JUSTICE V.K.JAIN, PRESIDING MEMBER (ORAL)

          The petitioner obtained a mediclaim policy from respondent no.2 Oriental Insurance Company Ltd. through respondent no.1 Oriental Bank of Commerce, for the period from 04.02.2016 to 03.02.2017.  The petitioner was admitted in Kaushalya Devi Hospital on 28.02.2016 and discharged on 26.02.2016.  He lodged a claim for re-imbursement of the expenses incurred by him in his hospitalization.  The claim however, was not paid by the respondent.  Being aggrieved, the complainant/petitioner approached the concerned District Forum by way of a Consumer Complaint.  The complaint was resisted by the respondent which inter-alia stated that in view of clause 4.2 of the policy, the ailments from which the complainant suffered, were not covered for 2-3 years from the commencement of the policy. 

2.      The District Forum having dismissed the complaint, the petitioner approached the concerned State Commission by way of an appeal.  The said appeal also having been dismissed, he is before this Commission by way of this revision petition. 

3.      Clauses 4.1 and 4.2 of the insurance policy read as under:

4.1 Pre-existing health condition or disease or ailment / injuries: Any ailment / disease / injuries / health condition which are pre-existing (treated/untreated, declared/not declared in the proposal form), when the cover incepts for the first time are excluded up to three Completed) years of this policy being in force continuously. For the purpose of applying this condition, the date of inception of this Mediclaim Policy taken from The Oriental Insurance Company shall be considered, provided the renewals have been continuous and without any break in period.

4.2 The expenses on treatment of following ailment / diseases / surgeries for the specified periods are not payable if contracted and / or manifested during the currency of the policy.  If these diseases are pre-existing at the time of proposal the exclusion no 4.1 for preexisting condition SHALL be applicable in such cases.

i  Benign ENT disorders and surgeries i.e. Tonsillectomy, Adenoidectomy, Mastoidectomy, Tympanoplasty etc.               1 year

ii Polycystic ovarian diseases .                                                     1 year

iii Surgery of hernia.                                                                       2 years

iv Surgery of hydrocele.                                                                 2 years

v Non infective Arthritis.                                                                 2 years

vi Undescendent Testes.                                                              2 Years

vii Cataract.                                                                                     2 Years

viii Surgery of benign prostatic hypertrophy.                               2 Years

ix Hysterectomy for menorrhagia or fibromyoma or

myomectomy or prolapse of uterus.                                             2 Years

x Fissure / Fistula in anus.                                                             2 Years

xi Piles.                                                                                            2 Years

xii Sinusitis and related disorders.                                                         2 Years

xiii Surgery of gallbladder and bile duct excluding malignancy.         2 Years

xiv Surgery of genito- urinary system excluding malignancy.   2 Years

xv Pilonidal Sinus.                                                                          2 Years

xvi Gout and Rheumatism.                                                            2 Years

xvii Hypertension.                                                                          2 Years

xviii Diabetes.                                                                                 2 Years

xix Calculus diseases.                                                                            2 Years

xx Surgery for prolapsed inter vertebral disk unless

arising from accident.                                                                     2 Years

xxi Surgery of varicose veins and varicose ulcers.                             2 Years

xxii Joint Replacement due to Degenerative condition.            3 Years

xxiii Age related osteoarthritis and Osteoporosis.                      3Years

If the continuity of the renewal is not maintained with the Company then subsequent cover SHALL be treated as fresh policy and clauses 4.1, 4.2, SHALL apply unless agreed by the Company and suitable endorsement passed on the policy. Similarly if the sum insured is enhanced subsequent to the inception of the policy, the exclusions 4.1, and 4.2 will apply afresh for the enhanced portion of the sum insured for the purpose of this section. 

4.      It would thus be seen that if the policy holder was already suffering from any of the above referred diseases at the time the policy was taken, clause 4.1 of the policy was applicable whereas in case the diseases were contracted by him during the currency of the policy, clause 4.2 would be applicable. 

5.      The case of the appellant is that he was not even aware of the ailments from which he was suffering, before he was admitted in Kaushalya Devi Hospital.  If this is so, the said ailments were not covered for a period of two years in view of clause 4.2 of the insurance policy.  The petitioner/complainant having been admitted in hospital within a few days of obtaining the policy, it would be difficult to decide that the expenses incurred by him on his hospitalization were not covered under the policy taken by him.  The view taken by the fora below, therefore, does not call for any interference by this Commission in exercise of its revisional jurisdiction.  The revision petition is therefore, dismissed.