DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Kirti d/o Unjit Singh Thakur, R/o H.No.1801, Phase-7, Mohali.

              ---Complainant

Vs.

(1)  Apollo Munich Health Insurance Co. Ltd., SCO No. 50-51, 4^th Floor, Sector 34-A, Chandigarh, through its Manager.

(2)  Apollo Munich Health Insurance Co. Limited, 10^th Floor, Tower-B, Building No.10, DLF Cyber City, DLF City, Phase-II, Gurgaon, Haryana – 122002 through its Managing Director.

(3)  Family Health Plan (TPA) Limited, Srinilaya – Cyber Spazio Suite #101, 102, 109 and 110, Ground Floor, Road No.2, Banjara Hills, Hyderabad, 500 034, through its Managing Director.

---- Opposite Parties

BEFORE:   MRS.MADHU MUTNEJA            PRESIDING MEMBER

SH. JASWINDER SINGH SIDHU    MEMBER

Argued By:    Sh. Gaurav Bhardwaj, Counsel for Complainant.

            Sh. R.S. Dhull, Counsel for Opposite Parties No.1 & 2.

            Opposite Party No. 3 ex-parte.

PER MADHU MUTNEJA, PRESIDING MEMBER

1.          The Complainant had taken a medi-claim policy from the Opposite Parties No.1 & 2 in the year 2009, which was being renewed annually. Prior to that the Complainant was insured with some other insurance company. The present policy was valid from 24.12.2011 to 23.12.2012 for a total sum insured of Rs.1.00 lac (Policy along with terms & conditions at Annexure C-1 (colly).

          The Complainant had severe abdominal pain and had heavy bleeding during the mensis, due to which she was advised diagnostic tests and surgery thereafter (Test Report Annexure C-2). The Complainant thus underwent diagnostic Laparoscopy and Myomectomey of the fibroid at Ivy Hospital (OPD slip and Discharge Summary at Annexure C-4 & C-5). Cashless request was sent to the company as per policy conditions prior to the admission but the same was denied by the Opposite Party No.3 on the ground that the ailment was under standard exclusion under Section 6-e (Primary Infertility since 1 ½ years) (Denial letter Annexure C-6). 

          The Complainant spent Rs.73,510/- on the treatment (Bills Annexure C-7 to C-16) and thereafter, lodged a claim with the Opposite Parties for payment of the said amount. However, Opposite Parties No.1 & 2 repudiated the claim on the ground that the hospitalization is related to treatment of infertility which is excluded from policy (Letter of claim and repudiation Annexure C-17 and C-18).

          Alleging deficiency in service and unfair trade practice, the Complainant has filed this complaint with a prayer that the Opposite Parties be directed to pay the amount of Rs.73,510/- along with interest, compensation and costs of litigation. 

2.          Notice of the complaint was sent to Opposite Parties seeking their version of the case.  

3.          Opposite Parties No.1 & 2 in their joint reply have stated that the Complainant was well apprised at the time of filling the proposal form that it was subject to terms & conditions of the policy. As per Section 6(e)(ix) of the Terms and Conditions of the Policy issued to the Complainant, treatment for infertility is permanently excluded unless expressly stated to the contrary in the Policy. The cashless authorization was specifically denied on this ground. Even the reimbursement was denied as the claim was not payable.

          On facts the answering Opposite Parties have given the policy details of the Complainant from the date of inception, but have stated that the claim has been denied as the treatment taken by the Complainant was not covered under the policy. It is revealed from the discharge summary that the Complainant was diagnosed for:-

1. Primary Infertility and   2. Fibroid Uterus.

          The other reports are also clearly suggestive of the fact that the treatment taken by the Complainant was for infertility.  

          The Opposite Parties have reproduced Section 6(e)(ix) of the Policy due to which the claim has been denied. Section 6(e)(ix) reads as under: -

           “Section 6 Exclusions:-

e)   We will not make any payment for any claim in respect of any insured person directly or indirectly for, caused by, arising from or in any way attributable to any of the following unless expressly stated to the contrary in this Policy.

ix.  Sterility, treatment whether to effect or to treat infertility; any fertility, sub-fertility or assisted conception procedure; surrogate or vicarious pregnancy; birth control, contraceptive supplies or services including complications arising due to supplying services.”

          On merits, the issuance of the medi-claim policy and treatment taken by the Complainant has been admitted. All other allegations have been denied. It has been stated that the doctor in the discharge summary has given that the diagnosis is relating to primary infertility and fibroid uterus with inability to conceive after 1½ years of marriage, thus no claim is payable and it has been rightly rejected. Opposite Parties No.1 & 2 have therefore prayed for dismissal of the complaint.  

4.          Despite service, nobody has appeared on behalf of Opposite Party No.3, therefore, it was proceeded against exparte on 16.01.2013.

5.          Parties were permitted to place their respective evidence on record, in support of their contentions.

6.          We have heard the learned counsel for the Complainant and Opposite Parties No.1 & 2 (Opposite Party No.3 being ex-parte) and have perused the record.

7.          The grievance of the Complainant is that despite being the medi-claim policy holder with the Opposite Parties No.1 & 2 for a number of years, payment of her medical ailment has been denied by the Opposite Parties. A scrutiny of the documents placed on record by the Complainant bring out the following:-

          Annexure C-1 is the Policy, wherein in Section 6(c), under the heading “Specific Waiting Periods”, it has been given as under: -

“c)  the illnesses and treatments listed below will be covered subject to a waiting period of 02 years as long as in the third Policy year the insured Person has been insured under an Easy Health Policy continuously and without any break.”

          Relying on aforesaid Section 6(c), the learned counsel for the Complainant contended that treatment for menorrhagia or fibromyoma are payable.  On the other hand, Opposite Parties No.1 & 2 in reply have relied on Section 6(e) (ix) which is already reproduced above for denial of claim. 

          Annexure C-3 is the MRI and CT scan report appended by the Complainant. The clinical detail of which are “K/c/o Fibroid. Primary Infertility”.

          Annexure C-4 is OPD Patient Record wherein Fibroid has been mentioned for which Myomectomy has been recommended.

          Annexure C-5 is the discharge summary of Ivy Hospital wherein diagnosis is given as:-

1. Primary Infertility       2. Fibroid Uterus.

          While in Clinical Summary, it has been given as under:-

“Clinical Summary:- A 35 yrs old non-diabetic, normotensive female patient presented with H/O heavy bleeding during mensis and lower abdominal pain, and inability to conceive after 1 ½ yrs of marriage.” 

          Annexure C-17 is the claim made by the Complainant and Annexure C-18 is the repudiation letter. Denial has been made to the Complainant on the following ground:-

“1)  As per our medical opinion and submitted documents, the present hospitalization is related to diagnosis/ treatment of infertility, which is excluded from your health insurance policy and also under Section 6) c of the policy. Hence we regret to inform that your claim is repudiated.”

8.          Myoma is an ailment in female patients because of which there is excessive bleeding. A person taking treatment for myoma could be covered under the policy conditions. However, in the present case, the patient had infertility because of the Myoma. When she was diagnosed for Myoma, myomectomy was done to treat the infertility.

          Since in terms of Section 6(e) (ix), already reproduced above, the treatment related to infertility was excluded from coverage in the policy, as such we do not find any illegality in denial of the claim of the Complainant by the Opposite Parties.

9.          Accordingly, we dismiss the present complaint, being devoid of any merit, with no order as to costs.

10.        The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

11^th July, 2013                            

Sd/-

(MADHU MUTNEJA)

PRESIDING MEMBER

Sd/-

(JASWINDER SINGH SIDHU)

MEMBER