Maharashtra

StateCommission

A/10/1114

UNITED INDIA INSURANCE CO LTD - Complainant(s)

Versus

SHRI MANHAR P HEMANT - Opp.Party(s)

S S SINGH

22 Oct 2010

ORDER


BEFORE THE HON'BLE STATE CONSUMER DISPUTES REDRESSAL

COMMISSION, MAHARASHTRA, MUMBAI
First Appeal No. A/10/1114
(Arisen out of Order Dated 30/07/2010 in Case No. 28/2010 of District DCF, South Mumbai)
1. UNITED INDIA INSURANCE CO LTD DO 13 UNION CO-OP INSURANCE BUILDING 2 ND FLOOR 23 SIR P M ROAD MUMBAI MUMBAI MAHARASHTRA ...........Appellant(s)

Versus
1. SHRI MANHAR P HEMANT 108 HIMALAYA HOUSE 79 PALTAN ROAD MUMBAI MUMBAIMAHARASHTRA ...........Respondent(s)

BEFORE :
Hon'ble Mr. S.R. Khanzode PRESIDING MEMBERHon'ble Mr. Dhanraj Khamatkar Member
PRESENT :S S SINGH , Advocate for the Appellant 1

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ORDER

Mr.S.R. Khanzode - Hon'ble Presiding Judicial Member:

 

 

(1)          This appeal takes an exception to an order dated 30.07.2010 passed in Consumer Complaint No.29/2010, Shri Manhar P. Hemani  V/s. United India Insurance Co. Ltd., passed by South Mumbai District Consumer Disputes Redressal Forum (hereinafter referred to as ‘Forum below’).  It is the case of the mediclaim.  It is not disputed that for the relevant period mediclaim policy was taken from Opposite Party/Appellant, hereinafter referred to as ‘Insurance Company’. 

 

(2)          It is not disputed that on 06.08.2008 Respondent/Original Complainant, hereinafter referred to as the ‘Complainant’ admitted in Jaslok Hospital for complaint of pain in the back.  He was operated there on the following day for infected Sebaceous and thereafter discharged on the later part of the same day.  Insurance claim made on 19th August, 2009 for expenses of Rs.40,123.67.  The same stood repudiated referring to clause 2.3 of the Insurance Policy on the ground that hospitalization ought to have been for minimum 24 hours.  Therefore, this consumer complaint was filed.  Forum below upholding the contention of the Complainant allowed the complaint and feeling aggrieved thereby Insurance Company preferred this appeal.

 

(3)          We heard Advocate Mr.S.S. singh for the Appellant/Insurance Company.  We have gone through Clause 2.3 of the policy to which the Insurance Company placed its reliance.  It reads as under:

 

“Expenses on Hospitalisation for minimum period of 24 hours are admissible.  However, this time limit is not applied to specific treatments, i.e. Dialysis, Chemotherapy, Radiotherapy, Eye Surgery, Dental Surgery, Lithotripsy (Kidney Stone removal), D & C Tonsilectomy taken in the Hospital/Nursing Home and the Insured is discharged on the same day, the treatment will be considered to be taken under hospitalization benefit.  This condition will also not apply in case of stay in hospital of less than 24 hours provided

 

a)       The treatment is such that it necessitates hospitalization and the procedure involves specialised infrastructural facilities available in hospital.

 

b)       Due to technological advances hospitalization is required for less than 24 hours only.”

 

(4)          It is not disputed that the procedure undergone by the Complainant needs hospitalization and the procedure involves specialized infrastructural facilities of the hospital since he had to undergo the surgery.  In the circumstances, Insurance Company read only first clause of policy condition and left the second clause and, thus, read the condition in a manner which was beneficial to them and detrimental for the consumer.  We are unable to accept the contention of the Ld. Counsel appearing for the Appellant, and, thus find no fault with the impugned order.  We hold accordingly and pass the following order:

 

O  R  D  E  R

 

       (i)     Appeal stands dismissed.

     (ii)     No order as to costs.

 

PRONOUNCED :
Dated : 22 October 2010

[Hon'ble Mr. S.R. Khanzode]PRESIDING MEMBER[Hon'ble Mr. Dhanraj Khamatkar]Member