JUSTICE V.K. JAIN (ORAL)

No one is present for the petitioner when this matter is called.  A letter has been sent by Sh. N.K. Bhalla, Advocate who appears to be the husband of the complainant/petitioner, enclosing a copy of the order of the Hon’ble High Court of Punjab and Haryana  dated 6.9.2019 and requesting that the matter may be decided on merits in his absence. I have, therefore, considered the record.

2.      Shri Nirmal Kumar Bhalla  husband of the complainant / petitioner obtained a Mediclaim Policy from the respondent for the period from 10.8.2017 to 13.2.2018. The complainant was admitted in a hospital on 11.9.2017 and was treated there, incurring an expenditure of Rs.197660/-. The claim for reimbursement in terms of the Mediclaim Policy taken by him was rejected by the respondent vide letter dated 28.6.2018 which to the extent it is relevant, reads as under:-

“The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any Insured person in connection with or in respect of:

4.9 Convalescence, general debility; run-down condition or rest cure, Obesity treatment and its complications including  morbid obesity, congenital external disease/defect or anomalies, treatment relating to all psychiatric and psychosomatic disorder, infertility, Sterility, Venereal disease intentional self injury and use of intoxication drugs/alcohol.”

3.      Being aggrieved, she approached the District Forum by way of a consumer complaint seeking payment of the aforesaid amount with compensation etc.

4.      The complaint was resisted by the insurer primarily on the ground that since the complainant had taken treatment for infertility, the claim was not admissible in view of the Exclusion Clause contained in the insurance policy.

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

6.      Clause 4.9 of the Medilciam Policy, which comes under the head ‘Exclusions’ reads as under:-

“4. Exclusions : The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any Insured person in connection with or in respect of:

          4.1    xxxx           xxxx                      xxxx                      xxxx

                   xxxx            xxxx                      xxxx                      xxxx “4.9 Convalescence, general debility; run-down condition or rest cure, Obesity treatment and its complications including  morbid obesity, congenital external disease/defect or anomalies, treatment relating to all psychiatric and psychosomatic disorder, infertility, Sterility, Venereal disease intentional self injury and use of intoxication drugs/alcohol.”

          It would thus been seen that the Mediclaim Policy taken by the husband of the complainant did not cover any treatment relating to infertility.

7.      This is not the case of the petitioner that the treatment taken by her was not related to infertility. Therefore, the said treatment is clearly excluded in terms of Clause 4.9 of the Mediclaim Policy taken by her husband. The view taken by the Fora below, therefore, does not call for any interference by this Commission in exercise of its revisional jurisdiction.

8.      The petitioner had filed a writ petition before the High Court of Punjab and Haryana which came to be withdrawn on 6.9.2019 with liberty to the complainant to avail her remedy against the order passed by the State Commission. A  Consumer Forum such as this Commission cannot go into the legality  or otherwise of the terms of an insurance policy. If the petitioner/complainant has a grievance with respect to Clause 4.9 of the terms and conditions of the policy, the Consumer Forum is not the appropriate Forum for this purpose. The Consumer Forum has to decide a consumer complaint on the basis of the contract of insurance executed between the parties and in terms of Clause 4.9 of the said contract, the condition for which treatment was taken by her was excluded from the benefits available under the Mediclaim Policy taken by the husband of the complainant.

9.      For the reasons stated hereinabove, the revision petition is dismissed with no order as to costs. One copy of this order be sent to the petitioner for information.