ORDER Date:
Vikram Kumar Dabas, Member
The complainant had purchased a Mediclaim Policy from OP1 which was effective wef 22/07/2014. As per the policy the complainants were entitled to reimbursement of a sum of Rs. 3 Lacs each. During the subsistence of the policy on 12/12/2014, complainant No. 2 was admitted in Max Super Speciality Hospital, I P Extn, Patpar Ganj, Delhi. She was diagonised as a case of post-partum cardiomyopathy, pneumonia with massive pleural effusion with severe sepsis with septic shock& was discharged on 22/12/14. A sum of Rs. 5,51,387.87 was incurred on her treatment. The complainants had informed the OPs about the admission of complainant No. 2in the hospital and had sought cashless facility which was refused by OP2. The complainants were however asked to submit their claim later on. The grievance of the complainants is that the OP’s have refused to settle their claim which was duly lodged. Hence the complaint.
The OPs have contested the complaintand have filed a reply wherein they have admitted that they have issued a policy of Mediclaim and that each of the complainantswere entitled to reimbursement of a sum of Rs. 3 Lacs subjectto the terms & conditions of the policy. Under the head true and correct facts the OPs have stated as below:-
That the ground of repudiation that the insured was suffering from post-partum cardiomyopathy. It is evident that the cardiomyopathy was related to pregnancy. Whereas the patient Shruti Mahajan was discharged on 01.11.2014 and she again admitted for the treatment of the above mentioned disease from 12.12.2014 to 22.12.2014.
In light of the above, situation, repudiation of this claim under clause 4.7 of NMP is correct.
OPs have contested the complaint on merit and have asserted that the claim is not payable in view of the preliminary submission as reproduced above. The OPs have prayed that the complaint be dismissed.
Evidence has been led on both sides by way of affidavit. We have heard arguments advanced at bar and have perused the record.
The sole question for our consideration is as to whether the OPs were justified in repudiating the claim lodged by the complainants. The OPs have justified their act of repudiation and have taken refuge in clause 4.7 of the terms & conditions of the policy of Insurance purchased by the Complainants. Clause 4.7 of the policy reads as under:-
‘’ 4.7 Pregnancy – Treatment arising from or traceable to pregnancy/childbirth including caesarean section, miscarriage, surrogate of vicarious pregnancy, abortion or complications thereof including changes in chronic conditions arising out of pregnancy other than ectopic pregnancy which may be established by medical reports.’’
We have consideredthe contention of the OPs with which we tend to disagree. The complainant has placed on record certificate Ex. CW 1/8, CW 1/9 and CW 1/10, a perusal of which shows that the patient had suffered from right side pneumonia with pleural effusion which had led to Septicemia. This cannot be related to or termed as a disease arising from or traceable to pregnancy. We are therefore, of the considered opinion that the OPs were not justified in repudiating the claim lodged by the Complainants. We holdOPs deficient in rendering service to the complainants and direct OP1 as under:-
1. Pay to the complainants as sum assured of Rs. 3 Lacs as reimbursement of the expenses incurred for the treatment of Complainant 2.
2. Pay to the complainants a sum of Rs. 30,000/- as compensation of pain and agony suffered by them.
3. Pay to the complainant a sum of Rs. 5,000/- as cost of litigation.
This order shall be complied with by the OP within a period of 30 days from the date of receipt of this order failing which interest @ 12% shall be payable on the entire above mentioned amount till realisation. Copy of this order is sent to all the parties free of cost. File be consigned to Record Room.
Announced on this …………….......
MEMBER MEMBER PRESIDENT
