JUDGMENT :

Heard Mr. P.N. Sahi, learned Senior Advocate for the petitioner and Mr. Ashok Priyadarshi for the Insurance Company (Respondent No.3). The counsel for the third party Administrator, namely, respondent nos.4, 5 & 6, viz., Mr. Sanjay Verma has also rendered his assistance in this matter.

2. The petitioner has come to this Court for a direction to annul Clauses 2.1,2.2 and 2.3 of the Mediclaim Insurance proposal which prescribe that the insured shall only get 50% of the claim amount in case of hospitalization in a non-network hospital and shall be reimbursed fully only if treatment is obtained in a network hospital.

3. Apart from this, the other prayer is that at the time of entering into the contract for such Medi-claim, the aforesaid clauses were not made available/known to the petitioner.

4. In that event, it has been submitted that even though a claim based on insurance is a contractual claim which has to be determined on the basis of terms of contract but in this case, the Insurance Company, being a stronger party, the principle of contra proferentem would apply and in the absence of specific knowledge having been provided to the insured with respect to such clauses which could permit the Insurance Company to reimburse 100% of the expenses incurred in only the network hospital, ought to have been made known to the insured.

5. Apart from this, it has been submitted that medical claim is a part of right to life which is mandated under the Constitution of India. In a policy governing Medi-claim, the Clauses which are contrary to the principle of the right to life cannot be sustained. Though an Insurance Company has a right to frame its clauses in a particular insurance proposal but considering the fact that it is a Government Insurance Company, no Clause which takes away the valuable right of a person could be sustained.

6. In support of the arguments raised on behalf of petitioner, Mr. Sahi learned Sri advocate has urged that the policy was subscribed by the petitioner sometimes in the year 2001 when he was only made to sign in the space provided, without affording him a copy of the brochure which contained the offending clauses. He further submits that any renewal of such policy, which is on an yearly basis, would be deemed to be a continuation of the earlier policy and therefore if the petitioner was not made known about the aforesaid offending clauses which had led to the non-payment of the 50% of his claim, the Insurance Company or the respondent nos.4,5 & 6 be directed to make full payment of the insured amount/the amount incurred in treatment.

7. The last of the arguments advanced by Mr. Sahi is that even assuming that the contents of the policy were made known to the petitioner, the rationale behind enacting those clauses is inscrutable. As a doctor, the petitioner chose a hospital which provided better medical facilities but on a lesser cost. It was quite fortuitous that the hospital where the petitioner received his treatment was not in the network of the Insurance Company. There is no justification, it has been argued, for denying the reimbursement of the expenses incurred by the petitioner in a hospital which provides better treatment to a patient but at a lesser cost.

8. The possible rationale behind the insertion of the aforesaid clauses could be to provide convenience to the Insurance Company and to the insured for a smooth procedure in case of treatment in a network hospital with a tie-up with the Insurance Company.

9. In the present case, as urged by Mr. Sahi, the strict interpretation of the clauses have only resulted in perpetuating a situation where inferior quality service is provided at a higher cost. By choosing a hospital where lesser cost was charged the petitioner has only shown his bona fides and therefore he should not be penalized for the same.

10. As opposed to the aforesaid contentions raised on behalf of the petitioner, Mr. Priyadarshi, learned advocate for the Insurance Company has sub