IMPORTANT POINT
Mediclaim cannot be allowed bypassing exclusion clause.

Ajit Bharihoke, Presiding Member—This revision is directed against the order of the State Commission Himachal Pradesh dated 21.11.2012 whereby the State Commission allowed the appeal preferred by the opposite party/insurance company and set aside the order of the District Forum Kangra at Dharamshala.

2. Briefly stated facts relevant for the disposal of this revision petition are that petitioner filed a consumer complaint alleging that she had purchased a medi-claim insurance policy from the opposite party effective from 09.03.2005 to 08.03.2006. During the currency of this policy, the petitioner / complainant was blessed with a child. The child was delivered through a caesarean procedure at the clinic of respondent no.2. The cost for the procedure was Rs.55,436/-. The petitioner through her father-in-law submitted the medi-claim for the said amount. The respondent / opposite party however, repudiated the claim on the ground that expenses incurred on account of maternity were not reimbursable under Exclusion Clause 4.12 of the policy. The case of the petitioner is that at the time of issue of medi-claim policy, she was not informed that expenses incurred on account of maternity were not reimbursable nor she was provided with the terms and conditions of the insurance policy. Thus, claiming the repudiation of insurance claim as deficiency in service, the petitioner preferred the consumer complaint.

3. The appellant resisted the complaint and pleaded that maternity expenses were not reimbursable in view of Exclusion Clause 4.12 of the insurance policy.

4. Learned District Forum on consideration of the pleadings of the parties and evidence came to the conclusion that respondent / opposite party had failed to establish that Exclusion Clause 4.12 was brought to the notice of the complainant at the time of insurance policy and this amounts to violation of mandatory instructions contained in Regulation 3 of Insurance Regulatory & Development Authority (Protection of Policy Holders’ Interests) Regulations, 2002. The District Forum, thus allowed the consumer complaint and directed the opposite party to pay a sum of Rs.55,436/- alongwith 9% interest p.a. from the date of complaint to the respondent. Besides that a sum of Rs.10,000/- was granted as compensation and Rs.2000/- was awarded as litigation expenses.

5. The opposite party / insurance company being aggrieved of the order of the District Forum preferred an appeal and the State Commission Himachal Pradesh in view of Exclusion Clause 4.12 of the insurance contract allowed the appeal, set aside the order passed by the District Forum and dismissed the complaint.

6. Learned Sunil Mund, Advocate for the petitioner has contended that impugned order of the State Commission is not sustainable for the reason that it has been passed in violation of Regulation No.3 of IRDA (Protection of Policy Holders’ Interests) Regulations, 2002 which provides that the prospectus of insurance product shall clearly state the scope of benefits, the extent of insurance cover and in an explicit manner explain the warranties, exceptions and conditions of the insurance cover. It is contended that in the instant case, the terms and conditions of the insurance policy particularly the exclusion clause 4.12 of the insurance policy was not brought to the notice of the complainant.

7. We do not find merit in the above contention of learned counsel for the petitioner. Regulation 3 of Insurance Regulatory & Development Authority (Protection of Policy Holders’ Interests) Regulations, 2002 require that prospectus of insurance product shall clearly state the scope of benefits, the extent of insurance cover and in an explicit manner explain the warranties, exceptions and conditions of insurance cover. The opposite party has produced before the District Forum copy of the prospectus as Ex.Op-4. On reading of this prospectus, it is clear that prospectus meets the requirement of the above requirement and it specifically provid