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Policy No.                           Duration

200700/48/09/97/00000862             29.09.2009 to 28.09.2010

200700/48/08/97/00000864             29.09.2008 to 28.09.2009

200700/48/07/97/00000875             29.09.2007 to 28.09.2008

200700/48/06/12/00000284             29.09.2006 to 28.09.2007

Complainant had filled the proposal form when the first policy was issued by OPs for the period from 29.9.2005 to 28.9.2006. At that time complainant had gone through the terms and conditions of the policy and all the diseases were covered under the policy. After the First policy OPs never asked the complainant to fill up any new proposal form and represented that said policies were in continuation of the earlier policies without any change in the terms and conditions. Consequently, he paid the annual premium, as such, the above said polices were renewed by OPs from time to time. During the subsistence of the policy starting from 29.09.2010 to 28.09.2011 son of the complainant was suffered from pain in the chest and they consulted the Doctors in DMC & Hospital. It was diagnosed that his son was suffering from ACYANOTIC CONGENITAL HEART DISEASE-PDA WITH LEFT TO RIGHT SHUNT and he was admitted in the hospital on 01.06.2011.to 5.6.2011. Thereafter, complainant moved an application before OPs for the reimbursement of the amount. But they refused as his son was suffering from congenital disease and his case fell under the exclusion clause of the policy i.e. 29.09.2010 to 28.09.2011. Complainant visited the office of the OPs number of time to settle the claim but the OPs did not pay any heed to his genuine request. The above said act of the OPs amounted to deficiency in services. Hence, he filed the complaint before the District Forum seeking, following directions against the Op. i. to pay Rs.1,39,865/- spent on the treatment of his son along with interest @12% from the date of treatment till realization. ii. to pay Rs.1 lac as compensation on account of mental tension and harassment.

7. Aggrieved against the order passed by the Ld District Forum, the Appellant/OP No 2 has preferred the present appeal.

8. We have heard the learned counsel for appellant as no one appeared on behalf of the complainant and have carefully gone through the record of the case.

9. OP has alleged in the grounds of the appeal that complainant had purchased MEDI GUARD POLICY from 2005 to 2006 which was renewed from 29.9.2006 to 28.9.2007. After that complainant had purchased the INDIVIDUAL HEALTH INSURANCE POLICY from 2007 to 2008. This, policy was renewed from 2008 to 2009, 2009 to 2010, and 2010 to 2011. The terms and conditions of the above said policy was different from the Medi Guard policy and congenital disease was falling under exclusion clause 4.1 of the Individual Health Insurance policy reproduced as under:-

Exclusions:-
The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any Insured Person in connection with or in respect of: 4.1 All Congenital disease (Internal and external).

Son of the complainant was diagnosed as ACYANOTIC CONGENITAL HEART DISEASE-PDA WITH LEFT TO RIGHT SHUNT as per discharge summary ExC7. OPNO2 has placed on record Individual Health Insurance Policy as Ex.R1 in which it was mentioned that all the congenital diseases fall under the Exclusion Clause 4.1. Complainant alleged that he was not aware about the terms and conditions of the Individual Health Insurance Policy. The law has been settled in the judgment of 5 Judge Bench of the Hon'ble Supreme Court reported in AIR 1966 Supreme Court 1644 (General Assurance Society Ltd. v. Chandmull Jain and another), that a person obtaining a particular insurance policy is supposed to know the terms and conditions of that particular type of insurance policy. In Deokar Exports Pvt. Ltd. vs New India Assurance Company Ltd 2009(2) CLT Hon'ble S.C. held that in a contract of insurance, rights and obligations are strictly governed by the policy of Insurance-No exception or relaxation can be made on the ground of equity. Therefore, the case of the complainant falls under the exclusion clause4.1 of the Individual Health Insurance Policy. Accordingly, the claim for the expenditure incurred on the treatment of congenital heart disease is not payable. The District Forum wrongly held that the case of complainant falls under the Medi guard policy and Health Insurance Policy is in continuation of the earlier policy. The District Forum has erroneously allowed the claim ignoring the terms and conditions of the policy.