IMPORTANT POINT
Insurance claim cannot be allowed ignoring exclusion clause.

Dr. B.C. Gupta, Presiding Member—This revision petition has been filed u/s 21(b) of the Consumer Protection Act, 1986, against the impugned order dated 26.02.2015, passed by the Bihar State Consumer Disputes Redressal Commission (hereinafter referred to as the State Commission) in appeal No. 112/2014, “Branch Manager, United India Insurance Co. Ltd. vs Dr. Bihari Lal Singhania,” vide which, while allowing the appeal, the order passed by the District Forum Muzaffarpur in consumer complaint case No. 06/12 dated 23.12.2013, allowing the said complaint, filed by the present petitioner, was set aside.

2. The facts of this case are that the petitioner/complainant Dr. Bihari Lal Singhania obtained a medi-claim policy from the respondent/OP United India Insurance Company for a sum of Rs.5 lakhs, valid from 08.10.2009 to 07.10.2010 (midnight). During the currency of the said policy, the complainant suffered from breathlessness and stomach pain for which he was admitted in Shri Ram Hospital, Patna on 22.12.2009 where he was made to stay in the ICU upto 30.12.2009, after which he was transferred to Bombay Hospital and Medical Research Centre, Mumbai for further treatment. At that hospital, surgery was performed upon him for removal of his gall bladder, after which he was kept in the ICU for treatment of the problem of breathlessness. The complainant claimed expenditure from the insurance company of Rs.3,74,701/- for the said treatment, but the Insurance company paid a sum of Rs.98,536/- only, on 14.12.2010. The balance amount was not paid on the ground that as per exclusion clause 4.3 in the terms and conditions of the policy, if the removal of gall bladder was done “with stone” within a period of 2 years from the date of issue of the policy, the claim was not payable. The OP Insurance company stated that they had made payment for treatment towards lung infection and breathlessness.

3. The complainant filed the consumer complaint in question, seeking directions to the respondents to make payment of the remaining amount of Rs. 2,76,165/- alongwith interest and compensation for mental agony and harassment.

4. In their reply filed before the District Forum, the Insurance Company stated that there was no deficiency in service or negligent act on their part. The balance claim of Rs. 2,76,165/- made on the treatment/operation for Cholecystectomy was not payable, as there was a locking period of 2 years in the terms and conditions of the policy.

5. The District Forum after taking into account the averments of the parties, held that the exclusion clause 4.3 of the Insurance policy was not applicable in the case, since the gall bladder had been removed ‘without stone’. They directed vide their order dated 23.12.2013 to pay the balance claim amount to the complainant alongwith a compensation of Rs.20,000/- for mental agony and litigation cost of Rs.5,000/-. Being aggrieved against the said order, the Insurance Company challenged the same by way of an appeal before the State Commission. Vide impugned order, the State Commission held that the claim was not permissible, because the expenditure had resulted from the removal of gall bladder ‘with stone’. Being aggrieved against the impugned order of the State Commission, the petitioner/complainant is before this Commission by way of the present revision petition.

6. It was contended during arguments by the Ld. Counsel for the petitioner that the complainant’s case was of removal of gall bladder, which is called Cholecystectomy. There was no removal of any stone, and hence, the case was not hit by the exclusion clause 4.3, as being alleged by the insurance company. From the discharge summary made by the Bombay Hospital and Medical Research Centre, it was clear that it was a case of acute Cholecystitis, which means, ‘inflammation of gall bladder’. Even the TPA, Heritage Health Private Limited had mentioned it to be a case of Cholecystitis. The report made by the Department of Histopathology at the Bombay