The facts of the present case, in brief, are that the complainant on 11/05/2017 by paying total premium of Rs.23,313/- purchased a policy under Happy Family Floater-2015 policy scheme from the Oriental Insurance Company Ltd. ( here-in-after called the Opposite party, in short O.P. ) for a sum assured of Rs. 5,00,000/- ( Rupees Five Lakh ) bearing Policy No.-322600/48/2018/207 for a period of 1 (one) year w.e.f. 13/05/2017 upto 12/05/2018. As per the said policy condition it covers the risk of personal accident and domiciliary hospitalization to the members of the complainant’s family including complainant himself, his wife and their two children. That in the month of November’2017 the complainant alongwith his all family members went to south India in a pleasure trip as well as for medical check up of the wife of the complainant as she was feeling problem in her lower abdomen. Smt. Tandra Bhattacharjee, the wife of the complainant attended Narayan Hridayalaya hospital in Bangalore for the purpose of medical check up and there it was diagnosed that she had been suffering from Umbilical Hernia Systematic Hypertension and she was advised to undergo surgery for her recovery from the said problem. Accordingly she was admitted in the said hospital on 21/11/2017 and on the following day the said surgery i.e., Laparoscopic Umbilical hernioplasty of Smt. Tandra Bhattacharjee was done at Narayan Hridayalaya and she was discharged on 24/11/2017. It is stated that all the original policy paper, medical papers, bills, vouchers and prescriptions etc. concerning medical treatment, hospitalisation of Smt. Tandra Bhattacharjee had been filed with the O.p. Insurance Company alongwith the medical claim. But on 24/05/2018 by a letter the O.P. informed the complainant regarding repudiation of the claim. According to the complainant, they are entitled to get the compensation and by illegally repudiating the claims the O.P. has caused disservice and unfair trade practice. Under the circumstances, it is prayed for passing an order awarding total sum of Rs.2,50,000/- alongwith interest etc. in favour of the complainant.
The Opposite Party filed written statement and contested the case stating , interalia, that there is no cogent reason for filing this complaint, that the complaint is not maintainable, that the claim is barred by limitation etc. etc. It has been denied that the answering O.P. caused disservice to the complainant and there was any act of negligence on the part of the O.P. The answering O.P. admits that the complainant availed the Happy Family Floater-2015 policy under TPA service system. It is stated that the answering O.P. forwarded all the medical documents received from the complainant to the TPA ( Third Party Administrator which has been licensed by the Insurance Regulatory & Development Authority under IRDAI Regulations, 2001 for providing health insurance services to the insured ) i.e., the Raksha Health Insurance TPA Pvt. Ltd. But ultimately the TPA by its letter informed that after scrutiny it is found that the patient’s ailments is a complication arising from the past caesarean section surgery and the same is not covered under the policy. It is further observed that the claim should be non-payable as per standard Happy Family Floater Policy-2015 Clause No 4.12 & 4.20 . Accordingly, the answering O.P. by a letter dated 24/05/2018 informed the complainant about the observation and opinion of the TPA and could not settle the claim. The answering O.P. has no control or authority over the TPA and it is bound to comply with the observations and opinions of the TPA. Under the circumstances it is prayed for dismissal of the case.
In support of his case the complainant has submitted his evidence as PW-1 on affidavit and has submitted Annexures and exhibited some documents. On the other hand, from the side of O.P. Insurance Company the evidence of D.W.-1 Sri Chandan Dev is also furnished by way of affidavit alongwith some exhibits. Both parties have also submitted written argument. Perused the entire evidence on record.
In his evidence as PW-1 the complainant has narrated the same facts as stated in his complaint petition. According to PW-1, on 11/05/2017 he purchased a policy under Happy Family Floater-2015 Policy scheme from the O.P. bearing policy no.-322600/48/ 2018/207 for a period of one year w.e.f. 13/02/2017 to 12/03/2018 by paying total premium of Rs. 23,313/- . As per said policy condition the O.P. is legally obliged to cover the risk of personal accident and domiciliary hospitalization to the complainant and his family members i.e., his wife Smt. Tandra Bhattacharjee and two children. Further version of PW-1 is that in the month of November/2017 he alongwith all his family members went to south India for a pleasure trip as well as for medical check up of his wife as she was ocassionally feeling pain on her lower abdomen. It reveals from the evidence of PW-1 that his wife attended the Narayan Hridayalaya Hospital , Bangalore for medical check up and it was diagnosed that she had been suffering from Umbilical Hernia Systematic Hypertension and she was advised to undergo immediate surgery. Accordingly on 22/11/2017 the said surgery i.e., Laparoscapic Umbilical Hernioplasty was done at the said hospital and she was discharged on 24/11/2017. As per advice of the doctor she (wife of PW-1) revisited the hospital for medical check up. According to PW-1 he incurred more than Rs.1,50,000/- ( Rupees one lakh fifty thousand ) only towards medical treatment , hospitalization expenses and cost of medicine etc. PW-1 has further averred that on their arrival at Silchar he lodged medical claim with the O.P. submitting all original papers regarding medical treatment but on 24/05/2018 the O.P. informed that the claim in question had been repudiated.
On the other hand DW-1 in his evidence has admitted the fact that the complainant had availed the Happy Family Floater-2015 policy from the O.P. under TPA service system. That the said policy covers both personal accident and domiciliary hospitalization of the family members of the complainant and that a claim for disbursement of medical expenses etc. of the wife of the complainant was submitted alongwith the original medical papers these facts are not in dispute in this case as reveals from the evidence of DW-1. According to DW-1, they forwarded all medical documents received from the complainant to the TPA i.e., the Raksha Health Insurance TPA Pvt. Ltd. but the claim file was returned with observation that the patient’s ailment is a complication arising from the past caesarean section surgery and the same is not covered under the policy and hence the claim should be non-payable as per Standard Happy Family Floater Policy-2015 under clause No. 4.12 & 4.20 . The DW-1 has also exhibited the copy of the letter as Ext.-A . The Version of DW-1 is that in compliance with the opinion of the TPA, the O.P. vide Ext.-B letter informed the complainant about the observation and opinion of the TPA with an opportunity to substantiate the claim within seven days .
According to the O.P. they are bound by the terms and conditions of the policy and the opinion of the TPA. The O.P. has no control or authority over the TPA and it is bound to comply with the observations and opinions of the TPA. As such, it has been claimed by the O.P. that they have not caused any negligence or disservice towards the complainant and hence no cause of action has arisen as against the O.P. It is a fact that it reveals from Ext.-C the prospectus of the concerned policy under clause 4.12 i.e., any treatment arising from or traceable to pregnancy, childbirth, miscarriage, caesarean section, abortion or complications of any of these including changes in chronic condition as a result of pregnancy etc the company shall not be liable to make payment. But the complainant side in written argument as well as during the course of oral argument categorically submitted that nowhere or never any of the doctors opined that the patient’s complications ever arose out of those conditions as claimed by the O.P. The DW-1 has exhibited the recommendation of the TPA as Ext.-A . But from Ext.-A it does not reveal in which medical paper of the concerned hospital it has been mentioned that the ailment of the patient is a complication arising from the past caesarian section surgery. There is also nothing to show that the patient was examined by an expert doctor at the instance of the O.P. On the other hand, from the policy document as well as from other papers of the case record it clearly reveals that the youngest son of the complainant was born in the year 1996. Smt. Tandra Bhattacharjee was treated in the hospital at Bengalore in the year 2017. So how can it be said that the ailment of Smt Tandra Bhattacharjee is related to the caesarean section surgery done in the year 1996. Moreover there is no such comment available in any of the medical papers of the patient.
In view of the above discussion it can be easily said that simply the point raised in the TPA report so to say by the O.P. for non-availability of the claim by the complainant can not sustain when there is no dispute regarding policy , medical examination in the concerned hospital, amount incurred in treatment etc. are concerned . As such by not paying the complainant his due claim the O.P. has caused disservice to the complainant. The complainant has got valid reason or cause to come with his complaint before this commission. The complaint is also not barred by any defect.
Under the circumstances, it is ordered that the O.P. Insurance Company shall pay to the complainant an amount of Rs. 1,39,910/- ( Rupees one lac thirty nine thousand nine hundred ten ) only towards medical expenses, an amount of Rs.15,000/- ( Rupees fifteen thousand ) for mental pain, agony & harassment and also an amount of Rs. 20,000/- ( Rupees twenty thousand ) only towards legal expenses. The entire amount shall be payable within 90 (ninety) days from today otherwise the O.P. will be liable to pay interest @ 9% per annum from the date of this order till payment on the amount in addition.
Signed and sealed on this 24th day of March’ 2022 .
