PAYAL GARG Vs. ORIENTAL INSURANCE CO LTD

JUDGEMENT

(1.) This revision is directed against the order of the State Commission Himachal Pradesh dated 21.11.2012 whereby the State Commission allowed the appeal preferred by the opposite party / insurance company and set aside the order of the District Forum Kangra at Dharamshala.

(2.) Briefly stated facts relevant for the disposal of this revision petition are that petitioner filed a consumer complaint alleging that she had purchased a medi-claim insurance policy from the opposite party effective from 09.03.2005 to 08.03.2006. During the currency of this policy, the petitioner / complainant was blessed with a child. The child was delivered through a caesarean procedure at the clinic of respondent no.2. The cost for the procedure was Rs.55,436/-. The petitioner through her father-in-law submitted the medi-claim for the said amount. The respondent / opposite party however, repudiated the claim on the ground that expenses incurred on account of maternity were not reimbursable under Exclusion Clause 4.12 of the policy. The case of the petitioner is that at the time of issue of medi-claim policy, she was not informed that expenses incurred on account of maternity were not reimbursable nor she was provided with the terms and conditions of the insurance policy. Thus, claiming the repudiation of insurance claim as deficiency in service, the petitioner preferred the consumer complaint.

(3.) The appellant resisted the complaint and pleaded that maternity expenses were not reimbursable in view of Exclusion Clause 4.12 of the insurance policy.