============

Avneet G. Singh W/o Sh. Gurujeet Singh, R/o House No.2118, Sector 38-C, U.T. Chandigarh – 160 038.

                      ^-Complainant

^VERSUS

1.      ICICI Lombard General Insurance Company Limited, through its Managing Director, TGV Mansion, 6th Floor, Plot No.6-2-1012, Khairatabad, Hyderabad  - 500 004, Andhra Pradesh.

2.      The Managing Director, TGV Mansion, 6th Floor, Plot No.6-2-1012, Khairatabad, Hyderabad-500 004, Andhra Pradesh.

3.      ICICI Lombard General Insurance Company Limited, through its Branch Manager, SCO No. 24-25, Sector 8-C, 1st Floor, Madhya Marg, Chandigarh.

^{- Opposite Parties}

BEFORE:   SH. RAJAN DEWAN              PRESIDENT

MRS.MADHU MUTNEJA            MEMBER

SH. JASWINDER SINGH SIDHU    MEMBER

Argued By:    Sh. Arun Kumar, Counsel for Complainant.

           Sh. Sandeep Suri, Counsel for Opposite Parties No.1 & 3.

           Opposite Party No.2 ex-parte.

^{PER MADHU MUTNEJA, MEMBER}

1.                 ^{The Complainant was approached by the representatives of the Opposite Parties in September, 2010, for getting a cashless health insurance policy. A premium of Rs.8,089/- was paid and policy was issued effective 07.09.2010 to 06.09.2011 in the name of the Complainant and her husband. The Complainant, thereafter, suffered health problems in October, 2010. She got herself checked from Fortis City Centre, Sector 9-D, Chandigarh on 14.10.2010 and the doctors advised her some tests. After medical examination, it was found that the Complainant was suffering from Dengue. The Complainant was accordingly, admitted in Fortis Hospital for treatment of Dengue fever with Thrombocytopenia. She was admitted from 16.10.2010 to 24.10.2010. At this time, the Complainant was in her seventh week of pregnancy. Before getting discharge certificate from the hospital, the husband of the Complainant approached the Opposite Parties for payment of the bill. However, cashless facility was not provided and ultimately, the husband of the Complainant paid a sum of Rs.1.82 lacs to the hospital from his own sources (Receipts attached). Thereafter, the husband of the Complainant approached the Opposite Parties No.1 to 3 for getting the payment of the bill. However, the claim was repudiated by the Opposite Parties on the ground that the prolonged admission for Dengue was because of complicated maternal condition of the patient who was pregnant. The Complainant has stated that at the time of issuance of the policy, she was not pregnant and she only conceived after the issuance of policy. Hence, there was no concealment from her side. The Complainant has, thus, filed the present complaint with a prayer that the Opposite Parties be directed to release the amount of Rs.1.82 lacs along with interest, compensation and costs of litigation.}       

2.                 ^{Notice of the complaint was sent to Opposite Parties seeking their version of the case. However, despite service, nobody has appeared on behalf of Opposite Party No.2, therefore, it was proceeded against ex-parte on 24.05.2012.}

3.                 ^{Before filing reply, the Opposite Parties No.1 & 3 had been requesting the Complainant repeatedly for providing the complete medical record of the Fortis hospital, which the Complainant was not able to provide.}

4.                 ^{Opposite Parties No.1 & 3 in their joint reply have given the factual position of the Complainant that she was 14 weeks pregnant lady with fever 3 days, vomiting and rashes. She was investigated and diagnosed with Dengue fever with Thrombocytopenia. She was a Primigravida and treatment was given to her for maternity relating condition along with Dengue fever. Cashless facility was denied to the Complainant due to multi ailment hospitalization, in which maternity is permanent exclusion in the policy and bifurcation for both ailments could not be done.  Opposite Parties have further stated that despite repeated requests, the Complainant has not provided the complete medical record or bills for processing of her claim. It has been informed that there was some dispute between the Complainant and the Hospital as the treatment taken by the Complainant was related to the medical condition arising out of and related to advanced stage of pregnancy, which was not covered under the policy conditions. It is also stated that initially approval for cashless facility was given, but was later revoked, when it was found that the treatment was being taken for pregnancy related condition, which was not covered under the Policy. Refuting the allegations of the Complainant answering Opposite Parties have stated that repudiation is not on the ground that the Complainant was pregnant prior to issuance of policy, but on the ground that the treatment was taken for pregnancy, which was not covered under the Policy. Hence, the claim was not found to be payable.}    

5.                 ^{Parties were permitted to place their respective evidence on record, in support of their contentions.}

6.                 ^{We have heard the learned counsel for the parties and have perused the record.}

7.                 ^{The grievance of the Complainant is that the Opposite Parties have not settled here claim for Rs.1.82 lacs for the treatment taken by her at Fortis Hospital for Dengue fever, as also for complication in pregnancy. She has also stated that her pregnancy was after the Policy was issued.}

8.                 ^{The Opposite Parties No.1 & 3 have stated that as per terms & conditions of ‘Exclusions’ placed on record by the Complainant herself, any claim for pregnancy is not covered and even though initially the claim of the Complainant was initiated for payment. However, when it was found that the major cause of her problem/ ailment was pregnancy, the claim was refused. Even though the Opposite Parties No.1 & 3 have filed an application seeking directions to the Complainant to provide copy of the medical history as well as complete papers of her treatment, but she was unable to provide the same. However, the Complainant has herself given course of treatment in the hospital, in the complaint, which is reproduced hereinbelow:-} 

                                ^{“Course in the hospital:-}

^{Patient admitted with above complaints. Her TLC was 2.2 thou/ul with 69% neutrophils, platelet count 20 thou/ul, OT/PT-142/82. USG whole abdomen revealed GB wall edema, mid splenomegaly, minimal ascites, single live intrauterine pregnancy, uterine fibroid. She was started on i/v fluids and other supportive treatment. She was given platelet apheresis. She had an episode of spotting P/V. Gynaecology consultation was taken under Seema Wadhwa. Obstetric US revealed funneling of internal Os with dilated cervical canal with low position of detus, obligohydrominos, small amount of Subchorionic Haemorrhage of anterior aspect, uterine Fibroid. She was managed conservatively with Duvadilan infusion, Tab Susten, Risk of expelling the fetus and need for D C. If required was explained to the patient and her relatives. There was no further episode of bleeding P/V. She had persistent vomitings. She developed hypokalemai and hypomagnesemia. She was started on TPN supplemented with inj KCI, Inj Magnesium sulphate. Her urine analysis showed large number of WBC, few bacteria. She was started on Inj Oframax Forte. Her hepatitis viral makers (HBsAg, anti HCV, HEV, HAV) were negative. She was transfused 6 units of platelet apheresis and 7 units of PRP during her entire hospital stay. Repeat USG (23/10/10) revealed single live intrauterine fetus with average gestational age of 14 weeks 1 day, funneling of internal os with dilated cervical canal with Low position of fetus with fetal head in the cervical canal with hyperextension of head? Cervical incompetence, severe Oligohydramnios, uterine fibroid. She was continued on conservative treatment. Her platelet count improved to 113000/mcl at discharge. She is being discharged in stable condition on following advice.”}    

                From above, it is evident that her complete medical ailment related to her pregnancy and as pregnancy is among the exclusions, the claim was denied to her.

9.                 ^{We do not find anything wrong in the denial of claim by the Opposite Parties. If there is any treatment which comes under the exclusion clause, the Opposite Parties are not liable to make payment. The Opposite Parties are not bound to pay in each and every situation.}

10.                ^{As a sequel to the above discussion, we are of the concerted view that the present complaint deserves dismissal. Hence, the present complaint of the Complainant is dismissed. No costs.}

11.                ^{Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.}

^Announced 

31st October, 2013                               

^Sd/-

^{(RAJAN DEWAN)}

                                             ^PRESIDENT

^Sd/-

 ^{(MADHU MUTNEJA)}

^MEMBER

^Sd/-

 ^{(JASWINDER SINGH SIDHU)}

^{“Dutt”                                                                                             MEMBER}