JUDGEMENT

          Complainant by filing this complaint has submitted that complainant insured himself under the Hospitalisation Benefit Policy bearing No. 154300/48/12/850003741 issued by the op No.2 through the op no.3, the TPA covering the complainant being the insured and his family members residing with him for the period from 15.09.2012 to midnight of 14.09.2013.  During subsistence of the said valid Mediclaim Policy the wife of the complainant Mrs. Mondrita Majumder delivered a female child in the hospital on 12.09.2012 by caesarean section and all expenses were borne by the employer/company of the complainant and after delivery of the child, the wife of the complainant had been staying with her parents at her paternal home.  On 24.09.2012 she accidentally fell down in the bathroom of her paternal house at midnight and after contacting the doctor she was admitted into the Columbia Asia Hospital situated at 1B-193, Sector-III, Salt Lake City, Kolkata-700091on 24.09.2012 at 3 AM as per the advice of the doctor Abhinibesh Chatterjee, a Consultant Gynaecologist, Advanced Laparoscopic Surgeon & Infertility Specialist, attached to the said Columbia Asia Hospital and was put in the ICU and on that date i.e. 24.09.2012 complainant was undergone the following tests- i.e. Biochemistry, Urine Examination, Urine –Microscopic Examination, Hematology –Platelet Count, Haematology- Complete Blood Count & Total and Differential Count, but findings were found to be normal.

          On 27.09.2012 CT Scan was done and no obvious detectable abnormality was found.  On 28.09.2012 Renal Doppler was done and findings were no obvious detectable abnormality was reported.  Echocardiography was done on the same date and the findings were normal LV chamber, no regional wall motion abnormality, normal systolic function and normal valvular structure.  The result of Biochemistry on Liver Function Test and Culture & Sensitivity and the M.R. Scan of brain was done on 28.09.2012 and the result was found normal and also the Serology test was done on 29.09.2012 and it was found that Rheumatoid Factor Assembly was negative.

          After due treatment administered, the Biochemistry on Liver Function was done on 30.09.2012 and the Bilirubin was found to be within the Reference Range and other tests were found all in order.  Thereafter we wife of the complainant was discharged on 01.10.2012 from the said hospital with discharge report – Seizure disorder and hypertensive surge, condition at discharge- Hemodynamically Stable, Afebrile, No further seizure.  But on 01.10.2012 at 10:45 AM, while she tried to leave the bed, she again had some problem in raising her head from the pillow, and again she had been readmitted into the hospital on 01.10.2012 and after investigation she was discharged finally on 02.10.2012 with condition at discharge portion that patient was Haemo Dynamically stable, symptomatically better, being discharged in a fabourable condition.

          For that period complainant after discharge of his wife paid entire bills and initial assessment and discharge certificate etc were sent to the op but op did not admit the complainant’s bills on the ground that the problem had arisen from or traceable to pregnancy and child birth which are excluded vide Exclusion Clause 4.12 of the policy and thereafter complainant took one Medical Certificate from Dr. Ansu Sen, Consultant Neurologist of the said hospital on 05.03.2013 certifying that the patient as admitted in the hospital on 24.09.2012 with the history of Convulsion and there is unlikely any relation to Eclampsia as there is no past history of hypertension or Protenuria.  BP was raised at the time of Convulsion and another certificate was given by Dr. Abhinibesh Chatterjee, the Consultant Gynaecologist to the effect that it was no Eclampsia and not related to pregnancy but a clear case of Convulsion as there is no past record/history of hypertension and there was no Protieneuria, BP was raised at the time of Convulsion.  So the case was handed over to the Neurologist Dr. Ansu Sen.  But complainant quoted that the Clause 4.12 of the said policy and submit in the instant case there was no miscarriage, no abortion or complications whereby there could have any changes in chronic condition arising out of pregnancy and secondly there was no instance of Seizure as op no.3 had been stressing and thirdly it was a simple case of Convulsion and there are many reasons for Convulsion.

          Complainant submitted the bills for Rs.1,65,425/- for the period 24.09.2012 to 01.10.2012, for 02.01.2012 Rs.4,088/- and for Rs.1,392/- for further check up of the patient/wife on 11.10.2012 and for 12.10.2012 Rs.50/- and on 31.10.2012 Rs.530/- i.e. total Rs. 1,71,485/- issued by Columbia Asia Hospital which includes the Hospital charges covering medicines administered, fees for consultants, tests conducted and all others which the complainant paid in full.  But op without considering the above medical certificate repudiated the claim by mentioning the provision 4.12 and such a decision on the part of the op is proved without any foundation and the rejection of the claim on the part of the op is uncalled for and for which complainant has appeared before this Forum for relief.

          On the other hand National Insurance Co. Ltd. by filing written statement has submitted that the claim is not maintainable and there is no negligence and deficiency on the part of the op and repudiation has been made on the basis of discharge summary of operation of the complainant’s wife and as per Clause 4.12 of the Policy, the complainant is not entitled to get any such relief and in the above context op has submitted that there was no laches, negligence and deficiency on the part of the op and it was rightly repudiated by the TPA after considering all the materials and documents and fact remains op National Insurance Co. Ltd. has also relied upon and considered the same and repudiated the same.

                                                       Decision with reasons

          On careful consideration of the entire complaint and the written version including the argument as advanced by the Ld. Lawyers of both the parties and also on proper evaluation of the Medical Discharge Certificate, it is clear that Caesarean delivery was made on the patient just preceding to 12 days from the admission of the patient in the present Columbia Hospital.  No doubt she was admitted for Convulsion after 12 days of her Caesarean delivery and from discharge summary, it is specifically mentioned that her admission diagnosis is Caesarean disorder and discharge diagnosis is also Caesarean disorder and it was post Caesarean Section and it was history on generalized Tonic Clonic Convulsion at home a week back, post caesarean section held on 12.09.2012 and no doubt after treatment she recovered and was discharged and she was under treatment of Dr. Ansu Sen and Abhinibesh Chatterjee.  Anyhow the main question is whether it was caused as Post operative Caesarean problem or related problem or not.  In the regard it is found from the discharge certificate Caesarean was done on 12.09.2012 and was under treatment of Dr. Abhinibesh Chatterjee, the Consultant Gyanaecologist and during treatment Anti-Hypertensive and Anti-Convulsion medicines were used and several tests were done for investigation, but they failed to search out any Neuro problem and the Dr. Ansu Sen issued a certificate stating that there is no nexus in between Convulsion and related Caesarean delivery.

          Similarly Abhinibesh Chatterjee also issued certificate that after through checking it was found that it was not related to past history and clear case is convulsion as there is a past history of hypertension.  So, it was a case of neuro problem and for which she was handed over to Neuro-Surgeon Dr. Ansu Sen.  But Ansu Sen also failed to search out any neuro problem.  If we consider the certificate of the doctors then it can be said that doctors as per request of the complainant issued such certificate.  But from the discharge summary, it is clear that patient suffered from convulsion within 12 days from the date of Caesarean delivery.  But now as per authoritative book of Gynaecologist, it is found that several type of problem regarding convulsion due to high pressure/hypertension may be caused after Caesarean delivery and in this case Ansu Sen only used such medicines to control convulsion and the hypertension which was found at the time of convulsion but no other problem was detected.

          Peculiar factor is that at the time issuing discharge certificate by the said Columbia Asia Hospital there is no such reference that it was not related with after Caesarean delivery but it was subsequently submitted by the complainant  after collecting on requesting doctor and doctor supplied those certificates when already repudiation has been made by the op.  So, we are not relying upon those certificates of the doctors at this stage.  But fact remains the insurance coverage was for Rs.1,00,000/-.  But complainant has claimed for Rs.1,71,000/- and odd what the complainant is not entitled to.

          But anyhow considering the entire materials and documents we find that the TPA and the op must have to re-consider the same after collecting medical opinion from any Government Medical College and Hospital and thereafter consider the entire claim and to settle the same as per law and if under any circumstances the opinion of the specialized doctor of any Govt. Medical College and Hospital goes against complainant and complainant is bound by that invariably but if it is otherwise in that case complainant shall have to get relief but if opinion of this is otherwise in that case ops shall have to settle the claim as per policy and also as per limit of mediclaim as per insurance policy of the complainant and accordingly this matter is disposed and the repudiation as made by the complainant shall be treated as valid if opinion of those specialized doctors are in favour of opinion of the TPA for repudiating the same.  Accordingly ops shall have to reconsider the same and settle the claim.  But we are sure that complainant is not entitled to a sum of claim of the complainant in respect of Rs.1,71,000/- which is completely not as per insurance policy and it is no doubt excessive.

          In the result the complaint succeeds accordingly.

          Hence, it is

                                                                ORDERED

          That the complaint be and the same is allowed on contest without any cost against the ops.

          Ops are hereby directed to verify the discharge certificate including discharge certificate of Caesarean delivery and also the two certificates issued by Ansu Sen and Dr. Abhinibesh Chatterjee and same shall be placed before the retired/in service specialized doctor one Neuro Surgeon and one Gyanecologist of any Government Medical College for opinion and after collecting their opinion, the op shall have to decide the claim of the complainant as per law policy condition within two months from the date of this order and thereafter report this Forum about their action in this regard and about their final settlement of the claim as ordered by this Forum and if it is not complied by the ops, in that case Insurance company shall have to pay a sum of Rs. 50,000/- to the complainant without any fail forthwith after completion of two months from the date of this order and invariably it shall be paid if no action is taken by the ops as per direction of this Forum.

          Disobeyance of the Forum’s order shall be treated as violation of the Forum’s order for which ops may be prosecuted penalty and fine may be imposed for that.  So, op shall have to comply the order very strictly within the stipulated time and to report before this Forum about ops action