Ld. Advocate(s)
For Complainant: Makbul Rahaman
For OP/OPs : Raj Kumar Mondal
Date of filing of the case :27.04.2016
Date of Disposal of the case : 02.06.2023
Final Order / Judgment dtd.02.06.2023
Complainant above named filed the present complaint u/s 12 of the Consumer Protection Act, 1986 against the aforesaid opposite parties praying for direction to OPs to pay Rs.1,20,205.97, interest at the rate of 10% per annum over the said amount, compensation amounting to Rs.50,000/- and cost of the case.
She further alleged that she had purchased one Insurance Policy (Jeevan Arogya(without profit)) of LICI table no.904 term 30 years. Date of commencement of the policy was 28.03.2014 premium was Rs.3867/-. Said Policy was covered by Principal insured Srinibash Sarkar with his spouse Sutapa Sarkar i.e complainant and with their two minor sons namely Sanjoy Sarkar and Sourav Sarkar. Number of the said policy is 48728440. After payment of first premium on 27.03.2014, complainant felt abdomen pain on 15.04.2015 and consulted with Dr. T. Saha. She again consulted with him on 26.04.2015 and thereafter he went to Zenith Super Speciality Hospital, Kolkata on 07.05.2015. Doctor of the said hospital advised her to take for some medical examination and advised her some medicines. Thereafter, doctor of the said hospital advised him to take admission on that hospital because surgery is required on 19.05.2015. Thereafter, she was admitted thereon 19.05.2015 and she was discharged on 27.05.2015. Surgery was done on 20.05.2015 under Dr. P.K. Mitra. Principal Policy Holder paid Rs.1,20,205.97 before Zenith Super Speciality Hospital, Kolkata. Thereafter, Principal Policy Holder claimed before the OP NO.1 on 05.06.2015 regarding reimbursement of aforesaid amount. On that time he filed relevant documents before him. On 18.09.2015 Principal Policy Holder had written an application before the OP NO.1 to settle the claim. On 23.11.2015 OP No.2 sent a claim rejection letter to the Principal Policy Holder. They stated “Your claim has been examined by E-MEDITEK TPA services and they have sent intimation on 20.11.2015 regarding your claim rejection. We are informing the decision of TPA in respect the claim as follows: CLAIM IS rejected under codeW-06 (The specific waiting period in respect of the treatments specified in the list IS APPLICABLE) for benign uterine complaints is within 2 years from commencement of policy.” As the OP NO.1 did not allow the claim of the complainant. Hence, the complainant filed this case praying for aforesaid relief.
(3)
OP No.1 & 2 contests the case by filing a W/V they denied the entire allegations of the complainant.
They further contended that they issued one policy in favour of the Principal Policy Holder and complainant namely Jeevan Arogya Policy. Being no.487028440. Complainant was suffering from benign uterine disorder like fibroids, uterine, prolapsed, dysfunctional, uterine bleeding etc. prior to the commencement of the policy. In the said claim there was specific waiting period for availing the benefit of the said policy. Policy holder Sutapa Sarkar was admitted at Zenith Super Speciality Hospital on 19.05.2015 for the treatment of recurrent appendicitis’s and adeno-myosis of uterus and date of surgery was 20.05.2015 and date of discharge was 27.05.2015. Complainant had filed the claim for the cost of treatment along with documents and after scrutinise the same they repudiated the claim and inform the same to the complainant. They stated that under code W-06 (The specific waiting period in respect of the treatment specified in the list is applicable) for benign, uterine complaints is within two years from commencement of policy and such as complainant is not eligible for the claim as it does not fail under the purview and the liability under the claim was rejected.
Trial
During trial complainant did not file any affidavit in chief. He had filed a petition on 27.07.2016 praying for an order to treat the petition of complaint as affidavit in chief. Said prayer was allowed. Thereafter, OP NO.1 & 2 filed questionnaires and complainant gave answer of those questionnaires.
Kaushik Majumder Manager (Admn), LICI, Krishnagar Branch-I filed affidavit in chief. Complainant filed interrogatories and OP NO.1 & 2 filed answer.
OP NO.1 & 2 filed affidavit in chief of one Sudhangshu Sekhar Jana. Complainant filed questionnaire. Said witness gave answer.
Documents
Complainant filed following documents viz :
- Original Jeevan Arogya Policy...........(Eight sheets)
- Original Prescription of doctor in the letter head of Aid Pharmacy........(One sheet)
- Original prescription of Dr. P.K. Mitra ..........(One sheet
(4)
- Original Discharge Certificate issued by Zenith Super Speciality Hospital regarding indoor treatment of complainant from 19.05.2015 to 27.05.2015......(One sheet)
- Original bill issued by Dr. P.K. Mitra amounting to Rs.47000/- dated 27.05.2015..........(One sheet)
- Xerox copy of money receipt in respect of Rs.61,875/- issued by Zenith Super Speciality Hospital........(One sheet)
- Xerox copy of final bill issued by Zenith Super Speciality Hospital in respect of Rs.61,875/-...........(Six sheets)
- Xerox copy of Pharmacy bill details issued by Star Medicine amounting to Rs.22,476.08-Rs.1,091.01=21,385.07/-..........(Four sheets)
- Original bill issued by Zenith Super Speciality Hospital..........(Eleven sheets)
10)Xerox copy of document issued by LIC check list..........(One sheet)
11)Xerox copy of Hospital treatment form.............(Four sheets)
12)Xerox copy of settlement of claim issued by Sutapa Sarkar dated 18.09.2015 before the Chief Manager LICI,KGR, Br.-I........(One sheet)
13)Original copy of claim rejection issued by Manager health insurance KSDO in favour of the Sutapa Sarkar dated 23.11.2015.........(One sheet)
14)Xerox copy of claim rejection letter issued by E-MEDITTEK dated 20.11.2015.........(One sheet)
15)Xerox copy of hand bill of LIC............(One sheet)
16)Xerox copy of Policy bill details of Jeevan Arogya LIC...........(Four sheets)
Brief Notes of Argument
Complainant filed BNA on 15.02.2017. Complainant filed another BNA on 03.06.2022. Complainant filed BNA on 16.03.2023.
OP No.1 & 2 filed BNA on 03.06.2022. He also filed another BNA on 24.01.2017. He also filed another BNA on 16.03.2023
Decision with Reasons
We have carefully gone through the petition of complaint filed by the complainant, W/V filed by the OP NO.1 & 2, affidavit in chief filed on behalf of OP NO.1 & 2 and documents filed on behalf of complainant.
(5)
We have carefully considered those documents.
On perusal of W/V of OP NO.1 & 2 ,evidence OP NO.1 & 2 and BNA of OP No.1 & 2, we find that they rejected the claim as it has been described specifically in the policy that the aforesaid claim of the complainant is not entertainable as per the policy condition.
We have carefully gone through the original policy filed by the complainant in point no.6 it has been described as follows:-
“WAITING PERIOD:
General Waiting period:
There shall be no general waiting period in case Hospitalization or Surgery is due to Accident Bodily injury. There shall be a general waiting period during which no benefits shall be payable in the event of Hospitalization or Surgery, if the said Hospitalization or Surgery occurred due to Sickness.
- The general waiting period shall be 90(ninety) days from the Date of Cover of Commencement in respect of each insured.
- If the policy is revived after discontinuance of the Cover then the following shall apply in respect of each insured.
- If the request for revival is received by the Corporation within 90 (ninety) days from the due date of the first unpaid premium, then there shall be a general waiting period of 45(forty five) days from the Date of Revival in respect of each insured.
- If the request for revival is received by the corporation beyond 90(ninety) days from the due date of the first unpaid premium, then there shall be a general waiting period of 90(ninety) days from the Date of Revival in respect of each insured.
Specific waiting period:
Besides the above, in respect of each insured no benefits are available hereinunder and no payment will be made by the Corporation for any claim under this Policy on account of Hospitalization or Surgery directly or indirectly caused by based on arising out of or howsoever attributable to any of the following during the specific waiting period:
i. Treatment for adenoid or tonsillar disorders.
ii. Treatment for anal fistula or anal fissure.
iii. Treatment for benign enlargement of prostate gland.
(6)
- Treatment for benign uterine disorders like fibroids uterine prolapsed, dysfunctional uterine bleeding etc.
- Treatment for Cataract.
- Treatment for Gall Stones.
Vii. Treatment for Slip Disc.
Viii. Treatment for Piles.
ix. Treatment for Benign Thyroid Disorders.
x. Treatment for Hernia.
xi. Treatment for Hydrocele.
xii. Treatment for Degenerative Joint Conditions.
xiii. Treatment for Sinus Disorders.
xiv. Treatment for Kidney or Urinary Tract Stones.
xv. Treatment for Varicose of Veins.
xvi. Treatment for Carpal Tunnel Synodrome.
xvii. Treatment for Benign Breast Disorders e.g. Fibroadenoma., Fibrocystic Disease, etc:
The specific waiting period in respect of the treatment specified in the list above shall be as follows:
- The specific waiting period shall be 2(two) years from the Data of Cover Commencement in respect of each insured.
- If the policy is revived after discontinuance of the Cover then the following shall apply in respect of each insured.
- If the request for revival is received by the Corporation within 90(ninety) days from the due date of the first unpaid premium, then the specific waiting period shall continue to be till 2(two) years from the Date of Cover Commencement in respect of each insured.
- If the request for revival is received by the Corporation beyond 90(ninety) days from the date of the first unpaid premium, then there shall be a specific waiting period of 2 (two) years from the Date of Revival in respect of each insured.”
It is clear before us that a waiting period of two years has mentioned therein in respect of some disease including treatment for benign uterine disorder like fibroids, uterine prolapsed, dysfunctional uterine bleeding, etc.
(7)
On perusal of the aforesaid policy we find that said policy has started on 28.03.2014. Complainant got admission at Zenith Super Speciality Hospital on 19.05.2015. Her surgery was done on 20.05.2015 and date of discharge was 27.05.2015. Complainant prayed for the treatment cost relating to the said treatment amounting to Rs.1,20,205.97.
On perusal of discharge summary issued by Zenith Super Speciality Hospital, we find that doctor of the said Super Speciality Hospital found recurrent appendicitis + adeno-ryodis uterine. We also find that laparoscopy surgery was done in the uterine. I find from the affidavit in chief of Dr. Sudhangshu Sekhar Jana , we find that he examined the discharge certificate issued by Zenith Super Speciality Hospital in respect of the patient namely Sutapa Sarkar who was admitted thereon 19.05.2017 and she was discharged on 27.07.2015. He further stated that doctor diagnosis was “recurrent appendicitis and adeno-myosis of uterus in case of rapid caesarean section with multiple curse over abdomen uterus.” Adeno-myosis is a benign uterine disorder and is a indication of hysterectomy with bilateral salpingo-oophorectomy.
So, it is clear before us that complainant was suffering with benign uterine disorder which comes within restriction where has mentioned above.
Having considered the entire matter and aforesaid restriction which has clearly mentioned in point no.8 of the policy, we find that as the complainant claimed the treatment cost relating to benign uterine disorder within two years from the date of purchase of policy, so, complainant is not entitled to reimbursement of treatment cost which she paid before the Zenith Super Speciality Hospital relating to her indoor treatment and laparoscopy surgery which has done on 20.05.2015 that is within two years from the date of issue of aforesaid policy. So, complainant is not entitled to reimbursement of the aforesaid amounts from the OP No.1 & 2.
In the result present case fails.
Hence,
It is
Ordered
that the present case be and the same is dismissed on contest against the OP NO.1 & 2
(8)
and dismissed ex-parte against the OP NO.3 but without any order as to costs.
Let a copy of this order be supplied both the parties as free of costs.
Dictated & corrected by me
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PRESIDENT
(Shri DAMAN PROSAD BISWAS,) ..................... ..........................................
PRESIDENT
(Shri DAMAN PROSAD BISWAS,)
We concur,
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MEMBER MEMBER
(NIROD BARAN ROY CHOWDHURY) (MALLIKA SAMADDAR)