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2. It would be apposite to mention that hereinafter the parties will be referred, as have been arrayed before the District Forum.

3. Detailed facts have already been given in the impugned order. However, the relevant facts for the disposal of the present appeal, in nutshell, are that the complainant purchased General Insurance Policy for ₹5,00,000/- for himself and his wife. The policy covered the medical treatment expenses of the insured persons. In August, 2014, wife of the complainant felt some problem and after diagnosing from the Beams Hospital Pvt. Ltd., Amritsar, she was found to be suffering from 'primary infertility with multiple fibroid uterus'. She underwent 'hysteroscopic Myomectomy' and since then, she is regularly taking the treatment, which is very expensive. Intimation about the diagnosis was given to the opposite parties immediately on phone. The claim form was also submitted to them in writing. The officials of the Company made inquiries and the complainant completed the formalities to recover the medical claim, as per the policy, but nothing was done. The complainant made requests to the opposite parties to do the needful, but of no use. The said policy was valid upto 02.12.2014. Feeling harassed due to non-settlement of the claim, the complainant filed the complaint before the District Forum, alleging deficiency in service and unfair trade practice on the part of the opposite parties and sought the following directions to the opposite parties:

i) to pay ₹69,629/- as medical claim, along with interest at the rate of 12% per annum from the date of treatment till realization;
ii) to pay ₹20,000/-, as compensation; and
iii) to pay ₹10,000/-, as litigation expenses.

4. Upon notice, opposite parties appeared and filed reply, taking preliminary objections that complicated questions of fact and law are involved in the complaint, which cannot be decided in summary manner. The complaint is not maintainable. On merits, they admitted that "Happy Family Floater Policy" was issued in the name of the complainant and his wife. His wife was hospitalized in Beams Hospital, Amritsar from 21.08.2014 to 23.08.2014 with diagnosis of 'primary infertility with multiple fibroid uterus' and she underwent diagnostic 'hysteroscopy with laparoscopic myomectomy'. It was further pleaded that as per the exclusion clause 4.3 of the policy, the disease of the wife of the complainant does not cover the expenses on treatment of sterility, any fertility, sub-fertility and surgery of genito urinal system. Hence, the claim was not admissible. The claim of the complainant was rightly repudiated. Denying other allegations of the complaint, it was prayed that the complaint be dismissed.

i) General Assurance Society Ltd. v. Chandmull Jain & Another 1966 AIR (SC) 1644; and
ii) M/s BHS Industries v. Export Credit Guarantee Corp. & Anr. 2015 (3) CPJ 1;

8. On the other hand, learned counsel for the complainant contended that the terms and conditions of the policy were not explained to him. The cover note and the policy, which were issued to him, were not accompanied by any terms or conditions. Therefore, he is not bound by those terms and conditions, including exclusion clause 4.3. He further submitted that the insurance companies charge premium from the insured persons, but when their turn to pay the claim comes, they reject the claim on flimsy grounds. The wife of the complainant felt some problem and after diagnosing from the Beams Hospital Pvt. Ltd., Amritsar, she was found to be suffering from 'primary infertility with multiple fibroid uterus'. She underwent 'hysteroscopic Myomectomy' and since then, she is regularly taking the treatment. The claim with regard to medical expenses lodged in this regard was wrongly repudiated by the opposite parties, vide letter Ex.C-2. The District Forum has passed a legal and valid order and the appeal is liable to be dismissed.