PER SHRI. S.S. PATIL - HON’BLE MEMBER :
1)This is the complaint regarding the deficiency in service on the part of Opposite Parties as they repudiated the mediclaim of the Complainant on frivolous and wrong ground.
2) The facts of this case as stated by the Complainant are that the Complainant has obtained a Hospitalization and Domiciliary Hospitalization Benefit Policy from the Opposite Party for his family including his wife Smt. Manju J. Prajapati. The policy was valid from 23/12/05 to 22/12/06. During the validity of the above said mediclaim policy the wife of the Complainant Smt. Manju Prajapati suffered from “incisional Hernia” and was advised for treatment of the same. For the treatment of this disease she was hospitalized in Ravi Surgical Nursing Home, at Bhayandar (W) from 28/11/06 to 30/11/06. During the hospitalization the Complainant incurred expenses of Rs.15,597/-. The Complainant submitted preauthorization form to the Authorized agent, Health Service Pvt. Ltd. But on 15/11/06 the authorized agent rejected the claim of the Complainant on the following ground on 15/11/06.
3) “The patient is admitted for incisional hernia which is complication of Tubectomy done one and half year ago. Hence, case denied as per clause 4.12 which states that treatment arising from or traceable to pregnancy, child birth including caesarean section not payable.”
4) Again on 19/02/07, the authorized agent communicated the Complainant that the reason for repudiation as under –
“Clause 4.8 :- Treatment arising from convalescence, general debility, cure, congenital external diseases or defects or anomalies, sterility, veneral diseases, intentional self injury & use of intoxicating drugs /alcohol not payable. It was further communicated to the Complainant by the authorized agent of the Opposite Parties that “as per available information, patient was admitted for incisional hernia which is complication of tubectomy done one and half year back. Hence case denied as clause 4.8.
5) The Complainant has further stated that the Opposite Parties have given reasons which were wrong and not based on scientific evidence. Therefore, the repudiation was unjustified and not proper.
Therefore, it is prayed by the Complainant that the rejection of his claim of Rs.15,597/-, be quashed and his claim be settled as per insurance policy. It is further contended by the Complainant that due to rejection of the claim he sustained mental agony hence, Opposite Party need to compensate damages of Rs.2,00,000/-. It is also stated that a cost of Rs.10,000/- be given to the Complainant towards the expenses of this complaint.
6) The Complainant has attached the xerox copies of the following documents in support of his complaint -
Notice dtd.28/02/08, Policy document, Birth Certificate of Rudha Medical Home, Birth Certificate of Mira Bhayandar Mahapalika, Receipt of Dr. Chitlangia, Report of Dr. Chitlangia, Preauthorization form, application dtd.17/11/06, Medical Papers, I Card from Heritage Health Services, Bill No.68/1106, Bill dtd.30/11/06, Discharge Certificate, Medical Papers in respect of hospitalization, Letter dtd.28/02/08.
7) The complaint was admitted and notices were served on the Opposite Parties. The Opposite Parties have filed their written statement wherein the Opposite Parties have stated that they have rightly rejected the insurance claim of the Complainant twice. The present complaint has been filed after a lapse of more than 100 days. The delay has not been explained satisfactorily and hence, the complaint be dismissed on this ground only.
8) The Opposite Party has admitted that the insured patient was diagnosed as incisional hernia (post T.L.) Incisional Hernias are caused due to stretching of scar tissue that occur after surgery and are always related to some surgery in past. There was a history of Laparoscopic Tubal Ligation 2 years back. Hernia is at the site of Ligation.
9) The Opposite Party has further stated that the claim was rightly rejected on 15/11/06 under clause 4.12. It is also explained further that incisional Hernia is a complication of surgery on abdomen and develops as a hernia in scar of previous operation. There is no explanation as to how incisional Hernia has developed in the patient if it is not in the scar of Tubal Ligation. In the discharge card it is mentioned that the incisional Hernia has developed post TL. Hernia has developed at the site of TL. Hence, claim has been rejected as a complication of sterilization operation which was done at the time of delivery of the Complainant’s wife.
10) Finally the Opposite Party has averred that as, the claim was rightly rejected as per the terms and conditions, there is no deficiency in service on its part and hence, the compliant be dismissed.
The Opposite Party has produced the terms & conditions of the insurance policy alongwith an handwriting remark of Dr. Manju Gupta, Medical Officer on the letter of Heritage Health Services Pvt. Ltd., dtd.19/02/07. It seems that this remark was put on 25/09/07. The remark is as under –
“Repudiation – As per detail given c Discharge Cert., due to sterility, infertility, subfartility or assisted conception pl.
11) Thereafter the Complainant has filed rejoinder, affidavit of evidence and written argument wherein he reiterated the facts and points mentioned in the complaint. The Opposite Parties also field affidavit of evidence and written argument wherein the Opposite Parties have reiterated the facts and points mentioned in their written statement. Both the parties have given in writing that their written arguments be treated as their oral arguments. We perused all the documents filed by both the parties and our findings are as follows -
12) It is admitted fact that the Complainant has obtained a mediclaim policy covering the hospitalization of his wife from 23/12/06 to 22/12/07. During the validity of this mediclaim policy the wife of the Complainant was diagnosed as suffering from incisional Hernia on her stomach. Therefore, she was hospitalized in Ravi Surgical Nursing Home at Bhayandar under a registered medical practitioner from 28/11/069 to 30/11/06. The Complainant has incurred an expenses of Rs.15,597/- for the said hospitalization. The Complainant preferred the claim of Rs.15,597/- but the agent of the Opposite Parties rejected the claim as per clause 4.12 and clause 4.8 of the policy.
13) Exclusion Clause 4.12 states as follows –
“Treatment arising from or traceable to pregnancy, child birth including caesarean section, miscarriage, abortion or complications thereof including changes in chronic conditions arising out of pregnancy not payable.”
The plain reading of this clause confirms that the ailment i.e. Incisional Hernia is not pregnancy. It is not a treatment for child birth. There is no caesarean section. There is no miscarriage, abortion, complications of these above ailments. There are no any changes in chronic conditions arising out of pregnancy. Therefore, the treatment of incisional Hernia for which the patient was hospitalized, does not fall under the exclusion clause 4.12. Probably the authorized agent of Opposite Party must have realized this point and then after some period i.e. on 19/02/07 they took a different view and vide their letter dtd.19/02/07 communicated to the Complainant that his claim was rejected under clause 4.8. Exclusion Clause 4.8 is as under –
“Convalescence, general debility, rest cure, congenital external disease or defects or anomalies, sterility, veneral disease, intentional self injury and use of intoxicating drug/alcohol are not payable.” It is the contention of the Opposite Party that incisional Hernia is complication of Tubectomy. Therefore, the claim is rejected. This is certainly not justifiable conclusion. The treatment for which the insured was admitted is not for congenital external disease, defect or anomaly, sterility, drug/alcohol. It is incisional Hernia. Though tubectomy is an operation for sterility, the patient (insured) was not hospitalized for tubectomy. Incisional Hernia is altogether different from Tubectomy. Therefore, in our candid view, the Opposite Parties have rejected the claim of the Complainant on wrong ground. There is a deficiency in service on the part of Opposite Parties and therefore, the Complainant must have suffered mental agony because of the rejection of his claim. The Complainant deserves the reimbursement of medical expenses and some compensation for the mental agony, and cost of this complaint. The compensation of Rs.2 Lacs sought by the Complainant is exorbitant. Taking into consideration the fact of the case and circumstances, in our candid view, the following order will be just and proper –
O R D E R
a. Complaint No.171/2009 is partly allowed.
b. Opposite Party No.1 & 2 are directed to reimburse to the Complainant jointly and/or severally the sum of
Rs.15,597/-with interest @ 9% p.a.from 30/12/09 till its realization.
c. Opposite Party No.1 & 2 are also directed to pay to the Complainant jointly and/or severally a compensation of
Rs.5,000/- (Rs. Five Thousand Only) for mental agony.
e. Opposite Party No.1 & 2 are also directed to pay to the Complainant jointly and/or severally an amount of
Rs.3,000/- (Rs. Three Thousand Only)towards the cost of this complaint.
f. Opposite Parties are directed to comply with the above order jointly and/or severally within 30 days from the
receipt of this order.
g.Certified copies of this order be furnished to the parties free of cost.
