BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.122 of 2017
Date of Instt. 28.04.2017
Date of Decision: 11.12.2019
1. Kapil Narula aged about 37 years S/o Sh. Bhagat Ram resident of H.no.68, Vijay Nagar, Jalandhar.
2. Mamta W/o Kapil Narula aged about 37 years S/o Sh. Bhagat Ram resident of H.no.68, Vijay Nagar, Jalandhar.
..........Complainants
Versus
1. HDFC ERGO General Insurance Company Limited, through its Branch Manager, Registered Office at Ramon House, H.T. Parekh Marg, 169, Bzckbay Reclamation, Mumbai-400020.
2. HDFC ERGO General Insurance Company Limited, through its Branch Manager, Branch Office at 3rd Floor, Eminent Mall, 261, Lajpat Nagar, Near Guru Nanak Mission Chowk, Jalandhar.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Sh. Karnail Singh (President)
Smt. Jyotsna (Member)
Present: Sh. Gurcharan Singh, Adv., Counsel for the Complainants.
Sh. R. K. Sharma, Adv. Counsel for the OPs.
Order
Karnail Singh (President)
1. This complaint has been filed by the complainants, wherein alleged that the complainant was regularly purchasing health/medical insurance policy from the OPs and accordingly, the OPs have also issued health card in favour of the complainant. The said health card is having No.HN0206201100123, No.HN02062011001123, which are valid from 20.06.2012 to 19.06.2013. Similarly, the Card No.HN02062011001123 was again issued for the period 20.06.2013 to 19.06.2014, Reference No.2952200781985900000 from 20.06.2014 to 19.06.2015 and Reference No.2952200781985901000 from 20.06.2015 to 19.06.2016. The complainant had never availed any claim till date.
2. After purchasing of the aforesaid health insurance policy, the complainant No.2 Mamta was not keeping good health and she has consulted Dr. Ranu Chhabra and was diagnosed of having uterine fibroid. The complainant No.2 was advised for Laparoscopic Myomectomy for uterine fibroid and underwent surgery as per advice of Dr. Ranu Chhabra. The complainant No.2 was discharged on 16.04.2016 and after discharge from the hospital, the complainant lodged the claim with the OPs bearing No.RR-HS16-10347285 as the complainant was having medical/health insurance policy with the OPs. The complainant even furnished the documents as demanded by the OPs, vide letter dated 20.05.2016 for realization of the claim amount but to the utter surprise, even after furnishing the requisite documents as demanded by the OPs, the claim of the complainant was arbitrarily repudiated on flimsy grounds without any cogent reason despite knowing the fact that the complainant has purchased the medical insurance policy from the OPs. The complainant even submitted the certificate issued by the Dr. Ranu Chhabra, wherein she has categorically stated that the complainant has been operated on 15.04.2016 for C/o Menorrhagia due to uterine fibroid. She underwent Laparoscopic Myomectomy for the uterine fibroid. It is not associated with infertility treatment. Despite furnishing of the said certificate and repeated request of the complainant, the OPs put off the complainant on one pretext or the other and failed to release the claim amount as claimed by the complainant. The treatment of the complainant does not fall in exclusion of the terms and conditions of the policy. The claim has been illegally and arbitrary repudiated by the answering OPs. The OPs have practiced unfair trade practice with the complainant and accordingly, the instant complaint filed with the prayer that the complaint of the complainant may be accepted and OPs be directed to release the claim amount of Rs.42,999/- alongwith interest @ 18% per annum. The OPs be also directed to pay compensation of Rs.50,000/- towards mental tension, mental suffering, mental agony and harassment and further, OPs be directed to pay litigation expenses of Rs.5000/-.
3. Notice of the complaint was given to the OPs and accordingly, both the OPs appeared through its counsel and filed joint written reply, whereby contested the complaint by taking preliminary objections that the instant complaint is not maintainable against the answering OPs and as such, the same is liable to be dismissed. It is further alleged that the complainant pertains to hospitalization claim of insured/Mamta Narula, who was insured under Health Suraksha Policy for the period from 20.06.2015 to 19.06.2016, subject to policy terms and conditions, which was never disputed by the complainant. It is further alleged that the claim was lodged for hospitalization expenses for Hysterolaparoscopy Surgery. After which the OPs proceeded the claim and documents were sought from the complainants. After the perusal of documents, filed by the complainants, it was found that as per the Discharge Summary dated 16.04.2016 the insured/patient was admitted on 14.04.2016. The insured was diagnosed with Primary Infertility and underwent Hysterolaprascopy on 15.04.2016. It is further averred that the claim of the complainant was repudiated as per the policy terms and conditions and as per the preview of Section 9-C x of policy terms and conditions and further averred that there is neither any deficiency in service nor any negligence and even there is no unfair trade practice on the part of the answering OPs No.1 and 2 and further submitted that the complaint of the complainant may be dismissed. On merits, it is admitted that the complainant purchased the policy in question and further admitted that the claim of the complainant has been legally and rightly repudiated, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, same may be dismissed.
4. Replication not filed.
5. In order to prove the case of the complainant, the counsel for the complainant tendered into evidence affidavit Ex.CA alongwith some documents Ex.C-1 to Ex.C-16 and closed the evidence.
6. Similarly, counsel for the OPs tendered into evidence affidavit of Pankaj Kumar as Ex.OA along with some documents Ex.O-1 to Ex.O-4 and closed the evidence.
7. We bestowed our thoughtful consideration to the submissions made by learned counsel for the respective parties and also gone through the case file very minutely.
8. We find there is no necessity to deeply discuss the facts and its reply, being reason the purchase of the policy by the complainant as well as getting treatment from the hospital and thereafter submitting of insurance medical claim and the same has been repudiated by the OP, are admitted facts.
9. Now the question before us is only whether the said repudiation is legal or not, for that purpose, we have to scan the repudiation letter and copy of the same is produced on the file by the complainant Ex.C-14 and same repudiation letter also produced by the OP as Ex.O-3 and in the said repudiation letter, the plea taken by the insurance company is as under:-
“We have received your request for reimbursement of claim for the above mentioned hospitalization. We have verified the same with respect to the coverage terms and conditions under the insurance policy plan. And on primary scrutiny of the submitted documents, we regret to inform that your claim is not payable due to following reasons:-
As per the submitted documents, Insured was diagnosed with Primary Infertility and underwent Hysterolaparoscopy for the same. This claim is repudiated under Section 9 c x of the policy terms and conditions which states that ‘sterility, treatment whether to effect or treat infertility, any fertility, sub fertility or assisted conception procedure, surrogate or vicarious pregnancy, birth control, contraceptive supplied or services including complications due to supply services’ is a part of general exclusions and hence beyond the scope of coverage of the policy.”
10. In support of above observation for repudiating the claim of the complainant, the OP has taken support a document i.e. terms and conditions of the insurance policy, which are placed on the file Ex.O-4 and further brought on the file Discharge Summary Ex.O-1 issued by the same treating doctor i.e. Mrs. Ranu Chhabra and one certificate issued by the said doctor Mrs. Ranu Chhabra Ex.O-2. In the Discharge Summary Ex.O-1, Diagnosis, Primary Infertility is very much mentioned in the Discharge Summary and further, in a certificate Ex. O-2 Doctor has categorically mentioned as under:-
“Certified that Mrs. Mamta Narula w/o Mr.Kapil Narula is undergoing treatment under my care. She was examined for the first time on 12.08.2011 and is still under treatment in OPD till date; for infertility. In the course of treatment, she was diagnosed as having a uterine fibroid on 17.03.2016; for which she was operated, i.e. Hysterolaparoscopy was done on 15.04.2016. Since the fibroid was removed piece meal with resectoscope, it was not sent for HPE.”
11. Apart from this certificate, the complainant also got available a certificate from the same doctor and copy of the same is available on the file Ex.C-12, wherein the doctor recorded her version as under:-
“Certified that Mrs. Mamta Narula w/o Meter reader. Kapil Narula, has been operated on 15.04.2016 for c/o menorrhagia due to uterine fibroid. She underwent Laparoscopic Myomectomy for the uterine fibroid. It is not associated with infertility treatment.”
We find from the Discharge Certificate as well as two certificate issued by the doctor Ex.O-2 and Ex.C-12, that the complainant was under treatment since 12.08.2011 for infertility, but during the course of that treatment, the complainant got some other problem and accordingly, she was diagnosed and was having a uterine fibroid on 17.03.2016. We like to make it clear that “uterine fibroid is also known ‘Uterine myoma’, the later on developed problem to the complainant is uterine fibroid, which is a problem Non-cancerous growths in the uterus that can develop during a woman’s childbearing years. The said problem of uterine fibroid required a Laparoscopic Myomectomy for removing the said uterine fibroid and these things has been very clearly explained by the doctor in her certificate Ex.O-2 that the said fibroid was removed with piece meal, but the OP has tried to wrongly interpreted the finding of the doctor given in the certificate Ex.O-2 rather as per version given by the doctor in certificate Ex.O-2, infertility treatment is separate treatment from the uterine fibroid. So, accordingly, we find that the OP has wrongly and illegally repudiated the claim of the complainant and accordingly, the same is setaside and further, find that the complainant No.2 Mamta wife of Kapil Narula is entitled for the relief claimed.
12. In the light of above detailed discussion, the complaint of the complainant is partly accepted and OPs are directed to pay the insurance claim of Rs.42,999/- to the complainant Mamta with interest @ 12% per annum from the date of repudiation of the claim i.e. 20.07.2016, till realization and further, OPs are directed to pay compensation for causing mental tension and harassment to the complainant Mamta Narula, to the tune of Rs.15,000/- and litigation expenses of Rs.3000/-. The entire compliance be made within one month from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.
13. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jyotsna Karnail Singh
11.12.2019 Member President
