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1.      This petition has been filed under section 21(b) of The Consumer Protection Act, 1986 in challenge to the State Commission’s Order dated 18.05.2011 in appeal no. 1004 of 2007 arising out of the Order dated 09.03.2007 of the District Commission in complaint no. 355 of 2006.

2.      We have heard the learned counsel for the petitioner (the ‘insurance co.’) and the respondent (the ‘complainant’) and have perused the material on record including the Order dated 09.03.2007 of the District Commission, the impugned Order dated 18.05.2011 of the State Commission and the petition.

3.      The dispute relates to reimbursement of a medical claim. 

In its impugned Order the State Commission has quoted clause 11(a) and clause 11(b) of the subject policy and has interpreted the said clauses to hold that the insurance company has wrongly repudiated the claim of the complainant. The relevant extract from the State Commission’s Order is reproduced below:

Shri Nitin Sanghi, learned counsel appearing on behalf of the appellants-opposite parties has argued that in view of clause 11(b) of the Insurance Policy, the expenses incurred by the complainant for implantation of stents from Forties Hospital, Mohali were not covered and for that reason the Insurance Corporation cannot be held liable to compensate the complainant for the expenses incurred by the complainant.

We do not find force in the argument raised on behalf of the appellants-opposite parties. In order to deprive the complainant to get the expenses incurred by him on his treatment for implantation of stents, the opposite parties is only referring to Clause 11(b) of the policy, which in itself is not complete without reading Clause 11(a) with the same.  For ready reference, Clause 11(a) and 11(b) of the Insurance Policy is reproduced as under:

“11(a) Benefit (B) of the Policy Schedule is not applicable, if any of the contingencies mentioned in Paragraph 11(b) occurs (i) at any time on or after the date on which risk under this policy is commenced but before the expiry of one year reckoned from the date of this policy or (ii) one year from the date of revival.

11(b)  Benefit (B) of the Policy Schedule is applicable on the occurrence of any of the following contingencies:

1. the Life Assured undergoes Open Heart By-Pass surgery performed on significantly narrowed/occluded coronary arteries to restore adequate blood supply to heart and the surgery must have been proven to be necessary by means of coronary angiography. All other operations (i.e. angioplasty and thrombolysis by Coronary Artery Catheterization) are specifically excluded or

2. the Life Assured undergoes Renal Dialysis or Renal Transplantation as a result of an end stage Renal Failure presented as chronic irreversible failure of both kidneys to function.”

Admittedly, the complainant had obtained the Insurance Policy on 28.5.1997 and he suffered from heart problem on 23.6.2005 i.e. after more than eight years.  The complainant could have been denied the claim if he would have suffered from the diseases mentioned in Clause 11(b) within one year from the date of obtaining the policy. Thus, the opposite parties have wrongly repudiated the claim of the complainant.

In view of the above, we do not