IMPORTANT POINT
Insured cannot claim anything more than what covered by insurance policy.

This revision is directed against the order of the State Commission Delhi in FA No. 520/2012 dated 06.08.2013 whereby the State Commission confirmed the order of the District Forum-VI in complaint case no. 1590/2012 and dismissed the appeal preferred by the insurance company.

2. Briefly stated facts relevant for the disposal of the revision petition are that respondent complainant purchased a mediclaim policy from the petitioner insurance company effective w.e.f. 11.07.2008 till 10.07.2009. The sum insured under the above policy was Rs.1,00,000/-. In March 2009, the complainant developed problem of pain in his abdomen for which he took treatment as out patient at Singhal Medical Centre, Krishna Nagar, Delhi. When the complainant did not get relief from the treatment, he got himself admitted in hospital on 24.03.2009. It is the case of the complainant that on the basis of clinical examination, he was diagnosed as suffering from septicemia as well as worm in gall bladder. The complainant was, therefore, operated upon for empyema gall bladder and worm in gall bladder on 25.03.2009 and was discharged from the hospital on 28.03.2009. After his discharge from the hospital, the complainant submitted insurance claim for expenses of Rs.50, 056/- incurred by him on his treatment during the period for which he was admitted in the hospital. The insurance claim, however was repudiated on the ground that as per clause 4.3 of the insurance contract, the surgery of gall bladder and bile duct was not covered for first two years of the insurance cover.

3. The District Forum on consideration of the pleadings and the evidence came to the conclusion that repudiation of insurance claim in view of Exclusion Clause 4.3 of the insurance contract amounted to deficiency in service and allowed the complaint. Relevant observations of the District Forum are reproduced as under:

“In terms of Doctor of the hospital, empyema Gall Bladder is a medical as well as surgical emergency requiring hospitalization for removal of infection in case of empyema Gall bladder. In our considered view, this surgery to remove infection and its sources, cannot be mixed with gall bladder or bile duct surgery in normal course. Such a medical emergency is inherently covered under any mediclaim policy, and its control, coverage cannot be disallowed in any event, to save the life by septicemia blood infection, which caused it. In our view, the OP has acted arbitrarily in repudiating the claim.”

4. Being aggrieved of the order of the District Forum, the petitioner preferred an appeal and the State Commission dismissed the appeal. Relevant observations of the State Commission are reproduced as under:

“From the meaning of empyema in Wikipedia as well as certificate of the Doctor Sunil Singhal and L P Duggar, it is clear that the treatment and surgery done on the complainant / respondent is not covered under the exclusion clause no. 4.3 of the cover and the surgery done on the complainant / respondent cannot be mixed with gallbladder and bile duct surgery done in normal course. The emergency medical treatment and surgery conducted on the complainant / respondent is inherently covered under any mediclaim policy and its control, coverage cannot be disallowed in any event to save the life by septicemia blood infection, which caused it. Accordingly, in our view there is no illegality or infirmity in the order passed by the District Forum and we uphold the judgment of the District Forum VI passed in Complaint Case No. 1590 of 2009 and dismiss the appeal. No order as to costs.”

5. Learned Dr. Sushil Kumar Gupta, Advocate for the petitioner has contended that it is well settled that an insurance policy is a contract and it has to be strictly implemented. It is argued that as per clause 4.3 of the insurance contract, the reimbursement of the expenses for gall bladder surgery is excluded for initial two years of the mediclaim insurance policy. It is argued that both the foras below have fail