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3. Defendant contested the suit by filing the written statement. In the written statement, defendant has not denied of plaintiff taking the individual health insurance policy-2010 bearing no.042500/48/13/97/00000504 and Super Top up Medicare Policy bearing policy no.042500/48/13/36/00000194 from the defendant company or plaintiff no.1 underwent a surgery namely Right Cochlear Implant Surgery. But the defendant has taken the objections that TPA has rightly repudiated the claim of the plaintiff CS No.16276/16 Naresh Chand Jain & Anr. Vs. United India Insurance Co. Ltd. Pg. 3 of 24 for the reason that as per terms, conditions and clause respective individual scheme date of proposal and declaration dated 30.05.2005 applicable to this policy, the expenses for cochlear implant surgery is not payable as per the information published on website of the company under FAQ medical queries. The company vide its publication dated 27.07.2013 (Health Circular) and inter site has already informed that cochlear implant surgery is not payable even otherwise as per exclusion 4.7 of the policy document cost of hearing aids not payable and cochlear implantation is a form of hearing aid implantation which is not covered under the policy. Even otherwise the Super Top up Medicare Policy not applicable because the disease was pre- existing at the time of taking Super Top up Medicare Policy. The plaintiffs have concealed the fact that they have taken the Super Top up Medicare Policy first time on 16.04.2013 with a view to bear the expenses of Cochlear Implant Surgery with malafide intention and thus defendant has prayed for dismissal of the suit.

(ii) The plaintiff no.1 was diagnosed with Bilateral Profound Sensorineural hearing loss and on 13.12.2013 he underwent a surgery namely Right Cochlear Implant Surgery and spent Rs.6,36,980/-.

(iii) The claim of the plaintiff was repudiated by the defendant on the ground that as per terms and conditions and clause the cochlear implant surgery is not payable. As per exclusion 4.7 of the policy document cost of hearing aids not payable and cochlear implantation is a form of hearing aid implantation which is not covered under the policy. Even CS No.16276/16 Naresh Chand Jain & Anr. Vs. United India Insurance Co. Ltd. Pg. 10 of 24 otherwise the Super Top up Medicare Policy not applicable because the disease was pre-existing at the time of taking Super Top up Medicare Policy and the plaintiffs have concealed the fact that they have taken the Super Top up Medicare Policy first time on 16.04.2013 with a view to bear the expenses of Cochlear Implant Surgery with malafide intention.

23. Further defendant through testimony of Sh.Subodh Sharma/ DW1 has deposed that the medical investigator invited by TPA has repudiated the claim of the plaintiff for the reason that Cochlear Implant Surgery is not payable as per the information published on website of the company under FAQ medical queries. The company vide its publication dated 27.07.2013 (Health Circular) on internet site has already informed that cochlear implant surgery is not payable and moreover as per exclusion 4.7 of the policy document cost of hearing aids not payable and cochlear implantation is a form of hearing aid implantation which is not covered under the policy.

25. Therefore in these circumstances, the plaintiff is not entitled for the cost of the cochlear implant being hearing aid however in my view on this ground the entire claim of the plaintiff cannot be rejected as defendant can only deduct the cost of the cochlear implant but is liable to pay the cost of the surgery under individual Heath Insurance Policy Ex.PW1/1 as even as per own FAQ cost of surgery is not excluded. As per Ex.PW1/7 (Colly) cost of Cochlear Implant is Rs.5,35,000/- whereas plaintiff has claimed amount of Rs.6,36,980/- as expenses incurred on treatment of said disease. The defendant has not given any suggestion that said amount has not been incurred. Even otherwise Ex.PW1/7 proved that package charges bill for surgery was Rs.94,000/-. Besides this plaintiff has also proved other bills. Therefore there is no ground to CS No.16276/16 Naresh Chand Jain & Anr. Vs. United India Insurance Co. Ltd. Pg. 22 of 24 dispute that plaintiff has spent Rs.6,36,980/- in Cochlear implant surgery. Therefore plaintiff is entitled to recover Rs.1,01,980/- from the defendant after deducting the cost of cochlear implant surgery i.e. Rs.5,35,000/-. Issue no.1 and 2 are decided accordingly. ISSUE NO.3 "Whether the plaintiff is entitled to interest, if so at what rate and for which period? OPP"