before us is as to whether
OP was justified in repudiating the claim  of the complainant on the
plea that the claim does not fall within the purview of the terms and
conditions of the policy.  Since Exclusion Clause 4.8 is relevant it
is reproduced as under:-

Clause 4.8 Convalescence general debility’ run down’ condition or rest
cure, congenital external disease or defects or anomalies,

0sterility, infertility/ sub fertility or assisted conception
procedures , veneral disease, intentional self –injury , suicide, all
psychiatric and psychosomatic disorders/ diseases, accidents due to
misuse or abuse of drugs / alcohol or use of intoxicating substance.

 The discharge summary of VIMHANS Hospital issued by Dr. Jitender
Nagpal (MD , DNB) Sr. consultant psychiatrist depicts that “Mr. Rahul
was admitted for treatment of psychotic symption” and diagnosed as a
case of paranoid Schizophrenia.

“In the case of United India Insurance Co. Ltd. vs. Harchand Rai
Chandan Lal (2005 ACJ 570), the Hon’ble Supreme Court has held that
the terms and conditions of the contract have to be strictly construed
and no variation can be made there from.”

 In view of the judgment cited by us above and facts and circumstances
of the case we are constrained to hold that there are no merits in
this complaint and the claim was rightly repudiated by the OP. we are
, therefore, constrained to hold that there is no deficiency on part
of the OP in repudiating the claim of the complainant under the
Consumer Protection Act. Accordingly, the same is hereby dismissed.

Copy of the order be made available to the parties as per rule.

    File be consigned to record room.

    Announced in open sitting of the Forum on.....................