Insurance policy terms must be strictly construed to avoid adversely affecting the parties' interests.

1. The appellant / Insurance Company has preferred the present appeal under S.15 of the Consumer Protection Act, 1986 against the order dated 9.7.2013, passed by the District Forum, Vikas Bhawan, I.P. Estate, New Delhi in Complaint case No. 1249 of 2010, titled as Sh. Amit Mittal v. National Insurance Co. Ltd. and Ors.' The appellant has prayed for setting aside the order dated 9.7.2013 passed by the Ld. District Forum.

2. Brief facts necessary for adjudication of this appeal are that the Respondent No. 1 / insured had purchased a Medi Claim Policy bearing No. 354500/48/09/8500000214 from the appellant / Insurance Company which was valid for the period 29.5.2009 to 28.5.2010. On 12.11.2009, the respondent No. 1 / insured had an accidental fall, leading to severe pain, swelling and instability in the left knee and for his treatment, the respondent No. 1 / insured got himself admitted to Artemis Health Institute, Gurgaon on 19.11.2009 and was discharged on 22.11.2009.

3. On 27.2.2010, the respondent No. 1 / insured raised a claim of Rs.88,067.00 with Respondent No. 2 / TPA. In reply to the claim, Respondent No. 2 / TPA vide their claim query letter dated 4.3.2010 called for some documents such as the original MRI receipt, the doctor's prescription with respect to the long duration physiotherapy and details of the physiotherapist. All the mentioned documents were submitted by the Respondent No. 1 / insured with the Respondent No. 2 / TPA.

4. Thereafter, upon the recommendation of Respondent No. 2 / TPA, a cheque of approved amount of Rs.9,527 was sent to the Respondent No. 1 / insured on 13.4.2010. Respondent No. 1 / insured was shocked to see the amount which was sanctioned by the respondent No. 2 / TPA since the claim was raised by the respondent No. 1 / insured was ten times the amount actually allowed by the respondent No. 2 / TPA. The respondent No. 1 / insured immediately sent a protest letter dated 16.4.2010 towards the amount approved by the respondent No. 2 / TPA, seeking clarification and justification for the deductions made and requested for reconsideration / review of the claim.

5. Vide letter dated 1.7.2010, Respondent No. 2 / TPA, informed the Respondent No. 1 / insured that the deductions made were as per the insurance policy and specifically the conditions number 4.16, 4.17 and 4.26 of the policy.

6. Being aggrieved by the acts of the respondent No. 2 / TPA and the appellant / Insurance Company of settling the claim at 1/10th of the actual amount claimed by the respondent No. 1 / insured, respondent No. 1 / insured preferred a consumer complaint bearing No. 12249/2010 before the District Forum, Vikas Bhawan, I.P. Estate, New Delhi. Before the District Forum, the respondent No. 1 / insured prayed that the Insurance Company be directed to pay a sum of Rs.88,067 for the treatment along with compensation of Rs.50,000 for harassment & mental agony caused to Respondent No. 1 and Rs.10,000 as cost of litigation.

7. The District Forum, in its order dated 9.7.2013 has observed as under:
"OP has taken plea in his W.S. referring clause of policy 4.16, 4.17 and 4.26 whereas the clauses of policy which are beneficial for complainant have not been referred by OP, neither in the W.S. nor evidence as per Clauses I A, B, C as per Exbt. OPW - 1/1 / CF dated 17.5.11. It appears that remains pre - determined not to release the claim to the consumers taking shelter of policy clauses which are beneficial for him without consideration of law and justice. It is arbitrarily denied the claim even to think about contract of law which is deficiency and unfair trade practices on the part of the OP. OP in its reply has not exp