Order by:

Smt.Priti Malhotra, President

1.       The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that complainant has no child from their marriage. So, in the year 2019 complainant and her husband mutually agreed to obtain IVF. So in the year 2020 two daughters were born through IVF, but no claim was lodged by complainant towards the Opposite Parties for IVF. Thereafter again complainant want to get another child and he consulted Ludhiana Children Hospital & Nursing Home, Sri Muktsar Sahib for IVF and applied for claim regarding the expenses incurred by her at Ludhiana Children Hospital and Nursing Home for IVF, but the Opposite Parties rejected the claim of the complainant vide letter dated 04.10.2023 on the ground that

“We have processed the claim records relating to the above insured patient seeking reimbursement of hospitalization expenses for treatment of secondary Infertility.

It is observed from the submitted medical records that the insured patient has undergone IVF treatment.

As per Coverage U-Assisted reproduction treatment-Special Exclusions (5) of the policy issued to you, the company is not liable to make any payment in respect of expenses incurred.

          Alleged that in the year, 2019, the complainant got conducted IVF for first child  and then she never lodged any claim and now the Opposite Parties cannot denied the IVF treatment expenses of secondary infertility. Alleged further that the Opposite Parties never issued any policy to the complainant regarding Special Exclusions (5) of the policy. Alleged further that due to such act and conduct of the Opposite Parties, the complainant has suffered mental tension and harassment. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-

a)       Opposite Parties may be directed to pay a sum of Rs.1,91,639/- with regard the policy bearing no.P/211222/01/2023/008082.

b)      To pay an amount of Rs.1,00,000/- as compensation on account of mental tension and harassment and for deficiency in service.

c)       To pay an amount of Rs.50,000/- as litigation expenses.

d)      And any other relief which this Commission may deem fit and proper be granted to the complainant in the interest of justice and equity.

2.       Opposite Parties appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the present complaint is filed without any cause of action, as the claim of the complainant was denied by the answering Opposite Parties as per the insurance policy terms and conditions. Averred that the present complaint pertains to insurance claim under “Family Health Optima Insurance Plan’ bearing no.P/211222/01/2023/008082 valid from 11.11.2022 to 10.11.2023 covering her husband Sahil Gupta as primary insured, complainant self and Ananya Gupta, Ahana Gupta dependent children for a sum of Rs.10,00,000/-. However it is submitted that the aforesaid insurance policy was issued to the insured by the answering Opposite Parties subject to the terms and conditions of the insurance policy. The complainant had accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. Averred further that the insured has submitted the reimbursement of the medical expenses towards the treatment of Secondary Infertility at Ludhiana Children Hospital and Nursing Home on dated 24.06.2023 to 24.06.2023. It has been observed from the submitted medical records that the insured patient has undergone IVF treatment. As per Coverage U – Assisted reproduction treatment- Special Exclusions (5) of the policy issued to insured, the Opposite Party Company is not liable to make any payment in respect of expenses incurred. Hence the claim was rejected and conveyed to insured vide letter dated 04.10.2023. Averred further that the instant complaint is neither maintainable in law nor on facts; no deficient services have been rendered by the answering Opposite Parties as alleged by the complainant. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.

3.       In order to prove his case, the complainant has placed on record his affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C42.

4.       On the other hand, Opposite Parties have placed on record affidavit of Sh.Sumit Kumar, Senior Manager, Star Health & Allied Insurance Co. Ltd. as Ex.OP1,2/A alongwith copies of documents Ex.OP1,2/1 to Ex.OP1,2/8.

5.         We have heard the ld. counsel for both the parties and also gone through the record.

6.       It is not disputed that the complainant is the holder of Insurance policy namely “Family Health Optima Insurance Plan” P/211222/01/2023/008082 valid from 11.11.2022 to 10.11.2023 covering her husband Sahil Gupta as primary insured, complainant self and Ananya Gupta, Ahana Gupta dependent children. It is also not disputed that in the year, 2019, the complainant got hospitalized for IVF and thereafter in the year, 2020 two daughters were born, but the complainant did not lodge the claim with regard to that treatment. Thereafter, the complainant was again hospitalized for IVF and taken the treatment accordingly and lodged the claim with regard to the same. The only dispute between the parties is that the claim lodged by the complainant for IVF taken by her for second time was rejected by the Opposite Parties..

7.       For the sake of convenience, the letter dated 04.10.2023, vide which the claim of the complainant was repudiated is reproduced as under:-

 “We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of Secondary Infertility.

It is observed from the submitted medical records that the insured patient has undergone IVF treatment.

As per Coverage U- Assisted reproduction treatment- Special Exclusions (5) of the policy issued to you, the company is not liable to make any payment in respect of expenses incurred

We therefore regret to inform you that for the reasons stated above we are unable to settle your claim under the above policy and we hereby repudiate your claim.”

8.       We have given the due consideration to the admitted and proved facts on record and also considered the rival contentions of the ld. Counsels for both the parties and have gone through the record meticulously. It is proved on record that the complainant underwent the treatment of IVF second time. It is also proved on record that as per the Special Exclusions (5) of the policy terms and conditions the Opposite Party-Insurance Company is not liable to pay any amount to the insured with regard to secondary IVF. For the sake of convenience, the said exclusion clause is reproduced as under:-

“Special Exclusions: The Company shall not be liable to make any payments under this policy in respect of any expenses what so ever incurred by the insured person in connection with or in respect of;

1………

2………

3………

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5.       Treatment undergone for second or subsequent pregnancies except where the child from the first delivery/previous deliveries is/are not alive at the time of treatment.

          As per the Special Exclusion as referred above, the complainant is not entitled for any expenses incurred for IVF. Hence, we are of the concerted view that Opposite Parties rightly repudiated the claim of the complainant as per terms and conditions of the policy.

9.       In view of the discussion above, the instant complaint is hereby dismissed. Keeping in view the peculiar circumstances of the case, the parties are left to bear their own costs. Copies of the order be furnished to the parties free of cost. File be consigned to record room after compliance.

Announced in Open Commission