Date of Filing:10/02/2011

        Date of Order:20/04/2011

BEFORE THE I ADDITIONAL DISTRICT CONSUMER DISPUTES REDRESSAL FORUM SESHADRIPURAM BANGALORE -  20

Dated:  20^th DAY OF APRIL 2011

PRESENT

SRI.H.V.RAMACHANDRA RAO,B.SC.,B.L., PRESIDENT

SRI.KESHAV RAO PATIL, B.COM., M.A., LL.B., PGDPR, MEMBER

SMT.NIVEDITHA .J, B.SC.,LLB., MEMBER

COMPLAINT NO.281 OF 2011

Mr. Jayanthilal Jain

S/o. Khimraj, No.2-3-4, 1^st Floor,

Bheru Complex, A.S. Achar Street,

Mamul Pet, Bangalore.                                                   ….  Complainant.

V/s

(1)  M/s. ICICI Prudential Life Insurance

Co. Limited, Trade Point, 1^st Floor,

Kamala Mills Compound, Sabapazi Road,

Mumbai, Rep. by its Manager.

(2) M/s. ICICI Prudential Life Insurance

Co. Limited, Legal Department,

4^th Floor, Santhos House, ICICI Venture

Building Appasaheb Marath Marge,

Prabhadevi, Mumbai-460 025,

Rep. by its Manager.

(3) M/s. ICICI Prudential Life Insurance

Co. Limited, 2^nd Floor, Jewels D Paragon

Building, M.G. Road, Bangalore,

Rep. by its Manager.                                                     …. Opposite Parties

BY SRI. H.V.RAMACHANDRA RAO, PRESIDENT

-: ORDER:-

The brief antecedents that lead to the filing of the complainant U/s 12 of the Consumer Protection Act seeking direction to the Opposite Parties to pay Rs.2,00,000/- are necessary:-

          As per the assurance of the opposite parties the complainant became a policy holder of the policy ICICI Prudential Health Saver policy bearing No.11256998 on 12.02.2009.  The insured persons under the policy are the complainant and his wife Neethu Jain and his child Bhoomi.  It commenced on 12.02.2009 and the cessation date is 12.05.2053.  The annual limit of the policy is Rs.3,00,000/-.  The complainant has paid Rs.15,000/- the annual premium.  The wife of the complainant Neethu Jain suffered severe headache, omitting, hypertension and giddiness, hence she was taken to St. John Medical College Hospital on 24.01.2010 at 1.00 AM after reference made by the St. Marthas Hospital, Bangalore.  Immediately thereafter she was admitted as an in-patient.  After completing clinical and radiological examination she was diagnosed as suffering from Cortical Venous Thrombosis i.e., blood clot in brain and she was treated as in-patient from 24.01.2010 to 05.02.2010.  On 25.01.2010 itself the complainant brought to the notice of the hospital authorities about the insurance policy and requested them to get pre-authorization and the hospital authorities collected the policy details and they complied the formalities to get the cashless treatment.  The opposite party has sent FAX massage to the St. John Medical College Hospital on 28.01.2010 stating that the said ailments of the wife of the complainant is related to pregnancy on the ground that the complainant’s wife gave birth to female child on 05.01.2010 and for the said reason any expenses incurred towards treatment taken for pregnancy and its complication is not payable as per the policy terms and conditions.  Hence cashless is denied by the opposite party.  The above said illness was started after 20 days after delivery.  It is in no way connected with the pregnancy or its complications.  The contention of the opposite parties is only on assumption without any basis.  Because of this reason the complainant has suffered mental agony.  The complainant has to pay from his pocket to the hospital authorities the sum of Rs.50,409/-.  The complainant has incurred another sum of Rs.10,000/- to get the medicine and the follow-up treatments.  The complainant contacted the opposite party over phone and also issued a notice on 10.04.2010.  On 06.05.2010 the opposite party replied stating that the policy Number varies.  Hence the complainant issued a further reply on 14.05.2010 enclosing the copy of the policy.  Even after that the opposite parties failed to settle the claim of the complainant.  The complainant had filed complaint No.2297/2010 before the Fourth Additional District Consumer Forum, Bangalore.  Which rejected the complaint on the ground that the complainant has not approached the authority and directed the complainant to approach the opposite party by filing claim application.  Accordingly the complainant has submitted the claim application with medical documents.  After that the opposite parties have rejected the claim of the complainant on 14.12.2010 without giving any reason.  Hence the complaint.

2.      In brief the version of the opposite parties are:-

          The allegations made in Para-3, 4, 6 are matters of record.  Regarding Para-5 the opposite parties has no comments to make.  The policy taken by the complainant does not cover any ailments or complication arising out of pregnancy and it does not cover under Clause-6(2) of the Insurance Regulatory and Development Authority (Protection of Policyholder’s Interests) Regulations, 2002.  On 25.01.2010 the opposite party has received a pre-authorization request from the hospital with respect to the wife of the complainant with the history of delivery 20 days back.  A panel of Doctors examined the papers and found that the symptoms and diagnosis was clearly a post cesarean complication/consequence and therefore rejected the pre-authorization request from the hospital under Clause-8.19 as per the terms of the policy vide letter dated: 28.01.2010.  The case summary and the discharge record clearly indicates Post Partum CVT and Loss Lower Segment Cesarean Section (LSCS) wound gaping dehiscence.  On 16.06.2010 and 14.12.2010 the opposite parties replied to the complainant of its stand that the expenses incurred by the complainant is not coverable under the policy as per Clause 8.19.  The legal notices were properly replied.  Regarding Para-9 nothing to comment.  All the allegations to the contrary are denied.

3.      To substantiate their respective cases the parties have filed their respective affidavits.  Both parties have filed their written arguments.

4.       The points that arise for our consideration are:-

:- POINTS:-

1. Whether Cortical Venous Thrombosis suffered by the complainant’s wife is attributable to pregnancy and delivery of a child by the complainant’s wife?

2. What Order?

5.      Our findings are:-

Point (A)    :        In the Negative

Point (B)    :        As per the final Order

                             for the following:- 

-:REASONS:-

Point A & B:-

6.       Reading the pleadings in conjunction with the evidence both oral and documentary on record it is an admitted fact that the complainant has taken Health Care Policy from the opposite parties on 12.02.2009 by paying the annual premium of Rs.15,000/- it covers himself, his wife and his daughter.  It was valid during the period in question and the policy commenced on 12.02.2010 and the cessation is on 12.05.2053 and the annual limit under the policy is Rs.3,00,000/-.  It is also an undisputed fact that the complainant’s wife was pregnant and she delivered a female child on 05.01.2010, it was a caesarian operation.  Subsequently she was taken to St. Martha’s Hospital for severe headache, omitting, hypertension and giddiness and from there she was taken to the St. John’s Medical College Hospital on 24.01.2010.  Wherein after examination she was diagnosed as “Cortical Venous Thrombosis” (blood clot in brain) and she was treated there for that as an in-patient between 24.01.2010 to 05.02.2010.  Regarding this the complainant has spent Rs.55,452/-  to the St. John’s Medical College Hospital.  The complainant sought this as cashless facility which was denied by the opposite party.  The complainant raised the dispute in CC No.2297/2010 before the Fourth Additional District Consumer Forum, Bangalore, wherein on 20.10.2010 the said Forum has passed an order directing the complainant to make the claim before the opposite party and if it is rejected it has permitted the complainant to raise the dispute again.  Accordingly the complainant made the claim before the opposite party and the opposite party has rejected the claim, repudiated the claim solely on the ground of Clause-8.19 of the policy.  Clause-8.19 of the policy reads thus:-

8. Exclusions for Hospitalization Insurance Benefit:-

            19. Any treatment arising from or traceable to pregnancy, childbirth, miscarriage, caesarean clause, abortion or complications of any of these including changes in chronic condition as a result of pregnancy, tests and treatment relating to infertility and in vitro fertilization.  However, the exclusion do not apply to Ectopic Pregnancy proved by Ultrasonography/diagnostic means and is certified to be life threatening by the medical practitioner.

          That is to say that any claim regarding treatment arising from or traceable to pregnancy, childbirth, miscarriage, caesarean, abortion are excluded.

7.       In this case the wife of the complainant had delivered a female child on 05.01.2010.  The caesarean operation means an operation on the stomach, it has no nexus to the brain.  Here 20 days later the wife of the complainant developed Cortical Venous Thrombosis i.e., blood clot in the brain.  This has nothing to do with the caesarean operation done, or to the pregnancy or the birth of a child.  How this is related has not been explained?  No expert Doctor of the opposite parties have filed any affidavit to show that this disease diagnosed by the St. John’s Medical College Hospital is attributable to the pregnancy or its operation.  The onus of proving that Cortical Venous Thrombosis is a complication arose out of the caesarean operation, highly vested on the opposite parties, but that has not been proved.  No Doctor has given any opinion in this regard to show that this diagnosed made in the St. John’s Medical College Hospital is the complication arose out of the caesarean operation done on the wife of the complainant.  This remain made of an kannada proverm:-

‘CArUÉ ºÉÆqÉzÀgÉ zÀªÀqÉ ºÀ®Äè ªÀÄÄjzÀAvÉ’

 8.      Hence it means only to repudiate the claim the opposite parties have repudiated and nothing else, taking the pregnancy and delivery of a child as a grounds to repudiate the claim.  This is nothing but an unfair trade practice and deficiency in service.  Thus the opposite parties are bound to pay the amount to the complainant the amount spent by the complainant in the hospital.

9.       The opposite parties have contended that their medical team is of the opinion that under Clause-8.19 this repudiation has to be made.  The opposite parties have not taken the records to any expert to show that Cortical Venous Thrombosis disease is a complication arose out of the caesarian operation.  In this case without that opinion how can the opposite party say that it is justified in repudiating the claim?  It is 20 days after the caesarian operation and the birth of a child the wife of the complainant developed Cortical Venous Thrombosis and she was treated as an inpatient and for which the insurance company is liable to pay as the complainant had insured with the opposite party.

10.     The insurance is made so that at the time of emergency health problem it can help the insured.  The insurance companies are making insurance for a social service and also they can earn some amount.  Here the opposite parties have forgotten their service but they are only interested in making money.  In large number of cases the premium paid were not claimed with respect to insurance, and it is an earning to the opposite parties.  But in a negligible case they have to pay some amount to policy holder, one such case is the complainant’s case.  In this case the opposite parties have behaved like shylocks, which is nothing but an unfair trade practice.

11.     In this case the complainant had paid Rs.55,452/- to the hospital authorities from 24.01.2010 to 22.03.2010.  Hence if we order the opposite parties to pay Rs.55,452/- along with interest at the rate of 12% per annum from 24.02.2010 we think that will meet the ends of justice.  Hence we hold the above points accordingly and proceed to pass the following:-

-: ORDER:-

1. The Complaint is Allowed-in-part.
2. The opposite parties are directed to pay to the complainant a sum of Rs.55,452/- with interest @ 12% pa from 24.02.2010 until payment within 30 days from the date of this order.
3. The opposite parties are also directed to pay Rs.2,000/- as costs of this litigation to the complainant.
4. If for any reason, the opposite party failed to pay the amount as ordered at Nos.2 & 3 above within 30 days, then the opposite party shall pay the said amount along with compensation of Rs.15,000/- to the complainant. 
5. The opposite party is directed to send the amount to the complainant through DD by registered post acknowledgment due and submit the compliance report to this Forum with necessary documents within 45 days from the date of this order.

6. Return the extra sets filed by the parties to the concerned as under Regulation 20(3) of the Consumer’s Protection Regulation 2005.

7.       Send a copy of this order to both parties free of costs, immediately.

(Dictated to the Stenographer, transcribed and typed by him, corrected and then pronounced by us in the Open Forum on this the 20^th Day of April 2011)

MEMBER                                  MEMBER                        PRESIDENT