: FINAL ORDER :
DATE OF FILING: 01.04.2016
ORDER No. 27
DATE. 20.09.2017
Shri Asoke Kumar Das – President
The case of the complainant in short is that the complainant purchased a Medi-Classic Insurance Policy bearing No. P/191123/01/2014/002205 from Star Health and Allied Insurance Company Ltd. on payment of premium of Rs. 2820/-. The date of commencement of the said policy was from 27.02.14 and it was valid up to 26.02.15 and the basic sum assured was Rs. 1,50,000/-. The complainant suddenly fell in ill due to abdomen pain and she went to Apollo Hospital, Chennai on 19.07.14. There she was treated by Consultant Dr. Vinutha Arunachalan who advised her to take admission in his Hospital. On 26.07.14 the complainant got herself admitted in the Apollo Hospital, Chennai for operation and Total Laparoscopic Hysterectomy by lateral Salphingectomy was done and she was discharged on 27.07.14. Thereafter, the complainant paid Rs. 1,46,169/- to Apollo Hospital, Chennai for charges of her operation and other expenses. It is alleged by the complainant that she claimed from the OP No. 1 cashless benefit but she was not given that facility by OP No. 1 and that OP, Star Health and Allied Insurance Company Ltd. cleverly, arbitrarily and whimsically rejected her cashless claim. Hence, this case. The complainant has prayed for Rs. 1,49,169/- i.e., total bill amount Rs. 50,000/- towards compensation for her harassment, mental agony etc. and cost of the proceeding.
The OPs Star Health and Allied Insurance Company Ltd. has contested this case by filing a written version denying and disputing, inter alia, the claim and contention of the complainant with prayer for dismissal of the case with cost.
The specific stand of the OP is that the insured patient (complainant) had undergone the treatment of hysterectomy which comes under two years exclusion as per policy terms & conditions (Exclusion No. 3 of the policy), the claim of the complainant was rejected on the ground of exclusion No. 3 and that was communicated to the treating Hospital as well as the insured vide letter dtd. 25.07.14. The insured has intimated her claim to them on 25.07.14 for the treatment of Abdenomyosis Uterus and the surgery was planned to be done on 26.07.14 and she took admission in the Hospital during the exclusion period. Hence, they rejected her claim on 25.07.14 basing on the submitted documents for the treatment of hysterectomy. The complainant filed a complaint before the Ombudsman for her redressal but that has also been closed and the complainant has suppressed that fact.
POINTS FOR CONSIDERATION
- Is the case maintainable?
- Is the complainant a consumer?
- Are the OPs liable for deficiency in service and or unfair trade practice as alleged?
- Is the complainant entitled to get the reliefs as prayed for?
DECISION WITH REASONS
All points are taken up together for consideration and decision.
After due consideration, of the materials on record i.e., the petition of complaint, the written version, the documents filed by the parties, the written notes of argument, all other relevant materials on record and oral argument advanced by the Ld. Lawyers of both sides we find that it is undisputed that the complainant purchased mediclaim policy No. P/191123/01/2014/002205 from Star Health and Allied Insurance Company Ltd. and that was valid from 27.02.2014 to 26.02.2015 and the sum assured of the policy was Rs. 1,50,000/-. It is also undisputed that on 26.07.2014 Laparoscopic Hysterectomy of the complainant was done at Chennai Hospital as she was suffering from “Adenomysis, Fibroid Uterus”. Admittedly the OP has repudiated complainant’s claim dtd. 25.07.2014 for cashless benefit. The complainant has filed this case on 01.04.2016 within statutory period of limitation of two years. Furthermore, this Forum has territorial and pecuniary jurisdiction to hear and to dispose of this case. So it is clear that this case is maintainable and this complainant is a consumer.
We now find that the OP has repudiated complainant’s claim for cashless benefit on the ground that complainant took admission at Chennai Hospital and her treatment of Adenomysis Uterus and her surgery was done on 26.07.2014 i.e., during exclusion period of two years in terms of exclusion clause No. 3 of the mediclaim policy of the complainant.
Ld. Lawyer for OP argued his case basing in on exclusion clause No. 3 of the policy agreement to justify the repudiation of complainant’s claim of getting cashless benefit.
Ld. Lawyer for the complainant argued that the repudiation of complainant’s claim of cashless facility by OP Insurance Company was not proper and that was arbitrary and whimsical. He argued further that disease of the complainant as written in her discharge certificate was Adenomysis Fibroid Uterus and the disease as mentioned in the exclusion clause No. 3 of the policy is Hysterectomy for Menorrhagia which is totally different from the disease of the complainant and as such the OPs are liable for deficiency in service and/or unfair trade practice for repudiation of complainant’s genuine claim of cashless benefit and as such the complainant is entitled to get the reliefs as prayed for.
On perusal of the Discharge Summery (Annexure – 5) of the complainant issued by Apollo Hospital, Chennai dtd. 27.07.2014, it appears that the Hospital diagnosed the disease of the complainant as ‘Adenomysis Fibroid Uterus’ and her ‘total laparoscopic hysterectomy bilateral Salphingectomy’ surgery was done on 26.07.2014 and she was discharged from the Hospital on 27.07.2014. It further appears from the Discharge Summary that the complainant, Smt. Basanti Sarkar was suffering from menorrhagia pain abdomen for 6 months and on USG found to have adenomysis and fibroid uterus and her menstrual cycle was irregular & with heavy flow.
‘Adenomysis’ is a non-cancerous condition of the uterus that can mimic many of the signs and symptoms fibroids (a benign tumour of muscular and fibrous tissues typically developing in the wall of the womb). Adenomysis may be mild and cause no symptoms at all, or, in more severe forms, it may lead to heavy bleeding and severe cramping during menstrual periods.
Hysterectomy is a surgical operation to remove all or part of womb. Discharge summary of the complainant goes to show that Adenomysis Fibroid Uterus i.e., part of the womb of the complainant was removed by surgery at Chennai Hospital on 26.07.14. Complainant’s mediclaim policy in question was commenced on and from 27.02.14 and that was valid up to 26.02.15. As per exclusion clause No. 3 of the policy he Insurance Company shall not be liable for any payment during the first two years of continuous operation of insurance cover, the expenses on treatment of Hysterectomy for Menorrhagia or Fibromyoma, knee replacement.
We find that the term total laparoscopic hysterectomy bilateral Salphingectomy used in the discharge summary of the complainant is similar and identical of the term Hysterectomy for Menorrhagia or Fibromyoma used in the Exclusion Clause No. 3 of the medical policy in question and as such claim of the complainant is totally bar as per exclusion clause No. 3 of the mediclaim policy. From the materials on record, we find that the complainant lodged complaint before the Ombudsman claiming her redressal but her complaint was closed by the Ombudsman on 15.03.2016 with observation that the repudiation of the insurer’s claim under clause 3(c) is justified.
In this view of the matter, we have no hesitation to hold that the repudiation as made by the OP against the complainant’s claim for cashless benefit was proper and justified. So the OPs are not liable for deficiency in service and or unfair trade practice as alleged and as such the complainant is not entitled to get any relief in this case. All points are disposed off accordingly.
Hence it is,
Ordered,
That the case/application stands dismissed on contest against the OPs but without cost.
Let plain copy of this final order be supplied to the parties / their Ld. Advocates / agents forthwith free of cost or send by ordinary post.
