Mrs. Jyoti P. Jani, Member:
1. The original opponent being aggrieved by and dissatisfied with the judgment and order passed by the Consumer Disputes Redressal Forum, Surat (Addl.) in Complaint No. 512 of 2008 dated 7.3.2009 whereby the complaint came to be allowed has filed the appeal for the sake of convenience, parties to this appeal are hereinafter referred to by their original nomenclature.
2. Short facts of the case are the complainant and his family had mediclaim policy from the opponent Insurance Company. During the subsistence of the policy, the complainants son was admitted on 7.3.2008 in the hospital and was diagnosed as acute viral hepatitis for which Rs. 23,143 were incurred as medical expenses. He was discharged from the hospital on 14.3.2008. The claim was lodged before the opponent Insurance Company which was repudiated on 28.4.2008 on the ground that the concerned hospital is unregistered and does not have operation theatre facility. Hospital must be registered or 15 bedded with OT facility for a claim to be admissible as per Clause 11 of the policy. The claim falls outside the scope of the policy coverage and is hence not payable. The District Forum appreciating the evidence on record, gone through the conditions of the policy and discussed the same in its judgment at page 16 and allowed the complaint holding unfair trade practice by the opponent Insurance Company.
3. Process was issued. We have heard Mr. J.N. Talpada, for Mr. V.P. Nanavaty, learned Advocate for the appellant.
4.The main controversy in this appeal is as to whether there is breach of condition No. 11 of the conditions of the policy or not Condition No. 11 reads as under:
â11. Hospital/Nursing Home means any institution within India established for indoor care and treatment of disease or injuries which is either registered as a Hospital or Nursing Home with the local authorities and is under the supervision of a registered and qualified Medical Practitioner or is complying with following criteriaâ
(i)Â It should have at least 15 in-patient beds. However, in Class âC town where population is less than 5 lakh the institution should have at least 10 in patient beds.
(ii) It is having fully equipped operation theatre of its own for carrying out surgical operation
(iii)Â It is having Qualified Nursing staff under its employment round-the-clock.
(iv)Â It is under charge of fully qualified Medical Practi-tioner(s) round-the-clock.
5. On a plain reading of the condition it appears that it is divided into two parts and they are âin alternative. First part provides that the hospital/nursing home means any institution which is registered as hospital or nursing home with the local authorities and is under the supervision of a registered and qualified practitioner. The second part which is alternative provides for the compliance of 4 conditions. The relevant condition so far as the facts of this case are (i) the hospital should have 15 in-patient beds; (ii) it is having fully equipped operation theatre of its own for carrying out surgical operation. Condition Nos. (iii) and (iv) relate to availability of qualified nursing staff and medical practitioners round-the-clock. As such as far as the facts and merits of this case are concerned, the first condition of 15 in-patient beds is complied with as the hospital where the insured has taken treatment has 35 beds. There is also availability of nursing staff and medical practitioner round-the-clock. In our view, condition regarding operation theatre is not relevant in the present case, as the patient did not require any surgery. Condition No. 11 therefore has been complied with sufficiently in letter and spirit. The unreported authority cited by the learned Advocate has no application to the facts of this case as there was clear breach of condition whereas in the present case there is not breach of condition. Moreover, in our opinion, the condition relied upon by the opponent appears to be unreasonable since the patient is first to get treatment and not find out specifications of the hospital as per the conditions. The order of the District Forum is therefore legal and proper and does not call for any interference in appeal. Accordingly was pass the following order.
Appeal No. 314 of 2009 is dismissed. Order passed by the Consumer Disputes Redressal Forum, Surat (Addl.) in complaint No. 512 of 2008 dated 7.3.2009 is confirmed. No order as to costs in appeal.