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2. A consumer complaint was filed by complainant against OPs on the averments that the husband of the complainant and complainant had purchased one insurance policy No. 11168101 from OPs on 19.02.2009 having coverage of Rs. 3 lac after paying annual premium of Rs. 7265/-. The policy cover was 10 year and date of cessation was 19.02.2019. However, in the year 2014, OPs approached the complainant with new insurance policy product i.e. ICICI PRU HEALTH SAVER UIN 105L087V01 and told that the previous policy was just for 10 years and new policy cover was up to the age of 75 years of the age i.e. up to next 22 years and that it was continuous policy of previous policy. On assurance of OPs, the complainant discontinued the previous policy and purchased the said new policy No 17505601 w.e.f 20.03.2013 on paying premium of Rs. 22000/- for sum assured of Rs. 3 lac. In the month of November 2013, the complainant had suffered pain in the left knee and she immediately approached Max Hospital, Bathinda where the doctor suggested that there was Osteoarthritis in the left knee and same was required to be replaced. She was admitted in the said hospital on 13.12.2013 for transplantation and in the history it was mentioned that the patient was having pain in both the knees for the last 4-5 years. There was no previous history or admission in any hospital for the treatment of knees. After treatment she was discharged from the hospital on 10.12.2013. The claim was lodged with OPs on 17.12.2013 alongwith complete medical record for a sum of Rs. 1,59,733.56 ps. However, to the utter surprise of the complainant, OPs vide their letter dated 25.01.2014 rejected the lawful claim of the complainant with the remarks that the claim was not payable which amounted to deficiency in services on the part of OPs. Hence, the complaint with the directions to OPs to pay the claim of Rs. 1,59,733.56 ps alongwith interest @ 18% p.a. and pay damages to the extent of Rs. 1 lac and litigation expenses of Rs. 50,000/-.

10. As per the case of the complainant, she was admitted in Max Hospital, Bathinda on 03.12.2013 for knee replacement and was discharged on 10.12.2013. She submitted the bill of Rs. 1,69,733.56 which was submitted to OPs and OPs vide their letter dated 25.01.2014 Ex. C-5 rejected the same on the ground that the claim is not payable and falls under exclusion clause 8.5 and 8.8.19. These clauses are reproduced as under:-

8. Clause Exclusions for Hospitalization Insurance Benefit:

8. Any expenses incurred during the first 2 years from policy commencement Date of revival date is after 60 days from the date first unpaid premium shall not be payable for the following diseases or surgeries and any complications arising out of them.

19. Osteoarthrosis leading to Total Knee Replacement of Total Hip Replacement (claim for up to one knee or one hip treatment will be covered in a policy year.)

12. Now come to clause 8.8.19. According to this clause, any expenses incurred during the first two years from the policy commencement date is not payable and clause 19 includes osteoarthrosis total knee or total hip replacement. Therefore, it is clear from this clause that the treatment is covered but expenses for total replacement of knee for the first two years is not payable. In patient bill summary placed on record reveals that charges for total knee replacement is Rs. 1,53,000/- and other blood bank charges, consultation and medical consumption etc relating to the knee, therefore, the complainant had not taken the treatment but had gone for total knee replacement which was not covered under this policy for the first two years of the policy. Counsel for the respondent/complainant was unable to controvert this clause of the policy. It is settled law that the Forum cannot go beyond the terms and conditions of the policy and parties are to be governed under the terms and conditions of the contract/policy. Therefore, claim was rightly repudiated by OPs but it was wrongly allowed by the District Forum on the plea that it was continuous policy of the previous policy taken by the complainant in the year 2009. In view of our above findings, it is new policy and not a continuous policy, then under the terms and conditions referred above, the claim is not payable. The findings so record by the District Forum are not correct findings and are liable to be set-aside.