IN THE HIGH COURT OF KERALA AT ERNAKULAM PRESENT:

THE HONOURABLE MR. JUSTICE SATHISH NINAN MONDAY, THE 5TH DAY OF MARCH 2018 / 14TH PHALGUNA, 1939 WP(C).No. 21965 of 2009 PETITIONER GEORGE EMMANUEL,S/O.LATE O.M.EMMANUEL, RESIDING AT PADAYATTIL HOUSE,THURAVUMKARA,, KANJOOR P.O.,ERNAKULAM DISTRICT.

BY ADVS.SRI.VINOD VALLIKAPPAN SMT.V.S.ARCHANA CHANDRAN SMT.K.R.SANGEETHA RESPONDENTS:

1. THE UNITED INDIA INSURANCE COMPANY LTD., IST FLOOR,K.G.TOWERS, THRISSUR ROAD,, ANGAMALY-683572, REP.BY ITS BRANCH MANAGER.

2. THE INSURANCE OMBUDSMAN, OFFICE OF THE INSURANCE OMBUDSMAN,, 2ND FLOOR, CC 27/2603, PULINATTU BUILDINGS, M.G.ROAD, ERNAKULAM. (R2 IS REMOVED FROM THE PARTY ARRAY AS PER ORDER DATED

11.09.2013 IN IA 12207/2013) R1 BY ADV. SRI.RAJESH THOMAS THE SECOND RESPONDENT IS REMOVED FROM THE PARTY ARRAY AS PER ORDER DATED 11 THIS WRIT PETITION (CIVIL) HAVING BEEN FINALLY HEARD ON 05-03-2018, THE COURT ON THE SAME DAY DELIVERED THE FOLLOWING:

APPENDIX PETITIONER'S EXHIBITS EXT P1 TRUE COPY OF THE HEALTH INSURANCE POLICY FOR THE PERIOD 2007-08 ISSUED BY THE 1ST RESPONDENT.

EXT P2 TRUE COPY OF THE LAWYER NOTICE DATED 08.08.2008 ISSUED BY THE PETITIONER.

EXT P3 TRUE COPY OF THE REPLY NOTICE ISSUED BY THE 1ST RESPONDENT.

EXT P4 TRUE COPY OF THE COMPLAINT DATED 5.11.2008 BEFORE THE 2ND RESPONDENT.

EXT P5 TRUE COPY OF THE ORDER DATED 16.2.2009 OF THE 2ND RESPONDENT.

vdv Sathish Ninan, J.

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Dated this the 5^th day of March, 2018

JUDGMENT

Petitioner had availed a health insurance policy from the first respondent Insurance company. The petitioner and his family members were the insured. His wife underwent a Hysterectomy operation. Claim was raised for `49,189/- being the treatment expenses incurred. The Insurance Company sanctioned only an amount of `10,000/- being 20% of the sum insured. Challenging the same, the petitioner approached the Insurance Ombudsman, who as per Ext P5 order dismissed the complaint.

2. Ext P1 is the insurance policy. Clause 1.2 of the policy reads thus:

“In the event of any claim(s) becoming admissible under this scheme, the company will pay through TPA to the Hospital/Nursing Home or the insured person the amount of such expenses as would fall under different heads mentioned below, and as are reasonably and necessarily incurred thereof by or on behalf of such Insured Person, but not exceeding the Sum Insured in aggregate mentioned in the schedule hereto A. Room, Boarding Expenses as provided by the Hospital/Nursing Home.

B. Nursing Expenses.

C. Surgeon, Anaesthetist, Medical Practitioner,Consultants, Specialists Fees.

D. Anaesthetist, Blood, Oxygen, Operation Theatre Charges, surgical appliances, Medicines & Drugs, Diagnostic materials and X-ray, Dialysis, Chemotherapy, Radiotherapy Cost of Peacemaker, Artificial Limbs &

Cost of organs and similar expenses.

Expenses in respect of the following specified illnesses will be restricted as detailed below:

Hospitalisation Benefits	LIMITS RESTRICTED TO
a. Contract b. Hernia c. Hysterectomy d. Major Surgery-Angioplasty e. Pre & Post Hospitalisation	a. 10% of SI or Max. Rs. 25,000/- b. 15% of the SI or Max. Rs.30,000/- 20% of the SI or max.Rs.50,000/- 70% of the SI or Max.Rs.2 lacs Maximum 10% of the sum insured

(N.B:Company's Liability in respect if all claims admitted during the period of insurance shall not exceed the sum Insured per person as mentioned in the schedule)”

Clause (c) therein refers to Hysterectomy. The policy specifies that in the case of Hysterectomy, the limit is restricted to 20% of the sum insured or maximum of `50,000/-. Going by the sum insured which is `50,000/-, 20% amount has been granted to the petitioner. The contention of the learned counsel for the petitioner is that the clause does not specify that the amount payable is the lowest among 20% of the sum insured or `50,000/-, and therefore, the claim amount being less than `50,000/- the entire amount should have been granted.

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