This is a complaint U/s 12 of the Consumer Protection Act, 1986 with the prayer for an order of direction upon O.P. to pay a sum of Rs.146293.34 as medical reimbursement for the purpose of treatment of “Adenomyosis Anaemia” under the policy, for compensation of Rs.50,000/-  and litigation cost of Rs.5,000/-.

The complaint case in short is that the complainant is a policy holder under the O.P., Oriental Insurance Company Limited vide policy No.313501/48/ 2014/1644 valid from 01.09.2013 to 31.08.2014. During subsistence of policy she fell seriously ill, was treated by different doctors ultimately referred to Apollo Hospital for her sufferings from “Adenomyosis Anaemia”. She was admitted in the hospital at Chennai on 10.09.2013 undergone surgery of Laparoscopic Hysterectomy and was discharged from hospital on 12.09.2013. She spent Rs.9.300/- for visit and advice and investigation under Dr. A. Akeel and she also spent Rs.1,33,138.34  for the surgery and Rs.3,855/- for medicine. She informed O.P./ Insurance Company about the illness and also submitted her claim towards medical reimbursement, but O.P. illegally repudiated the claim on the ground that the disease for which the claim is made has been detected within two years from the commencement of Medical Insurance Policy as mentioned in Clause-4.3. Petitioner alleges she was never informed or disclosed such terms and condition when she paid the premium and also about exclusion of any disease from the policy coverage. No instrument was handed over to her in this regard. She stated further that she never suffered from any disease before, nor at any point of time she had any symptom of suffering from “Adenomyosis Anaemia”. That the repudiation is totally illegal and void. She is suffering monetary loss, mental pain and agony. That cause of action arose on 30.03.2014 when O.P. sent letter repudiating her claim. Therefore she files this case before this Forum with the above mentioned prayer.

On the other hand, the O.P./ Insurance Company has contested this case denying all the material allegations against him made by the complainant rather contended that this case is not maintainable in its present form and law and is barred by limitation.

O.P.’s specific case is that, admittedly complainant is cashless policy holder of the company. At the time of inception of policy, the terms and conditions of the policy are well known to the complainant. Admittedly she was treated under one Dr. S. K. Ghosh on 10.08.2013, by Dr. Ghatak on 23.08.2013, Dr. P. S. Das on 31.08.2013 and was finally admitted to Apollo Hospital where surgery was done on 11.09.2013. So, the disease has been detected within two (02) years from the beginning of the Mediclaim Insurance Policy. The 1st policy of the complainant covering period 01.09.2011 to 31.08.2012 and the 2nd periof of policy from 01.09.2012 to 31.08.2013. Therefore as per terms and conditions she is not entitled to get medical expenses. There is no other latches and negligence on the part of the O.P. and O.P. prays for dismissal of the case with cost.

To establish the case, the complainant has relied upon an affidavit-in-chief sworn by her as P.W.1 along with documents of treatment at Apollo Hospital, Chennai as well as treatment by the doctors mentioned above in August, 2013. O.P.W.1 deposed on behalf of Insurance Company with authorized letter and filed documents, policy certificate, policy bond showing terms and conditions of the “Happy Family Floater Policy” and the letter dated 30.03.2014 of repudiation of claim.  

DECISIONS WITH REASONS

Giving due consideration to the contents of the complaint petition, oral and documentary evidence on record, hearing, arguments advanced by the lawyers of both sides, the Ld. Forum has come to the findings as follows: -

It is admitted fact that the complainant is the policy holder being policy No.313501/48/2012 from 01.09.2011 and onwards. The policy was valid up to 31.08.2013. The petitioner was undergoing treatment by various doctors at Raiganj and was finally operated upon on 11.09.2013 at Apollo Hospital, Chennai. The photocopies of prescriptions, treatment sheets, report of investigations, payment made for the treatment are filed. These are not disputed by the O.P./ insurance company. Lastly she was admitted in the Apollo Hospital, Chennai on 10.09.2013 and on 11.09.2013 was the date of surgery. On 12.09.2013 she was discharged from the Hospital. She was diagnose by the dieses “Adenomyosis Anaemia” by the Department of Obstetrics and Gynaecology of Apollo Hospital. The surgery conducted is total laparoscopic hysterectomy, bilateral salpingectomy, adhesiolysis.

In the Terms and Conditions of the said policy there are some exclusions as noted in point 4 that “The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured Person in connection with or in respect of : ……..” and point No. 4.3 states that “The expenses on treatment of fillowing ailment/ diseases/ surgeries for the specified period are not payable if contracted and/ or manifested during the currency of the policy”. Item No. IX of point No. 4.3 also stated that “Hysterectomy for menorrhagia or fibromyoma or mymectomy or prolapsed of uterus, the specified period is 2 years”.  In the discharge summary of the patient of the Apollo Hospital as shown in Page-5 in column “Course In The Hospital & Discussion” it is noted specifically that “This 42 year old lady was admitted with complaint of severe menorrhagia, diagnosed to have adenomyosis and severe anemia, was admitted for total laparoscopic hysterectomy. One unit PRC was transfused for correction of anemia.

After informed consent and pre anaesthetic check up, she underwent surgery” of total laparoscopic hysterectomy.

In evidence husband of complainant deposed as P.W.1 that complainant was under treatment 1½ / 2 months before she under gone surgery on 11.09.2013. So, the company repudiated her claim that the disease has been detected within two years from the beginning of the Mediclaim policy and was hit by Clause No.-4.3 of the Terms and Conditions. Complainant also filed the said letter dated 30.03.2014 of repudiation of claim.

From our above discussions it is clear that the documents filed by the parties specially from the medical documents we can safely conclude that the complainant’s disease has been detected within two years of the beginning of this mediclaim insurance policy. As per terms and conditions, the insured is not entitled to get any medical expenses under the purview of the insurance policy as stated in Clause No-4.3. So the company rightly repudiated the claim under the policy vide letter dated 30.03.14. Therefore there is no latches and negligence on the part of the O.P./ Insurance Company. As a result the case fails.

Fees paid are correct.

Hence, it is

ORDERED,

That the consumer complaint being No. CC - 02/2015 be and the same is dismissed on contest without cost.

Let copies of this order be supplied to the parties free of cost.