BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.86 of 2016

Date of Instt. 18.02.2016

Date of Decision : 18.08.2016

1.Sugreev Sharma son of P.N.Sharma;

2.Urmila Sharma wife of Sugreev Sharma;

Both R/o H.No.10, New Raj Nagar, New Shiv Mandir, Basti Bawa Khel, Jalandhar.

..........Complainants

Versus

1.MD India Healthcare Services Pvt Ltd., Maxpro INFO Park, D-38, Mohali Industrial Area, Phase-I, Mohali, Punjab-160056 through its MD/Directors/Principal Officer.

2.United India Insurance Company Limited, D-II, Syal House, Lajpat Nagar, Jalandhar through its Branch Manager.

.........Opposite parties

Complaint Under The Consumer Protection Act.

Before: S. Bhupinder Singh (President)

Sh.Parminder Sharma (Member)

Present: Sh.Atul Malhotra Adv., counsel for the complainants.

Sh.RS Arora Adv., counsel for OPs.

Order

Bhupinder Singh (President)

1. The complainants have filed the present complaint under 'The Consumer Protection Act' against the opposite parties (hereinafter called as OPs) on the averments that complainants both husband and wife being members of The Shri Krishna Co-op, N/A Thrift & Credit Society Ltd., Ajit Nagar, near Kapurthala Chowk, Jalandhar obtained group insurance mediclaim policy valid for the period from 2014-15 from OPs and they issued membership card to complainant No.2. Complainant No.2 Urmila Sharma suffered severe pain in abdomen on 3.7.2014 and contacted Shakuntla Devi Vig Hospital, Kapurthala Road, Jalandhar and she was admitted in that hospital on 4.7.2014 where she was medically treated and discharged on 9.7.2014 and complainant No.2 spent Rs.24,694/- on her treatment, medicines etc. Claim was lodged with the OP but the OP did not settle the claim of the complainant and complainant had to file complaint in this Forum i.e. complaint No.217 of 2015 which was decided on 4.11.2015 and OP was directed to decide the claim of the complainant within stipulated period of two months. Complainant submitted all the relevant documents with OPs and ultimately OP has repudiated the claim of the complainant vide letter dated 4.12.2015. On such averments, the complainants have prayed for compensation and litigation expenses.

2. Upon notice, OPs appeared through counsel and filed written statement pleaded that complainant became ill and was admitted in Shakuntla Devi Vig Hospital, Kapurthala Road, Jalandhar on 4.7.2014 where she was medically treated and discharged on 9.7.2014. Papers produced by the complainant regarding her treatment in the aforesaid hospital reveal that complainant No.2 was diagnosed of ruptured Ectopic pregnancy which is a case of pregnancy outside uterus whose layer was ruptured and surgery was done, called exploratory laparotomy-to-abort or in other words called Medical Termination of Pregnancy(MTP). As per terms and conditions of the policy, any amount spent on medical treatment of pregnancy is not payable by the insurance company under the policy in question. OPs submitted that OPs rightly repudiated the claim of the complainant vide letter dated 4.12.2015.

3. In support of her complaint, learned counsel for the complainants has tendered into evidence affidavit Ex.CA alongwith copies of documents Ex.C1 to Ex.C19 and closed her evidence.

4. On the other hand, learned counsel for the OPs has tendered affidavit Ex.OA alongwith copy of document Ex.O1 and closed evidence.

5. We have heard the Ld. counsel for the parties, minutely gone through the record and have appreciated the evidence produced on record by both the parties with the valuable assistance of Ld. counsels for the parties.

6. From the record i.e. pleadings of the parties and the evidence produced on record by both the parties, it is clear that the complainants both husband and wife being members of The Shri Krishna Co-op, N/A Thrift & Credit Society Ltd., Ajit Nagar, near Kapurthala Chowk, Jalandhar obtained group insurance mediclaim policy valid for the period from 2014-15 from OPs and they issued membership card Ex.C1 to complainant No.2. Complainant No.2 Urmila Sharma suffered severe pain in abdomen on 3.7.2014 and contacted Shakuntla Devi Vig Hospital, Kapurthala Road, Jalandhar and she was admitted in that hospital on 4.7.2014 where she was medically treated and discharged on 9.7.2014 and complainant No.2 spent Rs.24,694/- on her treatment, medicines etc. Claim was lodged with the OP but the OP did not settle the claim of the complainant and complainant had to file complaint in this Forum i.e. complaint No.217 of 2015 which was decided on 4.11.2015 and OP was directed to decide the claim of the complainant within stipulated period of two months. Complainant submitted all the relevant documents with OPs and ultimately OP has repudiated the claim of the complainant vide letter dated 4.12.2015. Learned counsel for the complainant submitted that all this amounts to deficiency of service on the part of the OPs qua the complainant.

7. Whereas the case of the OPs is that complainant became ill and was admitted in Shakuntla Devi Vig Hospital, Kapurthala Road, Jalandhar on 4.7.2014 where she was medically treated and discharged on 9.7.2014. Papers produced by the complainant regarding her treatment in the aforesaid hospital reveal that complainant No.2 was diagnosed of ruptured Ectopic pregnancy which is a case of pregnancy outside uterus whose layer was ruptured and surgery was done, called exploratory laparotomy-to-abort or in other words called Medical Termination of Pregnancy(MTP). As per clause 1.6 of the policy terms and conditions Ex.O1, any amount spent on medical treatment of pregnancy, is not payable by the insurance company under the policy in question. Learned counsel for the OPs submitted that OPs rightly repudiated the claim of the complainant vide letter Ex.C19 dated 4.12.2015. Moreover, the complainant had not challenged this letter of repudiation of the claim of the complainant in the complaint. Learned counsel for the OPs submitted that there is no deficiency of service on the part of the OPs qua the complainant.

8. From the entire above discussion, we have come to the conclusion that the complainants got group mediclaim insurance policy being members of cooperative society namely The Shri Krishna Co-op. N/A Thrift & Credit Society Ltd., Ajit Nagar, near Kapurthala Chowk, Jalandhar, for the period 2014-15 and OP have issued membership card to complainant No.2 which is Ex.C1, of Bhai Ghanhya Sehat Sewa Scheme. Complainant No.2 Urmila Sharma became ill and was admitted in Shakuntla Devi Vig Hospital, Kapurthala Road, Jalandhar on 4.7.2014 and was discharged on 9.7.2014 and as per discharge card of the aforesaid hospital pertaining to complainant No.2 Urmila Sharma ex.C7, she was diagnosed as ruptured Ectopic pregnancy which is a case of pregnancy outside uterus whose layer was ruptured and surgery was done, called exploratory laparotomy-to-abort or in other words called Medical Termination of Pregnancy(MTP). The complainant spent a sum of Rs.24,964/- on the treatment of complainant No.2 as per bills and test Ex.C3 to Ex.C6, Ex.C9 to Ex.C13. Complainant lodged claim with the OP and the OP repudiated the claim of the complainant vide letter dated 4.12.2015 Ex.C19 on the ground that claim of the complainant is related to diagnoses of ruptured Ectopic pregnancy i.e. pregnancy outside uterus, a layer of which was ruptured and surgery was done, called exploratory laparotomy which means abortion or in other words called Medical Termination of Pregnancy(MTP) and as per clause 1.6 of the terms and conditions of the policy Ex.O1, treatment for abortion of pregnancy of any kind is not covered under the Bhai Ghanhya Sehat Sewa Scheme. The complainant did not challenge this letter in the complaint. Learned counsel for the complainants simply stated that it was not a case of pregnancy but accumulation of some mass outside the uterus for which surgery of complainant No.2 was done at Shakuntla Devi Vig Hospital, Kapurthala Road, Jalandhar and the OP has wrongly repudiated the claim of the complainants.

9. This plea of the complainants is not tenable because the documents produced on record by the complainant No.2 herself i.e. discharge card Ex.C7 fully proves that it was a case of diagnosis of ruptured Ectopic pregnancy which is a case of pregnancy outside uterus, a layer of which was ruptured. So, it is a case of Medical Termination of Pregnancy. The treatment cost is not covered under the aforesaid Bhai Ghanhya Sehat Sewa Scheme insurance as per clause 1.6 of the terms and conditions of the policy Ex.O1.

10. Resultantly, we hold that there is no merit in the complaint and the same is hereby dismissed with no order as to cost. Copies of the order be sent to the parties free of cost, under rules. File be consigned to the record room.

Dated Parminder Sharma Bhupinder Singh

18.08.2016 Member President