DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: NORTH-WEST

GOVT. OF NCT OF DELHI

CSC-BLOCK-C, POCKET-C, SHALIMAR BAGH, DELHI-110088.

CC. No.1206/2012                                      

IN THE MATTER OF :

Saroj Gupta

R/o 18/400, 3^rd Floor,

Bagh Kare Khan,

Kishan Ganj,

Delhi-110007.

.                                                                                   ….                               Complainant

VERSUS

1. The Oriental Insurance Company Limited,

Through Branch Manager,

101, L.S.C., 1^st Floor,

H-Block Market, Vikas Puri,

New Delhi-110018.

2. Raksha TPA Pvt. Ltd.,

C/o Escort TPA Pvt. Ltd.,

15/5, Mathura Road,

Faridabad,

            ….                              Opp. Parties

ORDER

Ms. NIPUR CHANDNA, MEMBER

1. The complainant is Mediclaim policy holder of the OP-1 Company vide Policy No.212200/48/2012/1992 valid upto 26.11.2011 to 25.11.2012.

2. The complainant was admitted to Ekansh Nursing Home on 02.02.2012 for the treatment of DUB (Dysfunctional Uterine Bleeding) and discharged on 04.02.2012.  Intimation regarding the hospitalization was given to the OP-2 on 03.02.2012 through email at

3. The complaint has been contested by OP.  OP-1 filed its written statement  wherein it denied any deficiency in service as alleged.  It is further stated that the claim of the complainant was rightly repudiated as per Clause No.4.3 of the policy terms and conditions which speaks as under :-

“(During the period of insurance cover, the expenses on treatment of following ailment/disease/surgeries for specified periods are not payable if contracted and/or manifested during the currency of the policy) “During the first year of the operation of the policy the expenses on treatment of disease such as Cataract , Benign INT, Disorder and surgeries, Tonsillectomy, adenoidectomy, Mastoidectomy, Tympanoplasty Etc. and related disorders are not payable.”

4. He further stated that present complaint should be dismissed on the above mentioned ground.

5. Both parties have filed their evidence by way of affidavit as well as written arguments.

6. The complainant has placed on record the medical certificate dated 05.10.2012 issued by the treating doctor Anupma Gupta.  The contents of the certificate are reproduced as under :-

“This is to certify that Mrs. Saroj Gupta W/o Pramod Kumar, aged 45 Yrs. Female, R/o 18/400, 3^rd floor, Bagh Kare Khan, Kishan Ganj, Delhi-110007, was admitted in Ekarsh Nursing Home under my care w.e.f. 02.02.2012 to 04.02.2012 for the treatment of DUB (Dysfunctional Uterine Bleeding).Prior to admission in the hospital the patient was suffering from Excessive Bleeding P/V from 5 to 6 days.I performed diagnostic procedure as D&C, (dilation and curettage is an procedure performed on women to lightly scrape away the womb lining for a range of condition).

As per Policy clause No.4.3 sub Clause (IX)s Hysterectomy for Menorrhagia or Fibrumyoma or Myomectomy or Prolapse of Uterus.As per this clause Hysterectomy means removal of Uterus which is not being conducted by me for the mentioned reasons in the above said clause.”

As per clause No.4.3 sub Clause (XIV) Surgery of Genito-Urinary system excluding Malignancy.As per this clause no related Surgery was done by me.

7. It is clearly mentioned by the treating doctor in her certificate that she has not done Hysterectomy as alleged by OP in its repudiation.  It is further stated that doctor that Hysterectomy means removal of Uterus which was not being conducted, no such related surgery was also done by her.

8. On the contrary, the OPs Insurance Company has been failed to justify the exclusion clause as well as the treatment taken by complainant falling under the same.

9. In view of the above, we found that the repudiation by OPs is unjustified resulting in deficiency in service on the part of OPs.

10. In view of the above discussion, we are of the considered view that  OP-1 is under liability to compensate the complainant.  In such circumstances, we direct the OP-1 as under:-

1. To pay to complainant a sum of Rs.28,824/- as insurance claim.

2. To pay to complainant a sum of Rs.5,000/- on account of compensation and litigation cost.

3. OP is directed to comply the order within 30 days from the date of receipt of this order failing which OP is liable to pay to the complainant interest @9% per annum till realization.

Copy of the order may be forwarded to the complainant to the case free of cost as statutorily required. The orders be uploaded on www.confonet.nic.in. File be consigned to Record Room.

Announced in open Forum on   _____________.

(ARUN KUMAR ARYA)

                                         PRESIDENT

(NIPUR CHANDNA)                                                                                               (R C MEENA)

                    MEMBER                                                                                                            MEMBER