XIII Surgery of Gall Bladder & Bile Duet excluding malignancy two years" It is therefore, pleaded that since the alleged surgery was performed within two years and as such the mediclaim preferred by the complainant in respect of the treatment of Gall bladder of his wife is not maintainable. The quantum of expenses of Rs.30,000/- on her treatment is also disputed. It is further pleaded that mediclaim is a contract and same is binding on both the parties as per terms and conditions of the mediclaim policy duly supplied to the complainant. Therefore, there is no question of opposite party"s working under hidden policy. Thus there is no deficiency in service on the part of opposite party to repudiate unwarranted mediclaim of the complainant under the terms and conditions of the said policy.
4. In support of his version complainant has produced in evidence affidavit Ex.CA and documents Ex.C1 to C17 and Mark A.
5. On the other hand opposite parties produced in evidence affidavit Ex.OPA and documents Ex.OP1 to OP3.
6. We have heard arguments of learned counsel for the parties and perused ocular as well as documentary evidence on the record. Learned counsel for complainant has strenuously urged before us that repudiation of mediclaim in respect of medical treatment of complainant's wife Sukeshi Jain vide letter dated 4/3/2008 Ex.C16 by the opposite party Insurance Company is repugnant to the terms and conditions No.41, 4.2 and 4.3 of mediclaim policy Ex.OP1, OP2 and OP3 and amounts to deficiency in service. On the other hand it has been counterargued by learned counsel for the opposite party Insurance Company that mediclaim has been validly repudiated under clause 4.3 of the mediclaim policy as the surgery for gall bladder and Bile Duet excluding malignancy is not covered for first two years of the policy and as such there is no deficiency in service on the part of opposite party.
7. We have considered rival contentions of counsel for the parties. We find considerable merit in the contentions of learned counsel for the complainant.. These broad facts are not disputed that complainant got mediclaim policy for himself and for his family members bearing No. 233106/48/07/00149 vide cover note No. 187305 dated 18/10/2006 Ex.C1 from the opposite party Insurance Company for the period from 19/10/2006 till 18/10/2007 on payment of basic premium of Rs.5231/-. This fact is also not disputed that his wife Sukeshi Jain was admitted in the Patel hospital as per medical note Ex.C2 for treatment of gall bladder and was also operated surgical for the period 26/3/2007 to 28/3/2007. Earlier also she got medical treatment from Kidney Hospital & Lifeline Medical Institutions, Jalandhar vide Ex.C3 dated 13/3/2007 Ex.C3 and C4. It is also evident from the letter Ex.C11 dated 26/4/2007 that complainant intimated about medical treatment of his wife Sukeshi Jain in the Patel Hospital, Jalandhar alongwith medical billswherein clarification about previous consultation or any past history of similar complaints was sought by Paramount Health Services Ltd. from the complainant regarding ailment of his wife vide Ex.C12 dated 18/6/2007. The same was also supplied vide certificate Ex.C13 dated 9/7/2007 of Patel hospital that patient had no past history of similar pain but the Insurance Company through its Paramount Health Services Ltd. repudiated the mediclaim vide letter Ex.C16 based on its opinion that as per letter from the insurance Company policy date of inception is 19.10.2006 as per terms and conditions surgery for gall bladder & Bile Duet excluding malignancy two years and mediclaim repudiated under clause 4.3 of the policy.
8. Now adverting to the crucial terms and conditions of the mediclaim policy contained in exclusion clause 4.1, 4.2 and 4.3 Ex.OP1, OP2 and OP3, it is clear from exclusion clause 4.1 that this exclusion will also apply to any complications arising from pre-existing ailments/diseases/injuries. Such injuries shall be considered as a part of pre existing................
4.2 any disease other than those stated in clause 4.3 contracted by the insured person during the first 30 days from the commencement date of the policy except treatment for accidental external injuries.
4.3 During the period of insurance cover, the expenses on treatment of following ailments/diseases/surgeries for specified period are not payable if contracted and/or manifested during the currency of the policy.
XIII Surgery of Gall Bladder & Bile Duct excluding malignancy two years"
From the perusal of medical record of Kidney hospital & Lifeline Medical Institutions for the first time, scanning was done on the patient on 13.3.2007 whereas she was diagnosed in Patel hospital , Jalandhar for gall bladder disease and surgical operation was conducted on her admission in the said hospital from 26/3/2007 till 28/3/2007. There is nothing on the medical record that the patient had any symptom of pre existing disease of gall bladder as per exclusion clause 4.1 nor contracted this disease within 30 days from date of commencement of the policy a per exclusion clause 4.2 of the policy Therefore, exclusion clause 4.3 does not exclude surgery of gall bladder and Bile Duet excluding malignancy for the purpose of payment of expenses on the treatment of such disease when this clause is read in conjunction with clause 4.2 of mediclaim policy Ex.OP2 and OP3. These clauses in the light of fact situation of the present case analysed in its correct perspective does not exclude liability of the Insurance Company to pay mediclaim for gall bladder operation to the extent of Rs.24000/- as per bill Ex.C10 of Patel Hospital, Jalandhar. Therefore, Paramount Health Services Ltd. on which opinion the Insurance Company acted upon, succumbed to erroneous interpretation of clauses 4.2 and 4.3 in respect of medical expenses on surgical operation of gall bladder of complainant's wife Sukeshi Jain because clause 4.3 is controlled by clause 4.2 by the words "any disease other than those stated in clause 4.3...". It is settled principle of interpretation that if two views are possible on the interpretation of the terms of the insurance policy, one favourable to the policy holder has to be adopted as per pertinent observations of Apex Court in a case reported as Life Insurance Corporation of India vs. Raj Kumar Rajgarhia and another II (1999) SLT 362 wherein it was held that :
XX XX XX
"It is not always possible to be guided by the meaning
of the words as found in the dictionary while resorting to
interpret the actual meaning of a word found in an
agreement between the parties. While construing the
meaning of a particular word found in an agreement
between the parties the intention of the parties to the
document in question will have to be given necessary
weightage and it is not possible to give a wider and liberal
meaning merely because one of the parties to the said
agreement is a public authority. While interpreting the
terms of the insurance policies if two views are possible,
Courts will accept the one which favours
the policy holders."
XX XX XX
Therefore, we are of the considered opinion that complainant is entitled to mediclaim to the extent of Rs.24000/- incurred on medical treatment of his wife.
In the ultimate analysis of aforesaid discussion, we accept the complaint and direct the opposite party Insurance Company to pay to the complainant Rs.24000/- as expenses incurred on medical treatment of his wife under the mediclaim policy with further monetary compensation of Rs. 5000/- for mental agony and physical harassment besides cost of litigation to the tune of Rs.2000/- payable within one month from the receipt of copy of this order.
Let certified copies of judgment rendered be supplied/despatched to the parties without any unnecessary delay and thereafter file be consinged to record room.
Announced : (Gulshan Prashar ) ( Shashi Narang ) ( A.K. Sharma )
3.10.2008 Members President.
