IMPORTANT POINT
Insurance claim cannot be allowed ignoring exclusion clause.

D.K. Jain, President—By this Revision Petition, under Section 21(b) of the Consumer Protection Act, 1986 (for short “the Act”), the Complainant calls in question the correctness and legality of the order dated 04.03.2014, passed by the Maharashtra State Consumer Disputes Redressal Commission at Mumbai (for short “the State Commission”) in First Appeal No. A/12/150. By the impugned order, while overturning the order dated 31.12.2011, passed by the District Consumer Disputes Redressal Forum at Nashik (for short “the District Forum”) in Consumer Complaint No. 197 of 2011, the State Commission has accepted the Appeal, preferred by the National Insurance Company Ltd., the Respondent herein (for short “the Insurance Company”) and, consequently, dismissed the Complaint. By the said order, while partly accepting the Complaint, preferred by the Petitioner herein, the District Forum had directed the Insurance Company to pay to the Complainant a sum of Rs.1,50,000/- towards Mediclaim Insurance Policy, along with interest @ 9% p.a. from 10.01.2011 till realization, besides Rs.15,000/- towards mental harassment and Rs.1,000/- as litigation costs.

2. Succinctly put, the facts giving rise to the present Revision Petition, are:

2.1 The Complainant had obtained a Mediclaim Policy from the Insurance Company. The said Policy was valid between the period 27.09.2006 and 26.09.2007. Thereafter, it was renewed by the Complainant from time to time, on making payment towards the premiums. In this way, while the last renewed policy was valid between the period 27.09.2009 and 26.09.2010, due to sudden eruption of severe pain in the knees, on 14.06.2010 the Complainant was examined by one Dr. Arun Mullaji at Mumbai. On local examination, it was found that there was swelling in the knees, Fixed Flexion Deformity (FFD) was 10o and Range of Movements (ROM) was from 10o to 100o and varus was positive. The provisional diagnosis was “Bilateral Osteo-arthritis Knees” (BIL-OA Knees). He was advised to undergo Bilateral Total Knee replacement. Accordingly, on 29.06.2010 the Complainant was admitted in the Breach Candy Hospital at Mumbai. On 30.06.2010 the said Doctor performed the operation and replaced the bowl of both the knees and the Complainant was discharged from the said Hospital on 03.07.2010. Since for the said operation and medical treatment, the Complainant had incurred expenditure amounting to Rs.4,18,915/-, he preferred claim for reimbursement limited to the assured sum of Rs.1,50,000/- under the policy, with the Insurance Company, together with all the relevant documents.

2.2 On submission of the claim form and other relevant documents by the Complainant, the Insurance Company appointed M.D. India Health Care Services (TPA) Pvt. Ltd., the Third Party Administrator to scrutinize the said claim. Vide their letter dated 20.09.2010, the said TPA repudiated the claim, stating that, as per the policy terms and conditions, the claim fell in the Exclusion Clause 4.3 and the same was not payable. The said letter of the Third Party Administrator reads as under:

“Dear Sir/Madam,

This is regarding the claim lodged by you for patient, Mr. Surana Ajit Santokchand under mediclaim Policy No. 270701/ 48/09/8500000431, details mentioned above. Our panel of Doctors have scrutinized the claim documents submitted by you.

The observations are as follows:

1. Policy coverage for Mr. Surana Ajit Santokchand is for 4 Year/Years.

2. Inception date of policy is 27-Sep-2006.

3. Current policy is in fourth Year/Years.

4. Current illness OSTEOARTHRITIS BOTH KNEE (sic) since Acute as per MMR Form.

5. As per revised policy terms and conditions, Treatment for Joint replacement due to degenerative conditions. Age related osteoarthritis and osteoporosis are not payable for first four years of operation of the policy. Hence claim is repudiated.

6. As per Policy terms and conditions, claim is not payable, under Clause No. 4.3 (Please refer to policy copy for deta