RELIGARE HEALTH INSURANCE COMPANY LIMITED Vs. AYUSH GUPTA THROUGH HIS MOTHER VEENU NEXT FRIEND AND LEGAL GUARDIAN

JUDGEMENT

(1.) Challenge in this Revision Petition, by Religare Health Insurance Co. Ltd. (for short "the Insurance Company"), the sole Opposite Party in the Complaint, is to the order dated 19.9.2016, passed by the State Consumer Disputes Redressal Commission, Punjab (for short "the State Commission"), in FA/1237/2015. By the impugned order, the State Commission has over-turned the order dated 21.9.2015, passed by the District Consumer Disputes Redressal Forum, Gurdaspur (for short "the District Forum") in Complaint No.108/2015. On re-appraisal of the material on record, the State Commission has come to the conclusion that there was deficiency in service on the part of the Insurance Company in not reimbursing a sum of Rs 1,50,934/-, the amount actually expended by the Complainant, the Respondent herein, for the surgery undergone by him for Left frontoparietal flap craniotomy and removal of large tumor on 04.9.14. Thus, allowing the Complaint, the State Commission has directed the Insurance Company to pay to the Complainant a sum of Rs 1,59,934/- along with interest @ 9% p.a. from the date of repudiation till realization; a sum of Rs 20,000/- as compensation and Rs 11,000/- as litigation expenses.

(2.) The factum of the Complainant having undergone the afore-noted neurosurgery not being in dispute, the short question for consideration is whether or not the said claim falls within the ambit of the Exclusion Clause (4) in the terms and conditions of the Health Insurance cover, obtained by the Complainant ?

(3.) Having heard learned Counsel for the parties and perused the documents on record, including the said Clause in the Policy; the Discharge Summary dated 8.9.2014; Lab Reports dated 10.9.2014 and 23.9.2014, we are of the opinion that the Revision Petition is bereft of any merit.