1.       This is a Revision Petition filed by the Petitioners / Complainants against the Order of the Chhattisgarh State Consumer Disputes Redressal Commission (hereinafter referred to as the ‘State Commission’) dated 10.10.2018, wherein the Appeal filed by the Respondents / Appellants was allowed and the Complaint dismissed. The District Consumer Disputes Redressal Forum, Raipur (hereinafter referred to as the ‘District Forum’) by its Order dated 09.01.2018 allowed the Complaint of the Petitioner directing the Respondents / Opposite Parties to pay Rs. 98,033/- to the Complainants along with 6% rate of annual interest from the date of Complaint apart from Rs. 10,000/- towards mental agony and Rs. 2,000/- towards cost of litigation.

2.       The basic issue involved in the matter is whether the medi-claim Insurance Policy taken by the Petitioners would be restricted to the extent of admissible amount as per the terms and conditions of the Policy. The Insurance Company on the recommendation of the TPA paid an amount of Rs. 10,000/- to the Petitioner No. 2 for his hospitalization under the medi-claim Policy against the claim of about  Rs. 98,000/- on the ground of the exclusion clause no. 4.4.6.2, which limits payment in case of congenital disease to only 10% of the average sum insured in the preceding four years.

3.       The learned Counsel for the Petitioners submitted that the terms and conditions of the Policy were not supplied by the Insurance Company and was not even filed before the District Forum. Even in the written statement filed, no explanation was given for restricting the claim to Rs. 10,000/-. The Insurance Policy was being taken since 2010 onwards initially for Rs. 1 lakh and during the period, increased to Rs. 2 lakh at the time of the surgery for the Policy period 2014 – 2015 in relation to one of the Petitioners, Mr. Pawan Deep Singh. It was on 26.08.2014 that Mr. Pawan Deep Singh was hospitalized and a surgery performed for which an expenditure of Rs. 1,08,033/- was incurred.

4.       The hospital’s Discharge Summary, which is on record, states that the patient was suffering from Ureterocele and Undescended Testis (UDT) for which a Cystourethroscopy and urethral Dilation, excision of ureterocele done. Undoubtedly, UDT is a congenital disease as it usually forms at an early stage, may be at the time of the birth. A perusal of the relevant terms and conditions of the medi-claim Policy is as under:

4.4.6.2 Congenital Internal and External Disease or Defects of anomalies.

However, the exclusion for Congenital Internal Disease or Defects or anomalies shall not apply after twenty four months of Continuous Coverage, if it was unknown to You or to the Insured Person at the commencement of such continuous Coverage.

The exclusion for Congenital External Disease or Defects or anomalies shall not apply after forty eight months of Continuous Coverage, but such cover for Congenital External Disease or Defects or anomalies shall be limited to 10% of the average Sum Insured of the Insured Person in the preceding four years.

A careful reading of this Exclusion indicates clearly the vagueness of this clause. The normal understanding would be that if the congenital disease is not known and specifically is unknown to the insured person, the Exclusion shall not apply after 24 months of continuous coverage. In this case, it is four years of continuous coverage. A plain reading would indicate that the Insurance Company cannot apply the Exclusion clause after two years of continuous coverage when the disease was not known to the insured. In this case, no evidence has been filed to the effect that the insured was aware of the disease. Further, it is to be appreciated that UDT is a disease which nobody in their knowledge would like to wait for 19 years, which is the age of the insured, for undergoing a surgery. It is also a case that such disease would not be easily known unless there is a problem. In this case, the problem arose only at the time he was hospitalized as there was an issue of urination.

5.       The learned Counsel for the Respondents submitted that the next para of this clause is to be seen wherein it has been specifically mentioned that the coverage will be limited to 10% of the average sum insured of the insured in the preceding four years. A careful reading of this para would reveal that it is related to only a case where after 48 months of continuous coverage, the Exclusion shall not apply but limited to 10% of the sum insured. The two proviso to the Exclusion clause are given in two distinct paragraphs. The coverage of 10% has not been explicitly mentioned for cases where the insured is unaware of the disease. If the intention of the Insurance Company was to limit the coverage to only 10% in both the cases then the wording should have been as “in either case, the coverage shall be 10%....”. For writing vague terms and conditions, the insured cannot be made to suffer.

6.       After hearing the arguments of the learned Counsel for both sides and on perusal of the record, we come to the conclusion that the Petitioners / Complainants are entitled to their claim as determined by the District Forum and that the Order of the State Commission suffers from proper appreciation of the terms and conditions of the Insurance Policy.

7.       In view of the aforesaid discussion, the Revision Petition is allowed and the Order of the District Forum upheld.