West Bengal

Bankura

CC/30/2017

Sri Ashish Kusum Chaterjee - Complainant(s)

Versus

Sr. Branch Manager, National Insurance Co. Ltd. - Opp.Party(s)

Durgaprasad Sarkar

28 Mar 2023

ORDER

IN    THE   DISTRICT   CONSUMER   DISPUTES   REDRESSAL COMMISSION BANKURA

Consumer  Complaint  No. 30/2017

Date of Filing : 11.04.2017

Before:

1. Samiran Dutta                              Ld. President.      

2. Rina Mukherjee                          Ld. Member. 

3. Siddhartha Sankar Bhui            Ld. Member.

 

For the Complainant: Ld. Advocate Jayanta Kr. Mukhopadhyay

For the O.P. Ld Advocate Ardhendu Ghosh

Complainant           

Shri Ashish Kusum Chatterjee, S/o Late Loknath Chatterjee, at Rabindra Sarani, Bankura

Opposite Party  

1.Sr. Branch Manager, National Insurance Co. Ltd., Bankura Branch, Chandmaridanga, Bankura 

2.Medi Assist India TPA Pvt. Ltd., Premier Court, 4, Chandni Chawk Street (Beside Sabir Hotel), Kolkata- 72

FINAL ORDER / JUDGEMENT             

                                                                                                                                              

Order No.32                                                                                   

Dt. 28-03-2023

Both parties filed hazira through advocate.

The case is fixed for argument.

After hearing argument from both sides the Commission proceeds to dispose of the case as hereunder: -

The complainant’s case is that he had Mediclaim policy with family coverage issued by O.P.1/National Insurance Co.vide No.15040248158500000992, dt.22-08-2015 valid from 22-08-15 to 21-08-16 with Sum Assured Rs.1,50,000/-. All on a sudden during the Month of October, 2015 his wife Smt. Sumana Chatterjee felt some trouble in lower abdomen and thereby she was taken to Apollo first med Hospital at Chennai for necessary check up and treatment and on examination and as per the advice of the treating doctor Dr.Girish Ambat she remained hospitalized during 05-11-2015 to 09-11-2015 and she was discharged on 09-11-2015 and thereby the complainant has incurred a sum of Rs.1,33,395/- as the medical expenses but the Mediclaim was rejected by the O.P./Insurance authority by letter dated: 04-03-2016. The complainant has therefore approached this Commission for reimbursement of medical expenses on Rs.1,33,395/- together with compensation and litigation cost.

                                                                                                                                                                                       Contd……p/2

Page: 2

The O.P./Insurance Co. contested the case by filing a written version contending inter alia that the complainant is not entitled to get the mediclaim as prayed for as the treatment in question at Chennai is not covered under the policy and the same is excluded by the terms and conditions of the policy.

-:Decision with reasons:-

Having regard to the facts of the case, materials on record and contention and submission on both sides the Commission finds that the spouse of the complainant Smt. Sumana Chatterjee was under treatment at Chennai for her Abdominal Wall Scar endometriosis and the Discharge Summary issued by the Apollo first med Hospital has diagnosed so.

Ld. Advocate for the complainant relying on the Discharge Summary (Annexkure’C’ 10) has submitted before the Commission that the disease with which the complainant’s wife was diagnosed is not a pre-existing disease within the exclusion clause 4.7 of the terms and conditions of the policy as the disease has no connection with any pregnancy or post pregnancy factor.

Ld. Advocate for the O.P./Insurance Co. has however relied on the history of the disease appearing from the medical record of the said Hospital (Annexure ‘C’11) that the complainant’s wife being a female of 26 years came with pain over right lower abdomen during menstrual period and the pain started 8 months after first lower (uterine) segment Caesarean section (LSCS) in November, 2012.

It transpires from the medical evidence on record that the complainant’s wife was pregnant in 2012 and delivered caesarean child out of pregnancy but subsequently in 2015 i.e. after about three months of the issuance of the policy she experienced some trouble in lower abdomen for which she was treated at Chennai for her recovery but the O.P./Insurance authority linked her earlier LSCS treatment in November, 2012 as if it is a pre-existing disease within the exclusion clause-4.7 of the terms and conditions of the policy leading to the complication arising out of post-pregnancy surgery and thereby the claim has been repudiated on that ground.

                                                                                                                                                                                          Contd……p/3

Page: 3

The Commission is not ready to accept this logic of the Insurance Co. The treatment of the complainant at Chennai is for Abdominal Wall Scar endometriosis which is completely different from any pregnancy complication as enumerated in exclusion clause-4.7 of the terms and conditions of the policy.

The Commission therefore does not find the repudiation of claim justified and logical and the O.P./Insurance authority has denied the mediclaim on filmsy ground.

Upon consideration of the entire materials on record the complainant is entitled to get the claim of Rs.1,33,395/-.

The case therefore succeeds.

                                                        Hence it is ordered……

That the case be and the same is allowed against the O.P.

The O.P.s are jointly and severally directed to pay to the complainant Rs.1,33,395/- together with Rs.15,000/- as compensation for mis-interpretation of the terms and conditions of the policy within one month from this date in default the decretal amount may be realized in due process of law.

Both parties be supplied copy of this Order free of cost.  

 

   __________________                   ________________            ________________

HON’BLE   PRESIDENT         HON’BLE    MEMBER      HON’BLE    MEMBER