IMPORTANT POINT
Insurance claim cannot be repudiated on hypertechnical grounds.

ORDER

P.R. Shah, Member—The present appeal is filed by the appellant being aggrieved by and dissatisfied with the order passed by the Ld. District Consumer Disputes Redressal Commission of Vadodara (Additional) dated 27.10.2017 in complaint no.215/2017.

2. When the matter was called out Ld. Adv. P.H. Thakkar for the appellant was present and none appeared for the respondent.

Impugned judgment

3. Ld. District Commission has partially allowed the complaint and has ordered and directed the opponent to pay to the complainant Rs.34,088/- at 9% interest per annum from 16.09.2015 and Rs.2,000/- for mental harassment and Rs.1,500/- for litigation cost.

Facts of the case

4. The complainant is insured by United India Insurance Company under individual health policy no.1805002814P108753176 from 20.01.2015 to 19.01.2016 for sum insured of Rs.1,50,000/- for himself, Rs.1,50,000/- for his wife and for his children Rs.1,00,000/- each. During the policy period, the complainant’s son Sagar was admitted on 02.07.2015 for treatment of Acute Perianal Peri Rectal Abscess in the Siddhi Surgical Hospital and discharged on 04.07.2015. The complainant had incurred medical expense of Rs.34,088.33/- during the period of treatment. To get medical reimbursement under the policy, the claim form was submitted by the complainant along with other papers in the office of Vipul TPA Private Limited. But claim was rejected on the ground that as per the claim form part-B, the Hospital had only 10 beds as against the minimum requirement of 15 beds. Therefore, the complainant filed the case before the Ld. District Commission.

5. The Ld. Adv. for the appellant submits that the Ld. District Commission has failed to appreciate evidence on record of the case wherein in the claim form part-B filled up by the hospital, it is stated that the hospital has 10 beds against the requirement of 15 beds to qualify under the definition of ‘hospital’. That the said claim form bears signature of the treating doctor. It is submitted that claim was rejected as per clause 3.14 of the terms and conditions of the insurance policy. The Ld. District Commission has erred in holding the appellant liable and therefore, the impugned judgment should be quashed and set aside.

6. The undisputed facts of the case are

that the insured had a policy of the opponent which covered himself and his family

members with the sum assured of Rs.1,50,000/-. During the subsistence of the policy,

the insured’s son was hospitalized for the

treatment of Acute Peri anal Peri Rectal

abscess and incurred expenditure of Rs.34,088.33/-. The claim was rejected on

the ground of exclusion clause 3.14 of the

terms and conditions of the policy which at page 25 reads as under:—

“3.14 Hospital/Nursing Home

A Hospital means any institution established for in-patient care and day care treatment of illness and/or injuries and which has been registered as a Hospital with the local authorities under the Clinical establishments (Registration and Regulation) Act, 2010 or under the enactments specified under the Schedule of Section 56(1) of the said Act OR complies with all minimum criteria as under

- Has qualified nursing staff under its employment round the clock.

- Has at least 10 in-patient beds in towns having a population of less than 10 lacs and at least 15 in-patient beds in all other places;

- Has qualified medical practitioner(s) in charge round the clock;

- Has a fully equipped Operation Theatre of its own where surgical procedures are carried out;

- Maintains daily records of patients and makes these accessible to the insurance company’s authorised personnel.

7. It is further submitted by the appellant that, according to the IRDA circular no. HLT/REG/CIR/125/07/2013 issued on 03.07.2013 which is applicable to all life and non-life insurance companies, the definition of a ‘hospital’ at serial no.8 is the same as in the policy of the opponent. The appellant submits that for a hospital to qualify into definition