Insurance claims are bounded by the specific provisions outlined in the policy, and limitations must be adhered to as stated.

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. I am afraid that the interpretation sought to be given by the petitioner cannot be favoured. On a plain reading of the clause above referred to, it is only reasonable to understand that, in the case of hysterectomy, the claim amount is limited to 20% of the sum insured and in cases where 20% of the sum insured would fall over and above `50,000/-, the amount payable is limited to `50,000/-. In all other cases, the amount payable would only be 20% of the sum insured.

I do not find any infirmity in the order passed by the Ombudsman.

Accordingly the writ petition is dismissed.

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