DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, EAST, Govt of NCT of Delhi
CONVENIENT SHOPPING CENTRE, 1st FLOOR, SAINI ENCLAVE, DELHI 110092
Consumer complaint no.- 910/2013
Date of Institution 15/10/2013
Order reserved on 30/08/2016
Date of Order 31/08/2016
In matter of
Mrs Rama Raghu, adult
w/o Sh CP Raghunathan
R/o- C52/585, Gali no. 3, Ganesh Nagar II,
Shakarpur, Delhi-110092……………………………………...…………….Complainant
Vs
1-Mr Ajay Bhalla,
R/o- 181/3A, street no. 13,
Bholanath Nagar, Shahdara, Delhi 110032
2- The Div. Manager,
United India Insurance Co. Ltd.
705, Bhikaji Kama Bhawan,
Bhikaji Kama Place, New Delhi 110066.……………….……………..Respondents
Complainant’s Advocate - Sh Ramesh Chandra Kalra
Opponent’s Advocate - Sh S. Ghose
Quorum Sh Sukhdev Singh President
Dr P N Tiwari Member
Mrs Harpreet Kaur Member
Order by Dr P N Tiwari Member
Brief Facts of the case
Complainant had mediclaim policy from OP2 vide policy no 040101/48/12/06/00003356 from 11/03/2013 to 10/03/2014. Complainant had severe pain in her lower abdomen and on the advice of her doctor attended Max super specialty hospital at Saket on 27/04/2013. After examination, she was advised admission for investigation for pain abdomen. She was admitted on 29/04/2013.
Complainant gave her mediclaim card to the Max Hospital for her treatment benefit. As she did not get the cashless facility, so she deposited a sum of Rs 85,000/- in three stages by 30/04/2013. She was discharged on 01/05/2013 and she paid her hospital bill of Rs 60,493/-.
She had undergone diagnostic process and was advised to come after receiving the pathology report. She got again admitted on 06/06/2013. She underwent abdominal operation and her uterus was removed. She had deposited a sum of Rs 50,000/-. Her hospital bill was 80,150/-
As per complainant, two claims were filed with OP2 but none were proceeded and claim was passed. Despite number of visit to OP2, she did not get satisfactory response. Hence, she decided to file this complaint. So this complaint was filed with annexures like treating doctor’s certificate, discharge summary from treating hospital dated 06/06/203, duplicate hospital bill, OPs rejection letter, earlier hospital bill dated 29/04/2013.
After scrutinizing the facts and annexures of complaint, notices were served. OP 1 being the agent of OP2, so his appearance was not required during proceeding, hence OP1 did not put his appearance. OP 2 put their appearance and submitted written appearance along with all the related evidences. OP2 denied all the allegations of complainant and stated that it was accepted that a valid mediclaim policy was present. But complainant had not submitted all the related policies earlier to the present policy of 2013 to 2014.
It was also submitted that complainant had not submitted all the related treatment documents for claim process as claim had to be processed as per policy terms and conditions. OP2 submitted that no discharge certificate pertaining to first admission at Max Hospital for diagnostic procedure and only submitted. As the said process was for the diagnosis of pain in abdomen, TVS (trans vaginal sonography), was done which diagnosed a case of Uterine Fibroid with embedded Copper T(CuT) with missed tread. It was diagnosed as a case of pain due to swelling caused by impacted CuT and was removed. Besides this, a piece was taken from Uterus and was sent for histopathology and was discharged thereafter.
OP 2 did not pay first hospital bill as the procedure was done for diagnostic process for pain in her lower abdomen due to impacted CuT and all such diagnostic procedures were not covered under policy terms and conditions. OP 2 submitted that complainant submitted her second claim for hospital bill vide
annexure OP2/1 and payments were done as per details under annexure OP 2/2
as per policy terms and condition. She was admitted on 06/06/2013 for Hysterectomy operation in case of multiple Fibroids. As this operation was covered under policy terms and condition clause 1.2EC which is written as –
“20% of Sum Insured to a maximum of Rs 50,000/- has already been paid for disease Hysterectomy. Hence, no further payment can be made. Therefore claim is denied under policy clause 1.2EC”.
Analysing this clause, it has been observed that the complainant was insured for a sum of Rs 5 Lac under the said policy and her policy cover was from 2004, but the said operation, Hysterectomy, under the head ‘package’ where insured would be paid to 20 % of SI or Rs 50,000/- whichever was maximum. Here OP2 has paid the claim as per upper slab ie Rs 50,000/-
Complainant and OP submitted their evidences on affidavit which were on record.
Arguments were heard and order was reserved.
We analyzed all the evidences on record and facts of the complaint. By observing the second discharge summary of Max Hospital dated 06/06/2013 which clearly mentioned that the complainant was suffering from Fibroid Uterus and had history of pain abdomen with menorrhagia associated with clots. She was also a k/c/o Diabetes Mallitus on oral anti hypoglycemic medicines with hypothyroidism.
She had undergone USG on 29/04/2013 where she was diagnosed as a case of multiple Fibroid Uterus.
More so, her blood sugar indicator (HBS1C) was abnormal (9.7) which means a case of uncontrolled DM/Blood sugar in her past over 3 months. Abdominal Laproscopic Hysterectomy with Bilateral Salpingectomy operation was done under GA. Also she took discharge on request. All these facts were not disclosed by complainant in her complaint. She had not submitted her required treatment papers before OP2 and also before us. So, there is no deficiency in the services of OP2.
This proves that complainant had intentionally tried to hide her medical facts to treating doctors at the time of her admission in the hospital and also not disclosed in her complaint. All such facts were brought out by observing discharge summary, where treating doctor had written all her previous ailments and line of treatment she was taking.
It was also noted that the complainant had not disclosed about her history when she opted for CuT and duration of Menorrhagia treatment. In such condition, irregular periods leads continuous disturbance of hormonal cycle and opting for CuT, the main aim was to avoid her conception, leads further aggravation of menorrhagia. Keeping CuT for a long time(beyond 2 years) causes formation of Fibroids in many cases. But every lady has to take proper treatment. Here, no such history or evidence was available.
Also, her blood sugar was at uncontrolled stage, so it cannot be said that the symptoms were not known to her.
Hypothyroidism is also a chronic ailment of thyroid where thyroid hormone production is reduced which effects entire endocrinal system of body. All such persons have to take thyroid medicines lifelong. By seeing the discharge summary, where discharge was on request, complainant had suppressed many vital facts before OP and also in her complaint.
As far as not paying her claim amount by OP2, it is clear that OP2 had processed the claim under that policy terms and conditions and claim amount was paid. If claim process was defective or not acted under the policy terms, it amount deficiency in its service.
Here complainant has failed to prove deficiency of OP on even a single concrete evidence. This complaint is devoid of merit and hence, deserve dismissal. So complaint is dismissed without cost.
The copy of this order be sent to the parties as per Act and file be consigned to the Record Room.
Mrs Harpreet Kaur- Member (Dr) P N Tiwari -Member
Mr Sukhdev Singh - President
