1.      Heard the learned counsel for the petitioner.

2.      The present revision petition has been filed against the order dated 11.04.2023 of Andhra Pradesh State Consumer Disputes Redressal Commission, Vijayavada passed in first appeal No.158/2022 whereby the appeal filed by the respondents was allowed.

3.      The respondents/complainants have filed consumer complaint No.99/2020 with the District Commission for directing the opposite party to (a) refund the amount of Rs.1,47,273/- paid towards surgical operation; (b) pay a sum of Rs.12,000/- towards initial daily hospital cash benefits; (c) pay Rs.1 lakh towards compensation; (d) pay Rs.5000/- towards legal expenses; and (e) pass necessary orders in the interest of justice.

4.      Respondents are husband and wife and the petitioner is the insurance company. On 31.03.2008, complainant No.2 had taken LIC Health Plan Policy No.843758325 from the opposite party, covering the health insurance of complainant No.2 and his family. The policy was valid from 31.03.2008 to 31.03.2040 and the insurance premium was Rs.10500/- per annum. Complainant No.2 spent Rs.12000/- for treatment of complainant No.1 (wife) in Mathrutva Hospital where the patient was advised to take further treatment from Apollo Women’s Hospital. The patient was admitted in the Apollo Hospital on 06.05.2019 and discharged on 08.05.2019. Husband of the patient spent Rs.147273/- for her treatment. On 22.06.2019, the complainants submitted a bill of Rs.1,47,273/- with the opposite party for reimbursement. As the opposite party did not take any action on the reimbursement application of the complainants, they issued a legal notice dated 22.11.2019 to the opposite party. On 02.12.2020, the opposite parties replied to the legal notice stating that their claim has been repudiated. Therefore, the complainants filed consumer complaint No.9 of 2020.

5.      The complaint was contested by the opposite party by filing the written statement wherein the facts of the case were admitted. It was stated that the complainants were not entitled to claim of hospitalization benefit on the ground that the treatment was taken for less than 52 hours as per terms and conditions of the policy. Therefore, the opposite party rightly repudiated the claim and there was no deficiency in service on its part. The complaint is liable to be dismissed.

6.      The District Commission dismissed the complaint with the observation that the repudiation of claim by the opposite party was valid and in accordance with the terms and conditions of the insurance policy.

7.      The complainants filed First Appeal No.158 of 2022 with the State Commission and the State Commission, vide impugned order dated 11.04.2023 set aside the order of the District Commission and partly allowed the appeal with the direction to the opposite party to pay Rs.1,59,273/- with interest @ 6% p.a. from 02.12.2019 till the date of realization and Rs.25000/- as compensation as also Rs.5000/- as litigation cost. Hence, the opposite party has filed the present revision petition.  

8.      Counsel for the petitioner submitted that the State Commission failed to appreciate the provisions of clause 2 (1) of the insurance policy in correct perspective. The petitioner was justified in repudiating the claim on the ground that the period of treatment was less than 52 hours. The State Commission also failed to appreciate that the parties were bound by the terms & conditions of the insurance contract.

9.      Facts of the case are admitted by the parties. The only issue is whether the petitioner was justified in repudiating the claim on the ground that as per terms & conditions of the policy, it was mandatory that the treatment is taken for 52 hours. The State Commission has discussed the issue in detail and also quoted the relevant clauses on the point. I have carefully gone through the impugned order as well as the provisions of the insurance policy. I find that there is no provision that the patient must be treated continuously for 52 hours. Clause 2 (1) (a) provides that if an individual takes treatment continuously for a period of 24 hours or any part thereof (after having completed 48 hours), he shall be entitled for reimbursement of claim in view of clause 2 (1) (a) of the terms & conditions of the policy. It is evident from the record and also admitted by the parties that the patient was admitted in the hospital continuously for a period of 49 hours and 4 minutes. Therefore, the complainants are entitled for reimbursement of the claim. As far as argument of the counsel for the petitioner that it was necessary that continuous treatment for 52 hours is mandatory is concerned, the case of the respondents is covered under Clause 2 (1) (a) of the policy. The State Commission relying on the said clause 2 (1) (a) allowed the complaint and directed the petitioner to make payment of the reimbursement claim alongwith compensation and litigation cost. I do not find any illegality or material irregularity in the impugned order warranting interference in the revisional jurisdiction.

O R D E R

          The revision petition is devoid of merit and is accordingly dismissed with no order as to costs.