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CHATTISGARH STATE CONSUMER DISPUTES REDRESSAL COMMISSION
S.C. Vyas, President, Veena Misra and V.K. Patil, Members
ORIENTAL INSURANCE CO. LTD. - Appellant
Versus
JUGAL KISHORE PATNI AND ANR. - Respondents
Appeal No. 201 of 2010
Decided on : 03-08-2010
Mr. Shishir Bhandarkar, Advocate, for the Appellant; Mr. R.K. Bhawnani, Advocate, for the Respondent
Reasonable and necessary expenses for the treatment of the insured must be considered under the policy clauses.
Headnote:
Insurance Policy - Mediclaim Insurance - Clause 1.2, Exclusion Clause 4.10
Fact of the Case:
The complainant purchased a Mediclaim Insurance Policy and incurred expenses for a C.P.A.P. Machine and treatment at a hospital. The Insurance Company repudiated the claim, stating that the expenses were not covered under the policy.
Finding of the Court:
The court found that the C.P.A.P. Machine was part of the treatment advised by the hospital physician and should be reimbursed under the terms of the policy.
Issues: Interpretation of policy clauses and exclusion clause, coverage of C.P.A.P. Machine expenses
Ratio Decidendi: The court interpreted the policy clauses to include reasonable and necessary expenses for the treatment of the insured, and found that the C.P.A.P. Machine was part of the treatment and should be reimbursed.
Final Decision: The appeal succeeded in part, and the Insurance Company was directed to pay Rs. 46,800 to the complainant for the C.P.A.P. Machine.
ORDER
S.C. Vyas, President (Oral)- This appeal is directed against the order dated 25.2.2010 of District Consumer Disputes Redressal Forum, Raipur (hereinafter called as "District Forum" for short) in Complaint Case No. 62/2008, whereby the appellant/ Insurance Company, has been directed to pay Rs. 50,543 to the complainant/respondent No 1, along with interest @ 6% p.a. w.e.f. 22.5.2008 till the date of payment and also to pay Rs. 2,000 by way of compensation for mental agony and Rs. 700 as cost of litigation.
2. Facts of the case, as narrated in the order of the District Forum are that, complainant/respondent No. l had purchased a Mediclaim Insurance Policy from the appellant. He was having some breathing problem while sleeping, so had taken treatment at Ramkrishna Care Hospital, Raipur where it was diagnosed that he was suffering from Sarcoidosis and was advised to take treatment either at New Delhi or at Mumbai at some big health centre. Then after getting himself examined at A.I.I.M.S. New Delhi, he ultimately went to Hinduja Hospital, Mumbai where he was admitted as Indoor patient for sometime and was examined. The appellant/Insurance Company was having a tie-up with Hinduja Hospital, so hospital had not charged anything for tests conducted there and for the treatment given. Only complainant/respondent No. l was required to pay Rs. 717 to Hinduja Hospital and was required to purchase C.P.A.P. Machine, as suggested by the Physician of the Hinduja Hospital. He purchased that Machine for Rs. 46,800 including Value Added Tax (VAT) Rs. 1,800 (Annexure A-9) and then preferred a claim of Rs. 51,978 before the appellant/Insurance Company. The appellant/Insurance Company repudiated the claim of the complainant on the ground that the articles, which have been purchased and the amount which was paid, were not covered under the Insurance Policy purchased by the complainant/respondent No. 1. Then, a complaint was filed before the District Forum, in reply of which also the appellant/Insurance Company took the same defence that amount of claim was not covered under the terms of the policy and therefore, amount was not payable and so the appellant committed no deficiency in service in not paying the amount of cost of C.P.A.P. Machine, as well as other amount claimed by the complainant/respondent No. l.
3. Learned District Forum has not agreed with the arguments advanced by the Insurance Company before it and allowed the complaint by the impugned order.
4. We have heard arguments of both parties and perused the record of the District Forum.
5. Counsel for the appellant Mr. Shishir Bhandarkar has referred condition No. l.2 of the Mediclaim Insurance Policy, copy of which has been filed as Annexure A-2. He submitted that as per Sub-clause (d) of Clause No. l.2 of Mediclaim Policy, the expenses in respect of Anaesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines and Drugs, Diagnostic Material and X-Ray, Dialysis, Chemotherapy, Radiotherapy, Cost of Pacemaker, Artificial Limbs and Cost of Organs and similar expenses, can only be reimbursed by the Insurance Company. Thus, Insurance Company was liable to pay expenses in respect of aforesaid tests and articles only and not for C.P.A.P. Machine or any other appliances, which had been purchased by the complainant/respondent No. l. He also placed reliance on the Exclusions Clause 4.10 and submitted that under this exclusion, also charges incurred at Hospital or Nursing Home primarily for diagnostic, X-ray or Laboratory examinations not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment, sickness or injury for which confinement is required at Hospital/Nursing Home, are excluded from the coverage of the policy. On the basis of these provisions, learned Counsel for the appellant submitted that the Insurance Company has not committed any deficiency in not allowing the claim of the complainant/respondent No. l.
6. Wh
