Order-19.
Date-28/04/2015.
Complainant Mrs. Ruprani Munshi by filing this complaint has submitted that complainant is a bona fide Mediclaim Policy Holder of the op since more than 10 years for herself and her family members jointly. Subsequently, complainant separated her policy by payment of premium separately and renewed the same for several years and under the name and heading “Hospitalisation and Domiciliary Hospitalisation Benefit Policy” for which complainant paid last premium of Rs. 14,952/- on 07.05.2012 bearing Policy No. 104200/48/12/8500001221 but the said policy period of said Insurance from 07.05.2012 to 06.05.2013 having Insurance coverage for the complainant sum insured was for Rs. 5,00,000/- and bonus amount is Rs. 1,32,500/- for self policy holder.
During the policy period, complainant felt seriously ill and therefore she has been examined by Dr. Surendra Ugale at Kirloskar Hospital, Basheerbagh, Hyderabad on 03.01.2013 and after examination of the complainant the said doctor advised for immediate admission to the said hospital on 08.01.2013 for treatment and surgery on 09.01.2013 for surgery of Duodeno-lleal (Fundectomy) Gastroplasty and Sympathectomy and Cholecytectomy under the said doctor.
Complainant was admitted at Kirloskar Hospital, Hyderabad on 08.01.2013 under the care of Dr. Surendra Ugale where the doctor diagnosed for treatment as surgery “Laparoscopic surgery of Sleeve Gastrectomy with Duodeno-lleal Interposition due to uncontrolled diabetes” after through surgery patient was discharged on 15.01.2013.
Accordingly to such advance information complainant submitted through a letter on 27.12.2012 requested before the op nos. 1 & 2 with the entire information regarding treatment, hospitalization and surgery for considering the same as total expenditure of Rs. 5 lakhs. After discharge from the hospital complainant intimated the insurance company about such hospitalization during the period of admission in hospital and the complainant submitted claim in respect of reimbursement of medical expenditure for the said period of treatment to the extent of Rs. 4,51,590/- to the op nos. 1 & 2 for necessary action.
In the meantime op no.1 vide letter dated 25.05.2013 sent a letter to the complainant the Medical Superintendent of TPA and the op no.2 proposed and submitted claim and facility is not applicable for the complainant that was reported vide letter dated 25.03.2013. Op Insurance Company vide letter dated 07.05.2013 repudiated the claim of the complainant with the following observation – “as per the discharge certificate of the Kirloskar hospital as the patient was diagnosed for DM, Thyroid, Obesity, peptic ulcer are pre-existing. Therefore as per terms and conditions of the policy the claim is non-admissible as per policy Exclusion Clause 4.19”.
Complainant being informed the matter and aggrieved and dissatisfied with the repudiation letter of the ops thereafter complainant immediately sent one protest letter dated 16.05.2013 to the op no.1 Insurance Company with a request to reconsider the claim and denied the allegation raised by the insurance company and their TPA. Subsequently complainant again sent letter on 15.06.2013 to the op and submitted some documents for settlement of claim as the documents are vital importance in the settlement of claim but ops received the said letters but kept silent and having no other alternative the complainant requested the Insurance Company for payment of the claim amount otherwise the complainant will take legal necessary step in this regard and finding no result, complainant filed this complaint for proper relief and compensation.
On the other hand op no.1 Insurance Company by filing written complaint submitted that the complainant obtained an Individual Mediclaim Policy with sum assured of Rs. 5 lakhs and as per terms and conditions, complainant submitted his claim form along with medical bills and other medical papers with the op and after examining the claim form op no.2 TPA appointed by the Insurance Company and informed the op no.1 vide a letter dated 25.03.2013 that the claim is not payable for ‘Patient admitted for DM, thyroid with Obesity and underwent sleeve Gastrectomy’. Subsequently op no.1 Insurance Company vide letter dated 07.05.2013 addressed to the complainant, rejected the claim of the complainant as per the Exclusion Clause No. 4.19 of the Policy on the ground briefly and clearly stated in the said letter and repudiated the claim on 07.05.2013. Being dis-satisfied the complainant wrongly moved to the Ld. Forum and in fact there is no illegality on the part of the op and the allegation of the complainant are false and fabricated and repudiation was made rightly as per Clause and considering the treatment sheet. So the present complaint is not tenable in the eye of law and it should be dismissed with cost.
Decision with reasons
On proper consideration of the complaint and the written version including the documents and further hearing the Ld. Lawyers of both the parties, it is found that no doubt complainant is a bona fide policy holder of the op. Truth is that complainant submitted the claim being No. 10420048138590000196 against the Policy No. 10420048128500001221 for hospitalization period from 08.01.2013 to 15.01.2013 of Mrs. Ruprani Munshi and in the said claim application, complainant reported the nature of the disease as uncontrolled diabetes.
Op has submitted that in the written version that as per Clause-4.19, complainant is not entitled to get any benefit in view of the fact that the entire treatment was for obesity or condition arising there from morbid obesity and any other weight controlling programme/service or supplies.
Ld. Lawyer for the op submitted that the treatment was completely Sleeve Gastrectomy and Sleeve Gastrectomy is no doubt a treatment of world renowned treatment for purpose of controlling the obesity and practically Sleeve Gastrectomy was done for which as per Clause – 4.19 complainant is not entitled to get any claim and for which it was repudiated.
But after considering the discharge certificate issued by Kirloskar Hospital on 15.01.2013 it is clear that Ruprani Munshi W/o Sabyssachi Munshi was admitted on 08.01.2013 at the said hospital and discharged on 15.01.2013 and during that period, operation was done and the details of operation is Duodeno-lleal Interposition with medium size, Sleeve Gastrectomy, Relaxed (Fundectomy), Gastroplasty and Sympathectomy and Cholecytectomy which was done under GA on 09.01.2013 and history was 16 years diabetes, thyroid for 20 years along Peptic Ulcer.
Now we shall have to consider the entire treatment sheet wherefrom we find that certain portion, not single operation but general operation was made. So, we must have to ventilate the definition of particular type of operation- 1) Duodeno-lleal Interposition with medium size means combination of Laparoscopic-illeal Interposition with his upcoming procedure which offers good metabolic improvement and weight reduction without causing significant malabsorption. The objective of this operation is to evaluate the result if this novel procedure of control of type-II Diabetes Hypertension and related metabolic abnormalities whereas Gastroplasty means a surgery to that obesity it causes weight loss by decreasing the amount of food you can eat and this is only one type of weight loss surgery. Sympathectomy means surgical procedure that destroys nerves in the sympathetic nerves system and the procedure is done to increase blood flow and decrease long term plan in certain disease that caused narrowed blood vessels and it can also be decreased excessive sweating which is at the cause of obesity.
Another operation was done that is Cholecytectomy that means Gall Bladder was removed and after considering the definition of the different operation procedure has adopted in the present case by the Dr. Ugale, it is clear that complainant has been suffering from High Diabetes last 16 years, thyroid for 20 years and also suffering from peptic ulcer and all were caused due to diabetes and fact remains that Duodeno-illeal Interposition with medium sized was done for controlling Type-II Diabetes and Hypertension caused due to obesity.
In case of obesity no doubt complainant is a known patient of Hypertension, high diabetes and also thyroid and obesity. No doubt Gastroplasty was done to treat obesity to cause weight loss by decreasing amount of food one can eat and it is no doubt one type of weight loss surgery.
No doubt Sleeve Gastretomy is another procedure for decreasing excessive sweating and to control the sympathetic nerve system from any further damage or destruction and by that system or procedure the blood flow can be increased to decrease long term pain and sympathetic nerve system is destroyed due to high sugar and further obesity and also for thyroid. But no doubt Cholecytectomy is nothing but a simple operation of removal of gall bladder. If all those operations was done by the doctor of the complainant it is clear that due to diabetes for last 16 years, thyroid for 20 years and obesity complainant suffered from different type of ailment and practically his weight had been increased abruptly and for which her related metabolic abnormalities were detected and for which the general operation was done. Out of that Cholecytectomy is not always related to thyroid, hypertension and or diabetes. But other operations were related to no doubt obesity and for the purpose of metabolic improvement and weight reduction without causing significant malabsorption were done. But in the particular case all the diseases were caused due to diabetes, hypertension, thyroid etc. which are effect of obesity.
But it is to be mentioned in this regard that Cholecytectomy was also done in view of the fact that in the present particular case without Cholecytectomy if other operation would be done in that case the operation shall not be successful and the removal of gall bladder is primarily required in case of high sugar, thyroid and obesity and obesity was there which is proved and after considering the definition of operation as done by the doctor that all the operations were done for the purpose of controlling the diabetes, hypertension and related metabolic abnormalities the out cause of obesity and also to improve the sympathetic nerve system to decrease excessive swelling due to obesity and thyroid.
Considering all the above fact, it is found that diabetic problem caused for all the diseases of the complainant and for which different type of surgery which has been required which was done by the doctor for the purpose of saving the complainant. Practically for high diabetes, most of the operation was done i.e. Duodeno-illea Interposition for medium sized sympathetic Gastroplasty and at the time of such operation Sleeve Gastretomy damaged was required and growth was done in view of the fact that at the age of 49 and due to high sugar and that become infected for his body. But after considering the treatment sheet, we have gathered that the operations were not only related to obesity. But it was related to control high sugar and to control the damage of obesity and also to control his food habit.
If we consider the above fact and also the definition of the op, then it is clear that the defence of the op that Sleeve Gastretomy was done that means it was related to treatment of obesity. So, as per Clause-4.19 complainant is entitled to any claim. But after studying the definition from World known surgery of medical books and after collecting the defence, we have gathered that all the operations were related to obesity and in the particular case, the weight was increased due to high sugar and diabetic was the cause for such heavy weight and for which to control diabetes, hypertension also to control over sweating to remove metabolic abnormalities all those operations were done and no doubt those operations were done as it is the nobel procedure for controlling Type-II Diabetes, Hypertension and related metabolic abnormalities and operation of Sleeve Gastretomy for controlling obesity.
Fact remains that Sleeve Gastretomy adopted with present case along with other for the purpose of controlling the diabetes because the doctor diagnosed her diabetes and about obesity there is such diagnosis made by the doctor. So, considering all the above fact, we are convinced to hold that for the sake of the argument if it is accepted that doctor already adopted Sleeve Gastretomy along with other operation, then op must have to prove all the operations were done for the purpose of treatment of obesity. But the discharge summary shows that treatment was for removing fat (obesity) because according to diagnosis it is clear that complainant has been suffering from high diabetes and he is a diabetic patient and for which it was required to remove fat and to control the diabetes. So, different type of operations along with Sleeve Gastretomy for which it can safely be said that the entire operation was done for controlling obesity, but it was done for checking up fat which has been causing high sugar.
Moreover after considering the definition of the different operation adopted by the doctor for the particular case we are confirmed that of single operation only was not for the problem of obesity. So, the defence of the op in this regard is not completely uncalled for and practically ops did not follow the discharge summary and the total diagnosed procedure as adopted by the doctor and his decision. So, we are convinced to hold that the entire repudiation as made by the ops is completely uncalled for but part amount can be released.
But fact remains about pre-existing blood pressure or diabetes op cannot repudiated the claim because the complainant is a bona fide policy holder for long years and so he is entitled to get 1/4th of the entire claim. when Sleeve Gastretomy and three other operations were also done and that is Gastroplasty, Sympathetic and Duodeno-illeal Interposition for removal fat. Fact remains that claim was in respect of Rs. 4,51,590/- and as per our decision complainant is entitled to Rs. 1,12,125/- out of Rs. 4,51,590/- against the claim made by the complainant which has been repudiated by the op without any proper medical finding and as per clause terms and conditions of the policy of the complainant is entitled to 1/4th of the claim when other operations were made only to control fat to check high sugar and disease of the complainant, but obesity has caused different type of disease and for which she was admitted to hospital during that period for treatment by Dr. Uagle of Kriloskar Hospital of Hyderbad.
In the above circumstances, we are convinced to hold that op no.1 Insurance Company is liable to pay Rs. 1,12,125/- out of total claim of Rs. 4,51,590/- without any fail and accordingly op shall have to pay a sum of Rs. 1,12,125/- to the complainant against this claim application as finally disposed of and it shall be paid within one month from the date of this order failing which other relief shall be given to the complainant.
Accordingly, the complaint succeeds.
Hence, it is
ORDERED
That the complaint be and the same is allowed on contest against the op no.1 with cost of Rs. 5,000/- and exparte against op no.2 without any cost.
Op no.1 is hereby directed to pay a sum of Rs. 1,12,125/- to the complainant as final settlement of the claim of the complainant which has been wrongly repudiated by the op and it shall be paid within one month along with cost and if it is not paid within the stipulated time, in that case, penal interest at the rate Rs. 3,000/- per month shall be assessed till full satisfaction of the decree and if it is collected it shall be deposited to this Forum’s account.
Even if it is found that op no.1 is reluctant to comply the order, in that case, penal proceeding u/s 27 of C.P. Act 1986 shall be started against them for which further penalty and fine may be imposed against them.
