Taken up through video conferencing. 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: 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 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 find any merit in this appeal. Hence this appeal is dismissed being devoid of any merit. 4. The learned counsel for the insurance co. submits that a mere reading of clause 11(a) conjoined with clause 11(b) makes it abundantly clear that even if Benefit (B) of the Policy Schedule is applicable in a particular case, “angioplasty and thrombolysis by Coronary Artery Catheterization” is specifically precluded from the said Benefit (B). In the instant case even though Benefit (B) was applicable, the medical treatment having been taken after one year of the revival of the policy, Benefit (B) itself precludes “angioplasty and thrombolysis by Coronary Artery Catheterization”; the medical record and the discharge summary dated 26.06.2005 of the concerned hospital (Fortis Hospital) itself shows that the treatment fell within “angioplasty and thrombolysis by Coronary Artery Catheterization” which are explicitly excluded under Benefit (B). This is a plain and simple case of misinterpretation of the policy conditions by the State Commission. 5. The learned counsel for the complainant agrees with the submissions made by the learned counsel for the insurance co. in respect of misinterpretation of the policy conditions by the State Commission. He however goes on to submit further that the policy has matured and the total benefits in respect of the policy have been paid by the insurance company to the complainant. As such the matter may be closed and no recovery on count of the reimbursement of the subject medical claim may be made by the insurance company, even though it was not covered by the policy conditions. He bases his request on purely humanitarian grounds. 5. The learned counsel for the insurance co. submits that in 2011 in compliance of the State Commission’s impugned Order the treatment cost with interest has been paid to the complainant, in 2017 the policy matured and the complete maturity amount has also been paid to the complainant but after he gave an undertaking that the payment made in compliance of the State Commission’s Order will be subject to the final outcome of the instant petition before this Commission. 6. We have perused the relevant clause 11(a) and clause 11(b) of the subject policy. It is clear that certain conditions in respect of expiry of one year from the date of the policy or one year from its revival are laid down for availing Benefit (B) but even if these conditions are fulfilled Benefit (B) itself specifically precludes “angioplasty and thrombolysis by Coronary Artery Catheterization”. In the present case, the medical record of the concerned hospital clearly shows that the medical condition for which treatment was taken undoubtedly falls within “angioplasty and thrombolysis by Coronary Artery Catheterization” which are explicitly excluded from Benefit (B). We agree with the learned counsel for the insurance co. that the State Commission has erred in interpreting the policy conditions in favour of the complainant. 7. As such, we find that in the given facts of this case the State Commission has arrived at erroneous findings by misinterpreting the policy conditions. The impugned Order of the State Commission cannot sustain. 8. The learned counsel for the complainant again submits that the benefit for the treatment has already been made and the maturity benefits have also been given, the matter is very old, the complainant is now an aged senior citizen, the amount of the treatment cost and interest is very meagre, though he agrees that the State Commission has misinterpreted the policy conditions and arrived at erroneous finding, he requests that on humanitarian grounds recovery of the treatment cost and interest may not be made from the complainant. 9. The learned counsel for the insurance co. requests for a brief interlude to seek instructions in this regard. 10. After an interlude, the learned counsel for the insurance co. submits on instructions that in the instant case (only) the insurance co. will not insist on recovery of the treatment cost and interest paid in compliance of the State Commission’s Order. This may however not be made a precedent. 11. In the wake of the above submissions and examination, the petition is allowed, the impugned Order dated 18.05.2011 of the State Commission is set aside and the complaint is dismissed. However, in consonance with the submission made on instructions by the learned counsel for the insurance co., the amount paid in compliance of the State Commission’s Order dated 18.05.2011 shall not be recovered from the complainant; this shall not be treated as precedent. 12. The Registry is requested to send a copy each of this Order to the parties in the petition and to their learned counsel as well as to the State Commission immediately. The stenographer is also requested to upload this Order on the website of this Commission immediately. | 
