In  the  Court  of  the

Consumer Disputes Redressal Forum, Unit -I, Kolkata,

8B, Nelie Sengupta Sarani, Kolkata-700087.

CDF/Unit-I/Case No.  366 / 2008.

1)                   Smt. Archana Halder,

10850/1, Survey Park, Santoshpur, Kolkata-700075.                                ---------- Complainant

---Versus---

1)                   Royal Sundaram Alliance Insurance Co. Ltd.,

Sundaram Towers, 45 & 46, Whites Road, Chennai-600014.

And having its office at :

Subham Blosk, 1^st Floor, Room No. 101 & 102,

Sarojini Naidu Sarani, Kolkata-700017.                                                    ---------- Opposite Party

Present :           Sri Sankar Nath Das, President.

                        Dr. A. B. Chakraborty, Member

Order No.   2 8    Dated  1 5 / 0 2 / 2 0 1 2 .

The petion of complaint u/s 12 of the C.P. Act, 1986 has been filed by the complainant Smt. Archana Halder against the o.p. Royal Sundaram Alliance Insurance Co. Ltd. The case of the complainant in short is that complainant took one mediclaim policy being Health Shield Insurance in 2002 from Royal Sundaram Alliance Insurance Co. Ltd. and the said policy commenced on 5.3.02 and was renewed for the 2^nd time on 5.3.03, for the 3^rd time on 5.3.04, for the 4^th time on 5.3.05 and thereafter on 5.3.06 to the midnight of 4.3.07 and the policy number being HE 00000358000114 and master policy no.HLST AN 002 and the sum insured was Rs.75,000/- and cumulative bonus Rs.45,000/- i.e. to the extent of Rs.1,20,000/-.

            Having severe abdomen pain and fever complainant was admitted to Woodlands Medical Centre Ltd. on 19.12.06. Laparotomy was done on 21.12.06 at Woodlands for pelvic abscess and intraloop abscess  and UGA was done and was discharged on 28.12.06. Complainant lodged a claim with o.p. no.2 for settlement of the claim of Rs.1,35,213/- on 20.1.07. But on 19.2.07 o.p. no.2 repudiated the claim of the complainant on the ground that the discharge summary indicates that the patient was admitted for pelvic abscess with periotomitis and present hospitalization  was a complication of the previous infertility surgery dt.1.4.03 and the complainant claimed that she had never went any infertility surgery prior policy. Hence the instant case.

            O.p. had entered its appearance in this case by filing w/v and denied all the material allegations and supported the claim of repudiation and prayed for dismissal of the case.

Decision with reasons:-

            We have gone through the pleadings of the parties and evidence and documents in particular. It is an admitted position that complainant had valid policy with o.p. and the surgery was done during the policy period. But problem cropped up when complainant placed her claim for refund of Rs.1,35,213/- and o.p. repudiated the said claim on the plea that cause of her admission took place owing to pre-policy infertility complication. But it appears from the diagnosis arrived at by the hospital authority in discharge summary that “the patient admitted with pelvic abscess and peritonitis uncontrolled pelvic septics” and there is no whisper of any iota of pre-policy infertility surgery complication. That apart it is the specific averment of the complainant vide para 7 of the complaint that she had never underwent any infertility surgery at all, but o.p. could not demolish this averment by filing cogent, valid and acceptable peace of evidence either documentary and/or pathologically. But from the record we find a medical certificate dt.9.2.07 well after discharge and submission of claim dt.20.1.07 wherefrom it transpires that the condition could very well have arisen as a complication of foreign body in the penetorical cavity where there was already unhealthy endometriotic tissue and the same may be considered owing to complication of the previous surgery of infertility. It is surprising to take note that this certificate has been procured and filed by o.p. well after submission of claim. And it is an admitted position that the signatory of the certificate did not examine the complainant in person prior to issue of the certificate dt.9.2.07 and there is nothing to concede that the doctor issued the certificate dt.9.2.07 is at all independent competent person to issue certificate like this and there is no regn. number assign to the said certificate cannot be given credence at all. Accordingly, the plea taken by o.p. is noit acceptable since o.p. failed to demolish the averment of the complainant made in para 7 of the petition of complaint.

            Accordingly, in view of the above and on scrutiny of the entire materials on record and evidence due regard to the evidence made above we are of the view that o.p. has no basis to repudiate the claim of the complainant on such a filmsy ground and complainant is entitled to relief as prayed for being a consumer / complainant by a servife provider like o.p.

            Hence, ordered,

            That the petition of complaint is allowed on contest with cost against the o.p. O.p. is directed to pay a sum of Rs.1,20,000/- (Rupees one lakh twenty thousand) only together with interest @ 9% p.a. from 1.4.07 till the date of realization. O.p. is further directed to pay a sum of Rs.15,000/- (Rupees fifteen thousand) only for harassment and mental agony and litigation cost of Rs.5000/- (Rupees five thousand) only within 45 days from the date of communication of this order, i.d. an interest @ 9% p.a. shall accrue over the entire sum due to the credit of the complainant till full realization.

            Supply certified copy of this order to the parties.

   ____Sd-____                                                    ______Sd-______

     MEMBER                                                           PRESIDENT