Order No.  21  dt.  21/06/2017

       The case of the complainant in brief is that the complainant is the holder of a mediclaim policy of o.p. and the sum assured of the said policy was Rs.3 lakhs. The policy was renewed from time to time. On 1.11.12 the complainant was admitted to Woodland Hospital for maternity and she was under the treatment of Dr. P.S. Sinha, on 2.12.12 LSCS was done by Dr. Sinha and a female baby was delivered. During hospitalization the complainant had convulsion attack and after examining Dr. Sinha referred her to neurology department and C.T. Scan and MRI were done. The complainant had to spend an amount of Rs.31,317/-. From the report of C.T. Scan it was revealed that the complainant had the brain tumor on the left side and accordingly she was examined in Apollo Clinic under Dr. Amitabha Chanda and he suggested for operation. The complainant informed the said fact to o.p. insurance company and the operation was done at Woodland Hospital. After the recovery of the complainant the husband of the complainant submitted the bill to o.p. insurance claiming for reimbursement of the medical bill of Rs.53,407/- plus Rs.21,317/- totaling an amount of Rs.85,224/-, but o.p. repudiated the claim of the complainant. On the basis of the said fact the complainant filed this case praying for direction upon the o.p. to release the medical bill of Rs.85,224/- along with compensation of Rs.1 lakh and litigation cost of Rs.10,000/-.

            The o.p. contested this case by filing w/v and denied all the material allegations of the complaint. It was stated that the complainant was admitted to Woodland Hospital for maternity and underwent lower segment caesarean section by virtue of which she gave birth a female child. The complainant after filing of the claim o.p. asked for some documents to consider evaluation of reimbursement of medical claim sought for by the complainant: (1) claim settlement letter from other insurance company for settled amount and (2) insured amount assured by other insurance company. As per clause 5 if the insured person is covered by any other policy which covers any claim in whole or in part made under this policy then we shall not be liable to pay or contribute more than our ratable proportion of the claim. The claim lodged by the insured has been duly considered by the insurance company in the light of the terms and conditions of the insurance policy and thereafter the same has been repudiated stating the reasons for such repudiation. There was no deficiency in service on the part of o.p. and therefore the question of payment of compensation does not arise. In view of the said fact o.p. prayed for dismissal of the case.

            On the basis of the pleadings of parties the following points are to be decided:

1. Whether the complainant had the policy at the relevant point of time?
2. Whether the complainant was entitled to get the reimbursement of the medical bills?
3. Whether there was any deficiency in service on the part of o.p.?
4. Whether the complainant will be entitled to get the relief as prayed for?

Decision with reasons:

            All the points are taken up together for the sake of brevity and avoidance of repetition of facts.

            Ld. lawyer for the complainant argued that the complainant being the policy holder and during the subsistence of the said policy she was admitted to the hospital for delivery of a baby. After birth of the child the complainant had severe pain and she had also convulsion. She was treated by a neuro surgeon of the said hospital and after examination he advised for undergoing operation of the complainant. Accordingly operation was made and after recovery the complainant claimed the amount from o.p. but o.p. repudiated the claim without having any cogent ground whatsoever.

            Ld. lawyer for the complainant emphasized that o.p. repudiated the claim of the complainant in terms of clause 5 of the policy by mentioning that the maternity claim is not covered under the members benefit and are not payable within 1^st two years of the policy term. It was further emphasized that the plea taken by o.p. is contradictory to each other has been made with sole intention to make frivolous ground for legitimate claim of the complainant. On the basis of the said fact ld. lawyer for the complainant prayed for releasing the fund of Rs.85,224/- along with other reliefs.

            Ld. lawyer for the o.p. argued that the claim of the complainant falls within the exclusion clause contained in the policy wordings and the complainant was aware of this exclusion clause. The policy of the complainant was an individual policy and it does not include family. All the terms and conditions are laid down in the policy wordings itself and the complainant had entered into such insurance contract having full knowledge of the terms and conditions at the time of obtaining the policy. The complainant failed to abide by the terms and conditions and cannot seek any relief against the o.p. The claim of the complainant was rightly rejected by o.p. and there was no deficiency in service on the part of o.p. In support of the said contention ld. lawyer cited several rulings as reported in Air 1999 SC 3252, 2009(4) MLG 811 (SC). On the basis of the facts and circumstances as stated above o.p. prayed for dismissal of the case.

            Considering the submissions of the respective parties it is an admitted fact that the complainant was the policy holder of o.p. and the policy was valid at the relevant point of time. The complainant herself in the petition of complaint stated that she was admitted Woodland Hospital and she was under the treatment of Dr. P.S. Sinha and she gave birth a female baby. During her hospitalization suddenly she had the convulsion attack and she was treated by neurologist who advised some tests and after consulting the test report the doctor advised her for undergoing an operation. As per advice of the doctor the complainant underwent an operation at Woodland Hospital and subsequently after release she claimed the amount spent by her for the treatment amounting to Rs.85,224/-. The o.p. denied the claim of the complainant by relying on the clause 5 of the insurance policy on the ground that the maternity claim is not covered under the benefit and are not payable within 1^st two years of the policy term. It appears from the record that the complainant had to take admission in the hospital initially for delivering birth of a baby, but during convalescing period she was attacked with convulsion for which she had to be treated under neuro surgeon and as per the advice of the doctor she had to undergo several tests viz. C.T. Scan, MRI, etc. which compelled the doctor for advice for undergoing an operation. As per the advice of the doctor the complainant had to undergo an operation. After recovery the husband of the complainant submitted the bills to o.p. but o.p. without going into the actual fact denied the claim of the complainant on the basis of the fact that the complainant claimed the amount for the expenses incurred for the delivery of the child, but the fact is otherwise. The o.p. illegally denied the claim of the complainant for which we hold that that the complainant will be entitled to get the reimbursement of the complainant’s bills as claimed by her. Thus all the points are disposed of accordingly.

            Hence, ordered,

            That the CC No.773/2013 is allowed on contest with cost against the o.p. The o.p. is directed to pay to the complainant a sum of Rs.85,224/- (Rupees eighty five thousand two hundred twenty four) only along with compensation of Rs.10,000/- (Rupees ten thousand) only for harassment and mental agony and litigation cost of Rs.2000/- (Rupees two thousand) only within 30 days from the date of communication of this order, i.d. an interest @ 10% p.a. shall accrue over the entire sum due to the credit of the complainant till full realization.       

            Supply certified copy of this order to the parties free of cost.