Heard the learned counsels for both the sides.
2. This appeal is filed U/S-15 of erstwhile Consumer Protection Act,1986(herein-after called the Act). Parties to this appeal shall be referred to with reference to their respective status before the learned District Forum.
3. The case of the complainant, in nutshell is that the complainant has purchased medi-claim policy for himself for sum assured of Rs.1,50,000/- for the period from 05.07.2013 to 14.07.2014. It is alleged inter-alia that the complainant suffered from acute abdominal pain and vomiting and was treated as indoor patient from dtd. 06.09.2013 to dtd.11.09.2013 for the disease Acalculous cholecystitis, and thus incurred expenditure of Rs.47,024/-. The complainant made claim for the same but it was not repudiated by showing the Exclusion clause (3)(b) of the policy. Being aggrieved the complainant filed the complaint.
4. The OP filed written version stating that the claim is covered under the exclusion clause 3(b) of the policy and for that they have rightly rejected the claim. 5. After hearing both the parties, learned
District Forum passed the following order:-
Xxxxx xxxxxxxx xxxxxx
“As per above discussions and observations made by us, we allowed the complaint. The OP-Insurance Company is directed to reimburse the medical expenses amount to Rs.47,024/-(Rupees forty seven thousand twenty four) only to the complainant alongwith 9 % interest from the date of claim and Rs.3,000/-(Rupees three thousand)only towards cost within four weeks from the date of receipt of copy of this order.”
6. Learned counsel for the appellant submitted that that the learned District Forum has committed error in law by misinterpreting the exclusion clause 3(b) of the policy. According to him as per such clause all treatments (conservative, interventional,laparoscopic and open) for Hepatobiliary gall bladder and pancreatic calculi and genitourinary calculi in the 1st two years of the policy would not be admissible under the claim. Learned District Forum ought to have applied judicial mind to this provision of law. So, he submitted to allow the appeal by setting aside the impugned order.
7. Learned counsel for the respondent submitted that learned District Forum has rightly observed about the exclusion clause 3(b). According to him the policy is for one year but exclusion clause 3(b) is meant for two years period of treatment. According to him this term of the policy is not applicable to policy held by the complainant. So, he supports the impugned order.
8. Considered the submission of respective counsels, perused the DFR and impugned order.
9. It is for the complainant to prove the deficiency in service on the part of the OP. It is admitted fact that the complainant had purchased one year medi claim policy for sum assured of Rs.1,50,000/- for the period covering from 05.07.2013 to 14.07.2014. It is also not in dispute that the complainant suffered from acalculous cholecystitis and as such treated from 06.09.2013 to 11.09.2013 at Inspat General Hospital,Rourkella. In support of his treatment he has filed certain documents. The medical treatment papers are clear to show his hospitalization with treatment and bills are also submitted showing expenditure of Rs.47,024/-.
10. The OP denied the claim showing exclusion clause 3(b) which is as follows:-
“ during the first 2 years of continuous operation of insurance covered any expenses on;Gal bladder and pancreatic diseases and all treatments( conservative, interventional, laparoscopic and open) related to Hepato-pancreatobillary including gall bladder and pancreatic calculi. All types of management for kidney and genitourinary tract calculi.”
11. On scrutiny of aforesaid clause it appears that terms and conditions of the policy filed by the OP have not become the part and parcel of the policy purchased by the complainant because the terms of the policy being a part of contract do not bear the signature of the complainant. Even if assuming the terms and conditions applied but the fact remains that the complainant has purchased the policy for one year but the aforesaid clause is meant for the two years treatment from the date of commencement of the policy. Therefore, the exclusion clause 3(b) is not applicable to the policy in question purchased by the complainant. Besides learned District Forum has already analyzed the exclusion clause and has came to same conclusion that the terms and conditions of the policy are not applicable to the facts and circumstances of the complainant. On the otherhand, the terms and conditions of exclusion clause are not binding on the complainant.
12. In view of aforesaid discussion, this Commission is in full agreement with the finding of the learned District Forum. While confirming the impugned order this Commission modified the order by directing the OP to pay Rs.47,024/- to the complainant with interest @ 9 % per annum from the date of impugned order till the date of payment. Rest of the impugned order would remain unaltered.
The appeal is disposed of accordingly. No cost.
Free copy of the order be supplied to the respective parties or they may download same from the confonet or webtsite of this Commission to treat same as copy of order received from this Commission.
DFR be sent back forthwith.
