IMPORTANT POINT
Insurance Company should not agitate over petty amounts.

D.K. Jain, President—Challenge in this Revision Petition, by Religare Health Insurance Co. Ltd. (for short “the Insurance Company”), the sole Opposite Party in the Complaint, is to the order dated 19.9.2016, passed by the State Consumer Disputes Redressal Commission, Punjab (for short “the State Commission”), in FA/1237/2015. By the impugned order, the State Commission has over-turned the order dated 21.9.2015, passed by the District Consumer Disputes Redressal Forum, Gurdaspur (for short “the District Forum”) in Complaint No.108/2015. On re-appraisal of the material on record, the State Commission has come to the conclusion that there was deficiency in service on the part of the Insurance Company in not reimbursing a sum of Rs.1,50,934/-, the amount actually expended by the Complainant, the Respondent herein, for the surgery undergone by him for Left frontoparietal flap craniotomy and removal of large tumor on 04.9.14. Thus, allowing the Complaint, the State Commission has directed the Insurance Company to pay to the Complainant a sum of Rs.1,59,934/- along with interest @ 9% p.a. from the date of repudiation till realization; a sum of Rs.20,000/- as compensation and Rs.11,000/- as litigation expenses.

2. The factum of the Complainant having undergone the afore-noted neurosurgery not being in dispute, the short question for consideration is whether or not the said claim falls within the ambit of the Exclusion Clause (4) in the terms and conditions of the Health Insurance cover, obtained by the Complainant?

3. Having heard learned Counsel for the parties and perused the documents on record, including the said Clause in the Policy; the Discharge Summary dated 8.9.2014; Lab Reports dated 10.9.2014 and 23.9.2014, we are of the opinion that the Revision Petition is bereft of any merit.

4. For the sake of ready reference, the relevant Exclusion Clause is extracted below:

“Specific waiting period

1. Any Claim for or arising out of any of the following Illnesses or

Surgical Procedures shall not be admissible during the first 24 (twenty four) consecutive months of coverage of the Insured Person by the Company from the first Policy Period Start Date:

…………………………………

…………………………………

x. Internal tumors, skin tumors, cysts, nodules, polyps including breast lumps (each of any kind) unless malignant.”

5. The stand of the Insurance Company is that since the claim made by the insured was within the cooling off period of 24 months and the tumor was not malignant, it was not liable to reimburse the afore-stated amount, in view of the afore-extracted Exclusion Clause. According to the Insurance Company the onus was on the Complainant to prove that the tumor was malignant, which it failed to discharge.

6. It appears from the record, in particular, the Pathology Report dated 10.9.2014, that while recording the preliminary diagnosis, certain further investigations were advised. Perhaps, on the advice, further laboratory tests were got conducted on 12.9.2014. In the report dated 23.9.2014, the diagnosis was as under:

“Morphological features favour Neurocytoma, Extraventricular,

WHO Grade II.”

7. Though in the said report, there was no specific finding to the effect that the sample was malignant but it was opined that Morphological features favoured Neurocytoma, a clear indicator in favour of malignancy. At the same time, there is no clear finding that it was benign. At this juncture, we may note that now at this stage, an attempt has been made by the Insurance Company to place on record a report dated 22.12.2016 by an Expert, opining that according to the documents placed before him, Hispopathology Report is in favour of benign lesion. We fail to understand why such report could not be obtained by the Insurance Company before repudiating the claim or before filing its Written Version in opposition. Apart from the fact that under our limited Revisional jurisdiction under Section 21(b) of the Consumer Protection Act, 1986 (for short “the Act”)