Date of Filing:-01/12/2015
Order No. -11 Dt.- 30/05/2016
Shri Prabin Chettri, Member.
F I N A L O R D E R
Complainant’s case in brief is that she and her husband are jointly holder of mediclaim policy being number 153900/48/14/8500001251 of National Insurance co.Ltd. which was valid from 06/08/2014 to 05/08/2015.
Complainant felt pain in her lower abdomen in the month of August 2014. She went to Dr.G.B.Das i.e. Proforma O.P. for consultation and treatment. Dr.G.B.Das advised some tests such as C.T.Scan contrast etc. The complainant undergo with the test and went for treatment at New Ram Krishna Seva Sadan Nursing Home under the supervision of Dr.G.B.Das on 06/09/2014 Dr. G.B.Das after perusal of reports opined that a “cyst” is formed into her left ovary and advised for operation. The complainant was admitted for the operation on 17/09/2014 in the New Ram Krishna Seva Sadan under supervision of Dr.G.B.Das and was operated on 18/09/2014. She was discharged on 21/09/2014. The medical expenditure and the operation cost of the above mentioned nursing home was Rs.63,792/- which was paid by the complainant.
Complainant’s husband filed a claim petition before the National Insurance Co.Ltd.(O.P.) enclosing all the documents but the claim was repudiated/denied by the National Insurance Co.Ltd.(O.P.) on 27/10/2014 relying on clause 4.6 of mediclaim policy stating that the claim of the mediclaim policy bars this company to take any liability for payment in sterility, infertility, assisted conception procedure cases.
Complianant’s husband then lodged a complaint before Assistant Director of Consumer Affairs and Fair Business Practice, Jalpaiguri Regional Office, but no fruitful result came out.
Thereafter the complainant had filed the case. Complainant has prayed for 63,792/- for operation and medical treatment, Rs.1,00,000/- towards the mental agony and pain, Rs.30,000/- towards cost of present litigation with 12% interest p.a.
National Insurance Co.Ltd.(O.P.) appeared and contested this case by filing Written Version, wherein National Insurance Co.Ltd.(O.P.) has denied and disputed the claims and contentions of the complainant. National Insurance Co.Ltd.(O.P.) has categorically stated that there was no deficiency in service and/or Unfair Trade Practice on their part and that National Insurance Co.Ltd.(O.P.) has rejected/repudiated the claim of the complainant as per terms and conditions of the mediclaim policy under the clause 4.6, specially bars this company to take any liability for payment in sterility, infertility, assisted conception procedure cases. The National Insurance Co.Ltd.(O.P.) has prayed for dismissal of the complaint petition with cost.
POINTS FOR CONSIDERATION
- Whether the complainant a consumer?
- Whether the case is maintainable under the C.P.Act 1986?
- Whether there is any deficiency in service and /or Unfair Trade Practice as alleged by the complainant?
- Is the complainant entitled to get any award and reliefs as prayed for?
DECISION WITH REASONS
All points are taken up together for consideration and decision.
The case is heard ex-parte against Dr.G.B.Das(Proforma O.P.) as proforma O.P. didn’t appear to contest this case after service of notice.
Seen and perused the pleadings of the parties which are supported by affidavits, documents filed by both the parties and the written version by the O.P. (The National Insurance Co.Ltd.)
We have heard the arguments advanced by the Ld. Lawyer of the complainant and the O.P. in full.
After due consideration of the materials on record and the arguments of Ld. Lawyers of both sides and the written arguments we find that the complainant and her husband are jointly holder of mediclaim policy no. 153900/48/14/8500001251 which was valid from 06/08/2014 to 05/08/2015. So, we have no hesitation to hold that the complainant is a consumer under C.P.Act 1986.
Furthermore this complaint was filed on 01/12/2015 and the cause of action arose on 27/10/2014 when O.P. sent a repudiation letter to the complainant, so this Forum has no hesitation to say that the case was filed within the statutory period of the limitation of the C.P.Act 1986 and that O.P. carries on business from Jalpaiguri and the cause of action arose within the territorial jurisdiction of this Forum. So, it is clear that the case is maintainable.
The complainant felt pain in her lower abdomen in the month of August 2014 and so she went to Dr.G.B.das (Proforma O.P.) for consultation and for her treatment. As per Dr.G.B.das’s advice some tests such as C.T.scan whole abdomen contrast etc have been done and then she met Dr.G.B.Das with those reports on 06/09/2014, after perusal of report Dr.G.B.das opined that a “cyst” was formed into her left ovary and advised operation.
The complainant then admitted at New Ram Krishna Seva Sadan on 17/09/2014 under the supervision of Dr.G.B.das and her “Cyst” was operated and removed on 18/09/2014 and she was discharged on 21/09/2014 .
It is the case of the National Insurance Co.Ltd.(O.P.) that the complainant tried to suppress the vital fact which is found from her two prescriptions of Nurture Advanced Fertility Centre of Siliguri, wherein Dr.Sima Roy and Dr.Malay Roy have suggested her some treatment and those doctors are the doctors of a fertility centre, where the patients used to go to adopt sterility, infertility/sub-fertility assisted conception procedures etc, and so the complainant is not entitled to get the medical expenses as claimed as per provision of clause 4.6 of the mediclaim policy.
Here we find that “cyst” was detected in her left ovary after USG test, which was done as per advice of Dr.G.B.Das, MD/FICOG, FICS and that cyst was operated and removed by Dr.G.B.Das on 18/09/2014.
Therefore the claim of the O.P. that the infertility is the cause which has been removed by the removal of the ovarian cyst and the total course of treatment of this complainant leads only to removal of infertility has got no importance. The existence of cyst was found after the U.S.G. test done during her treatment. So it is clear that the problem of cyst neither leads to infertility nor the operation of the cyst is the procedure of infertility.
In view of the above discussion we may safely come to the conclusion that the O.P.National Insurance Co.Ltd. is guilty for deficiency in service and /or Unfair Trade Practice.
Therefore the complainant is entitled to the reliefs as specified below.
All points are disposed of.
In the result the case succeeds.
Hence, it is
O R D E R E D
that this case/application is allowed in part against The National Insurance Co.Ltd.(O.P.) with litigation cost of Rs. Rs.3000/-(Three Thousand.) only and dismissed ex-parte against proforma O.P. (Dr.G.B.Das) without cost.
The O.P.(National Insurance Co.Ltd.) is hereby directed to pay Rs.50,000/-(Fifty Thousand)(sum assured) as medical expenditure to the complainant within 30 days from the date of this order.
The complainant do get an award of Rs.2000/-(Two Thousand) in the head of compensation, mental agony, pain harassment etc.
The National Insurance Co.Ltd.(O.P.) is hereby directed to comply the aforesaid direction and to pay the litigation cost and the awarded sum of Rs.(3000+50,000+2000)= Rs.55,000(Fifty-Five Thousand) within 30days from the date of this order, failing which the entire amount will bear 7% interest p.a. and the complainant shall be at liberty to realise the entire amount by putting this order into execution in accordance with law.
Let copy of this final order be supplied free of cost forthwith to the parties/ their Ld. Advocates/agents on record by hand under proper acknowledgment/sent by ordinary post, in terms of Rule 5(10) of West Bengal Consumer Protection Rules 1987.
