IMPORTANT POINT
Insurance claim cannot be allowed de hors exclusion clause contained in policy.

V.K. Jain, Presiding Member—The complainant/respondent took a medi-claim policy from the petitioner company on 04.05.2005. On 15.07.2005, the complainant was admitted to Max Hospital in Wazirpur District Centre, New Delhi on account of pain, where his ailment was diagnosed as left lower ureteric stricture with stone (solitary left kidney). A procedure comprising Bilateral RGP+DJ stenting left side was done under GA on 16.07.2005, followed by left ureteric stricture dilatation with DJ stenting done under GA on 18.07.2005. The complainant came to be discharged on 19.07.2005. He submitted a claim form for reimbursement of the amount, which he had incurred on the aforesaid treatment in Max Hospital. The claim, however, was rejected by the Insurance Company on the ground that such an ailment was excluded in terms of the medi-claim policy issued to him.

2. Being aggrieved from the denial of the claim, the complainant approached the concerned District Forum by way of a complaint. Vide order dated 09.02.2008, the District Forum directed the following payments to the complainant:-

(1) OP will pay Rs. 47,801/- to the complainant, the amount spent by him in the hospital.

(2) OP will pay Rs. 15,000/- to the complainant as compensation for causing him mental agony and harassment.

(3) OP will pay Rs. 5,000/- towards cost of litigation to the complainant.”

3. Being aggrieved from the order of the District Forum, the Company approached the concerned State Commission by way of an appeal. The said appeal having been dismissed, vide impugned order dated 12.02.2009, the said Company is before us by way of this revision petition.

4. Clause C (2) of the Policy issued to the complainant reads as under:-

“C. What we will not pay We will not pay for claims arising out of or howsoever connected to the following:

(2) Without derogation from C (1) above, any Medical Expenses incurred during the first two consecutive annual periods during which You have the benefit of a Health Guard Policy with Us in connection with cataracts, benign prostatic hypertrophy, hysterectomy, menorrhagla, fibromyoma, endometriosis, hernia of all types, hydrocele, fistulae, haemorrhoids, fissure in ano, stones in the urinary and biliary systems, surgery on tonsils, adenoids, sinuses, ears, skin and all internal tumours/cysts/nodules/polyps of any kind including breast lumps, gastric or duodenal ulcer. This Exclusion period shall apply for a continuous period of a full 4 years from the date of Your first Health Guard Policy with Us if the above referred illness were present at the time of commencement of the policy and if You had declared such illness at the time of proposing the policy for the first time.”

It would thus be seen that the expenses incurred on account of stones in the urinary and biliary system were not required to be reimbursed by the Insurance Company to the complainant, for a period of two consecutive years. Admittedly, the treatment for which reimbursement was claimed by the complainant was taken within seven months of taking the policy. Therefore, if it can be shown that he had taken treatment on account of stones in the urinary and biliary system, his claim would be clearly inadmissible.

5. The learned counsel for the petitioner Company has drawn our attention to a diagram of a urinary system, which is available at page no. 46 of the paper book and which clearly shows that the urinary system comprises two kidneys, the ureter, the bladder, two sphincter muscles and the urethra. Therefore, there is no escape from the conclusion that a kidney of human being is a part of his urinary and biliary system. Since the stone was found in the kidney of the complainant, the treatment for removal of the said stone from his kidney would be inadmissible in view of the Clause C (2) of the medi-claim policy taken by the complainant.

6. The complainant who appears in person states that since he has one kidney, his case is to be treated differently. He also submits tha