DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (CENTRAL)

MAHARANA PARTAP BUS TERMINAL: 5^th  FLOOR.

KASHMERE GATE DELHI.

No. DF / Central/ 2015

Shri Rajkumar Sharma,

F2 Plot no A 151

SLF Ved Vihar

Loni Road Ghaziabad

UP                            ..........Complainant

Versus

1. ICICI Lombard GIC Ltd

DDA Market, Ist Floor,

101 J & K

Dilshad Garden Delhi-110095

2. ICICI Lombard Health Insurance

At House 414, Veer Sarvkar Marg,

Near Siddhivinayak Temple,

Prabhudevi, Mumbai 400025

                             ..........Respondent/OP

BEFORE

SH. RAKESH KAPOOR, PRESIDENT

DR. VIKRAM KR. DABAS , MEMBER

Nupur Chandna , MEMBER

ORDER/174/2014 1.

ORDER

Per Sh. RakeshKapoor, President  

The complainant is holder of a health insurance general mediclaim policy from the oP. His wife was one of the beneficiaries under the said policy. On 23.9.2012, she was admitted in St. Stephens Hospital and was discharged on 1.12.2012.   The OP had initially approved a cashless facility of Rs. 25,000/- which was later on withdrawn. The complainant had to make payment of a sum of Rs. 34,000/- as expenses on the aforesaid treatment.   The OP had refused to reimburse the said amount to the complainant. He had, therefore, approached this forum for redressal of his grievances.

    The OP has contested the complaint and has filed a written statement. It has denied any deficiency in service and has claimed that the complaint is false, frivolous, misconvieved  and is liable to be dismissed. It would be of benefit to reproduces paras 1 - 5 of the (Para-wise reply) of the written statement.  It reads :

1-5.The contents of Paras 1 to 5 of the complaint, in so far as matter of record, are not denied. 

ORDER/174/2014 2.

The complainant be, however,

pointed out that the alleged illness of wife of the complainant (Hyper Emesis Gravidarum) is a direct outcome of pregnancy. Reference be made to Wikipedia article stating “ Morning Sickness, also called nausea gravidarum, nausea, vomiting of pregnancy (emesisgravidarum or NVP) , or pregnancy sickness is a condition that affects more than half of all pregnant women. Sometimes symptoms are present in the early hours of the morning and reduce as the day progresses. However, in spite of its common name, it can occur at any time of the day. For most women it may stop around the 12^th week of pregnancy. Related to increased estrogen levels, a similar form of nausea is also seen in some women who use hormonal contraception or hormone replacement therapy.  The

ORDER/174/2014 3.

 nausea can be mild or induce actual vomiting , however, not severe enough to cause metabolic derangement. In more severe cases, vomiting may cause dehydration, weight loss, alkalosis and hypokalemia. This condition is known as hyperemesis gravidarum and occurs in about 1% of all pregnancies, Nausea and vomiting can be one of the first signs of pregnancy and usually begins around the 6^th week of pregnancy ( counting gestational age from 14 days before conception).”

Wife of the complainant suffered from Hyper Emesis Gravidarum around 8 weeks of pregnancy but the pre-authorisation was sought stating the illness to be “ Typhoid and paratyphoid fevers” and the OP provisionally authorized a sum of Rs. 25,000/-. Clause 3 (3) (xiii) of the policy

ORDER/174/2014 4.

wordings clearly state that the OP will not pay for:

”xii. Any Expense incurred on treatment arising from or traceable to pregnancy (including voluntary termination of pregnancy, childbirth, miscarriage, abortion or complications of any of these , including  caesarean section) and any fertility, infertility, sub fertility or assisted conception treatment or sterilization or procedure, birth control procedures and hormone replacement  therapy. However , this exclusion does not apply to ectopic pregnancy provided by diagnostic means and is certified to be life threatening by the medical practitioner.”

Upon receiving the complete treatment record including Discharge   Summary, the OP came to know that wife of the

ORDER/174/2014 5.

complainant had not suffered ‘ Typhoid and paratyphoid fevers’ but had suffered Hyper Emesis Gravidarum around 8 weeks of pregnancy as a direct outcome of the pregnancy. As such, the  Opposite Party had to refuse the claim and nullify the previous pre-authorization of Rs 25,000/-.

   We have heard arguments advanced at the bar and have perused the record.

The OP has nit disputed that the complainant is a holder of a mediclaim policy issued by it and his wife Sapna Sharma is a beneficiary under the said policy. The Op has also not denied that the wife of the complainant was admitted in St. Stephens Hospital on 23.9.2012 and was discharged on 1.10.2012.  The complainant has placed on record a copy of the treatment record and the discharge bill for  Rs. 32959/- paid by him out of his own pocket. The OP has repudiated the claim on the ground that the complainant’s wife was diagnosed as a case of Hyperemesis gravidarum and has claimed that it is a

ORDER/174/2014 6.

 direct outcome of pregnancy. It has referred to clause 3 (3) (xiii) of the policy purchased by the complainant  wherein it has been provided that expenses incurred on treatment arising from or traceable to pregnancy are not payable.   The learned counsel for the OP has , therefore, contended that the  claim lodged by the complainant was not payable under the terms and conditions of the policy purchased by the complainant.   We, however, are not in agreement with the Ld. Counsel for the OP .  The complainant has placed on record a copy of the certificate issued by Dr. Samir Gulati of St. Stephens Hospital with regard to the treatment of his  wife.  The certificate inter-alia reads as under:

Patient  Ms. Sapna Sharma 27/F, I.P. No. -1344355 was admitted in this hospital on 23.9.2012 for management of fever.  Patient was pregnant with 8 weeks Amenorrhea  as per records at the time of admission.  She was managed conservatively and discharged on 1.10.2012 with final diagnosis of Primi gravidarum with 8 weeks pregnancy with viral fever

ORDER/174/2014 7.

with hyperemesis gravidarum. 

 It is, therefore, clear that even though the patient was pregnant and was suffering from Nausea / Vomiting, she had also suffered from a viral fever for which she was admitted in the hospital.  The expenses incurred at the hospital were not entirely related to the pregnancy of the patient.    The OP should not , therefore, have resorted to clause 3 (3) (xiii) of the policy purchased by the complainant and repudiate the claim lodged in this case.   It is pertinent to point out that at the time of admission of the patient the OP had granted a cashless facility of Rs. 25,000/- which was unilaterally withdrawn without any rhyme or reason. We, therefore, hold that the OP was deficient in rendering services to the complainant. It ought not to have repudiated the claim which had been lodged on account of the admission of the wife of the complainant who was suffering from a viral fever during the course of her pregnancy. We, therefore, direct the OP as under:

ORDER/174/2014 8.    

1. Pay to the complainant a sum of Rs. 32959/-   (Thirty Two Thousands Nine Hundred Fifty Nine Only) along with interest @ 10% p.a. from the date of filing of this complaint i.e. 8.11.2012 till payment.

2. Pay to the complainant  a sum of Rs. 10,000/- as compensation for the mental agony and pain suffered by him.
3. Pay to the complainant  a sum of Rs. 5,000/- as cost of litigation.

The OP1 shall pay this amount within a period of 30 days from the date of this order failing which they shall be liable to pay interest on the entire awarded amount @ 10% per annum.  IF the OP1 fails to comply with this order, the complainant may approach this Forum for execution of the order under Section 25/27 of the Consumer Protection Act.

Copy of the order be made available to the parties as per rule. 

    File be consigned to record room.

    Announced in open sitting of the Forum on.....................

(NUPUR CHANDNA)    (DR.V.K.DABAS)    (RAKESH KAPOOR)

     MEMBER             MEMBER                PRESIDENT