JUDGEMENT

          Complainant by filing this complaint has submitted that he is a bona fide consumer under the op no.1 since 2007 in connection with Mediclaim Policy being No.101600/48/07/8500001670 valid from 04.06.2007 to 03.06.2008 and it was continued till date for the period 2012-13 without any break under this op no.1 and prior to this claim complainant has not lodged any claim before this op no.1 under the Mediclaim Policy.  Fact remains complainant no.2 the wife of complainant no.1 undergone a surgery of Laproscopic Ovarian Cystectomy and Salpingo – Ovariolysis under G.A. on 09.01.2012 at Institute of Reproduction Medicine, DD-18/5/1, Salt Lake City, Sector-I, Kolkata-700064 under Dr. B.N. Chakraborty for a period from08.01.2012 to 12.01.2012 within the period of the aforesaid Mediclaim Policy being No.101600/48/11/8500002603 valid from 04.06.2011 to 03.06.2012 and the total Medical Expenses of Rs.27,991.90 paisa incurred by the complainant no.1 for the said medical treatment of his wife and complainant no.1 already paid the aforesaid medical expenses to the aforesaid hospital.

          Subsequently complainant submitted claim to the op no.2 on 16.05.2012 along with all medical papers to op no.2 vide complainant’s letter dated 16.05.2012 for reimbursement of the said amount and though op received the said letter along with claim including all the enclosures intimated the complainant vide their letter dated 26.09.2012 that all their claim has been repudiated as per policy Exclusion Clause No.4.8 after observation as well as opinion of their service provider M/s Genius India Pvt. Ltd. TPA.

          Though the claim is pertaining to Mrs Ruma Addya is for the treatment of CYST and said repudiation was completely illegal, misleading and further from the Discharge Summary and Certificate that the Diagnosis of Mrs. Ruma Addya is Endometrial Cyst and the said diagnosis has duly admitted by the op no.1 vide their said letter dated 26.09.2012 and the said diagnosis does not under the purview of the Exclusion Clause No.4.8 of the Mediclaim Policy and in the above circumstances for adopting such unfair practice and for deficient manner of service this complaint is filed.

          It is further submitted that Discharge Summary and Certificate simply speaks that the said surgery was done for saving the life of the lady.  But it was not surgical treatment and primary Sub-fertility, so the entire claim of ops is fabricated, arbitrary and repudiation is illegal and accordingly complainant prayed for redressal.

          On the other hand op by filing written statement submitted that no doubt complainant obtained one Mediclaim Policy and it was continuous in nature and in fact complainant submitted that the claim for Rs.27,992/- with relevant papers on 16.05.2012 after a period of 124 days from the date of discharge and submitted an application prayed for condonation of delay on 21.08.2012 after a period of 225 days from the date of hospitalization.  Further considering the above fact the delay was condoned for consideration for reimbursement but after considering the material that is the Discharge Summary etc. it was found that it was related to Sub-fertility treatment.  So, the claim was repudiated as per Exclusion Clause 4.8 and that was communicated to the complainant vide ops letter dated 26.09.2012 and being dissatisfied complainant has filed this complaint.  But subsequently as per request of the complainant for reviewing the claim favourably the matter was settled by the op and op paid Rs.27,604/- after making deducting of Rs.388/- in favour of the complainant on 18.10.2013 through Union Bank of India, SSI Finance Branch, Noida, vide UTR No.SAA 64267825 for Rs.27,604/- which has been duly received by the complainant.  So, there was no laches on the part of the op and practically the matter was considered by the op and matter was settled.  So, there was no latches or deficiency on the part of the op and in fact complainant filed claim after lapse of 225 days that delay was condoned and that was filed after 225 days from the date of hospitalization on 21.08.2012.

          Practically it was filed after 7months and 15 days.  So, the claim application became alive after condonation of delay in the month of April-2013.  Thereafter claim was considered though it was related to Sub-fertility matter.  But as per Exclusion Clause 4.8 Sub-fertility matter is not tenable.  But after repudiation when complainant filed a reviewed petition and after appearance of the op on 08.10.2013 in this case, op forthwith decided the matter invariably considering the moral approach and disposed of the matter so the case is not maintainable.

                                                      Decision with reasons

          On careful study of the complaint and also the written version including the complaint of this case filed on 16.08.2013 it is clear that after appearance on 08.10.2013 op submitted written statement on 11.11.2013 and in that written version op already reported that on 18.10.2013 complainant already encashed a sum of Rs.27,604/- out of total claim of Rs.27,992/- that means complainant just after appearance within 10 days settled their review petition considering the entire aspect.  So, it is clear that there was no latches on the part of the op because complainant himself filed claim application after lapse of 8 months from the date of admission of the patient in the hospital and fact remains previous claim application became alive in the month of April-2013 after condonation of delay by the op.

          Thereafter op repudiated the claim on the ground that the said portion was related to Sub-infertility and no doubt after considering the Discharge Summary and Certificate it is clear that Endometrial Cyst can prevent ovulation and cause infertility and surgical technique is often used to remove and Endometrial Cyst to preserve fertility and the doctors objective during the procedure is to remove the Cyst or Cyst from the Ovary provider from first pain relief and reverse infertility, whereas Dyspareunia means painful sexual intercourse due to medical or psychological cases.  So considering the entire material that is Discharge Summary and Certificate no doubt it is related to some sex related problem and at the same time Cyst was there.

          Fact remains considering the entire fact after repudiation while complainant further submitted review clause op applied their moral approach and released the amount.  So, in our view we have gathered that no doubt it was related to Sub-infertility.  But it was caused due to Cyst.  But the op authority at the time of reconsidering the reimbursement as prayed, considered that only on the ground of in-fertility if the claim is refused in that case the present lady shall have to suffer for which that was released after deducting very small amount.  Then question is how the complainant has been able to prove the negligent and deficient manner of service on the part of the op but rightly op repudiated the claim because it was related to in-fertility matter.

          But after that when complainant prayed for reimbursement again at that time they applied their moral views and released it.  Then it is clear that there was no negligence and deficiency on the part of the op.  First repudiation was right as per contract i.e. Mediclaim Policy.  But laches was on the part of the complainant to file such claim after lapse of 8 months from the date of admission of the patient.  Thereafter the repudiation was no doubt forthwith done by the op on 26.09.2012 and after that when condonation of delay was filed that was again reviewed and ultimately on 08.10.2013 complainant received that amount.  But fact remains just before 2 months from the date of receiving the said amount after re-consideration of the claim by the op this complaint was filed and op just on appearance reported the matter before this Forum in writing.

          Then in our view we have gathered that there was no laches, deficiency on the part of the op and complainant’s claim was practically with moral approach was decided after repudiation and after considering condonation of delay.  So, in the particular case the approach of the op is very moral, social and having their no deficiency and for which this complaint fails.

          Hence, it is

                                                              ORDERED

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