IMPORTANT POINT
Non-settlement of mediclaim without any bonafide reason is not justified.

Mr. Ajit Bharihoke, Presiding Member—This revision petition is directed against the order of the State Commission, Punjab in F.A. No.1263 of 2013 whereby the State Commission dismissed the appeal preferred by the petitioner insurance company against the order dated 27.09.2013 passed by the District Forum, SAS Nagar, Mohali in C.C. No.214 of 2013.

2. Facts of the case are more or less admitted. It is not in dispute that the respondents/complainants had purchased Health Insurance Policy no.110281/48/11/97/00000017 valid w.e.f. 26.08.2011 to 25.08.2012. The insurance cover under the said policy was to the extent of Rs.2 Lakhs for one claim. The sum assured was Rs.3 Lakhs but the threshold limit for a single claim under the policy was Rs.2 Lakhs. The complainants also purchased a Top-Up Medicare Policy for the same period being policy no.110281/48/11/26/00000018. During the subsistence of the aforesaid two policies, the complainants took treatment while hospitalization. He filed medical claim under the original policy which was paid. However, as the expenses incurred by the complainants on the treatment were more than the maximum limit of the original mediclaim policy, the complainants lodged claim for remaining amount of Rs.1,40,345/-. The insurance claim was however repudiated on the premise that ‘the claim amount Rs.1,40,345/- was less than the threshold limit of Rs.2 Lakhs so cannot be paid’. Being aggrieved from the repudiation of the claim, the complainants raised a consumer dispute by approaching the District Forum, SAS Nagar, Mohali.

3. The District Forum, on consideration of the evidence and evaluation of the terms and conditions of the insurance policy, allowed the complaint and directed the petitioner/OP to pay to the complainant a sum of Rs.1,40,345/- with 9% interest p.a. from the date of repudiation i.e. 08.02.2012 till realization besides compensation of Rs.25,000/- was also awarded for harassment and litigation expenses.

4. Being aggrieved of the order of the District Forum, the petitioner insurance company approached the State Commission, Punjab in appeal. The State Commission however was not convinced with the submissions made by the appellant and on the interpretation of the threshold limit clause of the Top-Up Insurance Policy, the State Commission concurred with the finding of the District Forum and dismissed the appeal.

5. Learned Dr. Anand Vardhan Sharma, Advocate for the petitioner insurance company has taken us through the relevant provision of the insurance contract dealing with the threshold clause and submitted that as, according to the contract, the threshold limit for filing the insurance claim was Rs.2 Lakhs, the insurance company was justified in dismissing the insurance claim for Rs.1,40,345/- being less than the threshold limit. In order to appreciate, the contention of the learned counsel for the petitioner, it would be useful to have a look on the relevant terms of the insurance contract, which is reproduced as under:—

“Basis of Payment

1 Any claim under this policy shall be payable by the Company only if

a. It is in respect of Covered Expenses specified in this policy and

b. The Covered Expenses exceed the Threshold level and

c. All limits of reimbursement under any other Health Insurance Policy/Reimbursement Scheme available to the insured person have been exhausted.

2 The claim payable under this Policy will be the amount by which such Covered Expenses in respect of any hospitalization exceeds the higher of the following:—

i. The Threshold Level opted for the insured person/family as applicable and stated in the schedule or

ii. The amount received/receivable under any/all other Health Insurance Policies (whether or not issued by the Company)/Reimbursement Scheme covering the insured person/family as applicable for such Covered Expenses.”

6. On reading of the above, we find that under the Top-Up Medicare Policy, the insurance company has reserved its right to pay the insurance cla