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3] It was contended that the Complainant was diagnosed with Bilateral Inguinal Hernia on 16/02/2015 requiring urgent hospitalisation and surgery to cure the same. The Complainant was admitted in Kapadia Multi Speciality Hospital on 21/02/2015 after investigation. The Complainant had given prior intimation of Hospitalization to the Opponent on 19/02/2015. The Complainant underwent surgery of Bilateral Inguinal Hernia on 21/02/2015. The Complainant was discharged from the hospital on 22/02/2015. Accordingly, the Discharge Card was issued to the Complainant. The Complainant spent in all Rs.2,07,774/- towards the surgery and the hospitalization. It was contended that the complainant informed the Opponent regarding his operation and hospitalisation.

5] Notice of the complaint was issued to the Opponent. Opponent appeared and filed written version denying the allegations mentioned in the complaint. The Opponent has admitted that it had issued Health Protect Insurance Policy covering himself, his wife and two daughters. It was contended that the Complainant had lodged claim for an amount of Rs.2,07,774/- alongwith mandatory documents. It was contended that the Opponent had allowed the claim of Complainant to the extent of Rs.1,20,000/- only as per Mandatory Extensions/ Endorsements under the Plan HC4 - Sub limits on medical expenses /illness /surgeries/ procedure contemplates that the maximum liability of the Opponent for all the Hernia related surgeries/ procedure was Rs.60,000/- only. It was contended that the Complainant's case was of Bilateral Hernia (occurring on both sides) Inguinal Hernia, the maximum liability of the opponent as per the policy was Rs.60,000/- + Rs.60,000/- = Rs.1,20,000/-

6 (A/19/12) 6] The Complainant and the Opponent led their evidence. On going through the evidence on record, the District Commission allowed the complaint and directed the Opponent to pay sum of Rs.87,774/- along with interest @ 9% p.a. from the date of repudiation , until realisation to the Complainant. The District Commission also directed the Opponent pay sum of Rs.5000/- towards compensation and costs.

7] The said order is under challenge. Heard the learned Advocate for the Complainant and the Opponent. It is an admitted fact that the Complainant had taken 'Health Protect Insurance policy' from the Opponent by paying requisite premium. The opponent had given insurance coverage of Rs.3,60,000/-. The policy is produced on record. It is an admitted fact that on 16/02/2015, the Complainant was diagnosed with Bilateral Inguinal Hernia, requiring urgent hospitalisation and surgery. Information of the same was provided to the opponent on 19/02/2015. The Complainant was admitted on 21/02/2015 in Kapadia Multi Speciality Hospital. He was operated for Bilateral Inguinal Hernia and was discharge on 22/02/2015. The Hospital issued medical bill of Rs.2,07,774/-. Similarly, the Hospital also issued Discharge Card. It is admitted fact that the Complainant had submitted the Claim Form and mandatory documents on 27/03/2015 to the opponent. The Opponent had considered Claim Form and documents and allowed the claim of the Complainant to the extent of Rs.1,20,000/- and has rejected the claim of Rs.87,774/- on the ground that the mandatory extension under the policy Hernia related surgery was covered up to 7 (A/19/12) Rs.60,000/- only. It is an admitted fact that the Complainant was paid Rs.1,20,000/- for Bilateral Inguinal Hernia. The Insurance company has repudiated the claim to the extent of Rs.87,774/- as there was CAP for reimbursement of hernia operation to the extent of Rs.60,000/- only. As the Complainant had Bilateral Inguinal Hernia, he was paid sum of Rs.1,20,000/-. It is important to see the Policy document, which is produced on record by the Complainant. Admittedly, the Policy was issued on 28/07/2014 for a period of two years from 02/08/2014 to 01/08/2016. The Complainant has produced on record letter dated 28th July, 2014 wherein there is a specific instruction to the Complainant that he should go through the details as furnished in the format and in the policy document and confirm that the same are in order and in case there are any discrepancies, the Complainant was requested to write back to the Opponent immediately on consumer support system or to contact helpline within 24 hours. The Opponent had also given caution to the Complainant that in absence of any communication within 15 days from the Complainant, on receipt of letter, the Opponent would take it that the Policy issued was in Order and as per the proposal. Admittedly, the Complainant did not raise any objection regarding the policy document within 15 days from 28th July, 2014 rather the Claim Form was submitted to the Opponent. The Opponent has produced on record the Terms and Conditions of the Policy Mandatory Extensions/ Endorsements under the Plan HC4 - Sub limits on medical expenses /illness /surgeries/ procedure contemplates that the maximum liability of the Opponent for all the Hernia related surgeries/ procedure was Rs.60,000/- only. It 8 (A/19/12) was contended that the Complainant's case was of Bilateral Hernia (occurring on both sides) Inguinal Hernia, the maximum liability of the opponent as per the policy is Rs.60,000/- + Rs.60,000/- = Rs.1,20,000/- only. The Complainant has contended that the Opponent had not explained him that exception and clause extension HC4. But we are not inclined to accept the said contention because the 'Health Protect Policy' was given to the Complainant alongwith letter dated 28th July, 2014 wherein the Complainant's attention was invited to the policy document and the Complainant was asked to raise any objection doubt or discrepancy in the policy document within 15 days. But no objection was raised by the Complainant. Therefore, it can be said that the Complainant had accepted the Terms and Conditions of the Policy. Therefore, we are of the opinion that, the Complainant had agreed to the Terms and Conditions of the policy. Therefore, he cannot deny the same contending that the Terms and Conditions were not explained to him by the Opponent.

13] The District Commission has simply mentioned that the value of the Policy was Rs.3,60,000/- and premium was paid by the Complainant. Therefore, the Opponent was liable to pay the entire amount of medical expenses to the Complainant and directed to reimburse Rs.87,774/- to the Complainant. It was also observed by the District Commission that the insurance cover was 13 (A/19/12) quite sufficient to cover the Hospital bill. But the said findings are not proper and correct. The District Commission has not considered the terms and conditions of the policy namely extension HC4, which has given the details of amount entitled for reimbursement for each disease. We have already observed that as per Extension HC4 Sub limits on medical expenses /illness /surgeries/ procedure contemplates that the maximum liability of the Opponent for all the Hernia related surgeries/ procedure was Rs.60,000/- only. Complainant's case was of Bilateral Hernia (occurring on both sides) Inguinal Hernia, the maximum liability of the opponent as per the policy is Rs.60,000/- + Rs.60,000/- = Rs.1,20,000/- only. Therefore, the Opponent had allowed the claim of Rs.1,20,000/- to the Complainant, which was proper and correct. Therefore, the findings of the District Commission are required to be set aside. With this, we proceed to pass the following order-