By Smt. C.S. Sulekha Beevi, President,
1. Complainant is the wife of Adathil Noushad who is the authorized dealer of Duroflex (P) Ltd. M/s Duroflex provided a personal accident and medical policy under the name and style of “Universal Health Policy” in favour of Adathil Noushad and family with first opposite party for the period 18-4-2007 to 17-4-2008. While so, the complainant was admitted on 31-5-2007 at AlNoor Hospital, Tirur, with complaints of vomiting, chest pain and breathlessness. She was treated as inpatient in the said hospital till 13-6-2007. Due to illness she was again admitted in Baby Memmorial Hospital, Kozhikkode and treated as in patient till 23-7-2007. On investigation it was found that complainant had acute pancreatitis. Complainants USG showed severe oligohy draminos and continuing the pregnancy was detrimental. Hence a caesarian section followed by exploratory laprotomy was done. The lesser sac was opened, fluid drained and omentectomy done. During the period complainant suffered a lot and incurred expenses of rs.88,698/- for medicine and hospital expenses. After complainant was discharged from hospital she preferred claim under the above policy before first opposite party. The claim was repudiated stating that the treatment was done with respect to pregnancy and child birth. Complainant alleges that opposite parties have repudiated the claim on unsustainable grounds. Hence this complaint. 2. First opposite party has filed version admitting the issuance of Universal health policy to Adathil Noushad for the benefit of the dealer and his family members. That the policy specifically excludes the treatment and expenses in relation to pregnancy and child birth as per exclusion No. 4.12 of the policy. That as per prospectus of the Scheme exclusion No.3.13 the treatment and expenditure related to the pregnancy and child birth is excluded. That after verifying the documents produced along with claim form and also as per medical opinion obtained from the doctor who treated the complainant it was understood that the nature of illness was pregnancy with acute pancreatitis. Since the illness contracted by complainant was excluded as per the policy first opposite party repudiated the claim and the same was intimated to complainant on 03-10-2007. That the nature of illness given by the complainant in claim form is pregnancy with acute pancreatitis and the medical opinion received from the doctor, who treated the complainant also confirm the pregnancy. That it is understood from the medical records that after completing full pregnancy the complainant had given birth to a full grown baby. That under sub section 1.2 in the event of any claim becoming admissible it is limited to that as stated in the policy. That there is no deficiency in service and complaint is only to be dismissed. 3. Evidence consists of affidavits filed by both sides in support of their pleadings. Exts.A1 to A11 marked on the side of complainant. Exts.B1 to B4 marked for opposite party. 4. Points for consideration:- (i) Whether opposite parties are deficient in service.
If so, reliefs and costs.
5. Point (i):- The only question that poses for consideration in regard to deficiency in service is whether the act of first opposite party repudiating the claim for the reason that the treatment and expenditure is related to pregnancy and child birth and therefore comes within the exclusion of 4.12 of the policy is justifiable or not. 6. Admittedly complainant was pregnant at the relevant period for which benefit under the policy was claimed. According to complainant she suffered from chest pain, vomiting breathless etc. and was admitted in the hospital. Only after investigation her disease was diagnosed as acute pancreatitis for which she underwent treatment. Since the scan report showed that continuation of pregnancy was detrimental a caeserian section was performed by which she had a baby. After this operation, treatment for pancreatitis was done. It is contended by complainant that the illness for which she availed treatment was not at all related to pregnancy and child birth but it only happened to be that she was pregnant at that time. Complainant placed reliance on Ext.A6, which is a treatment certificate issued by Dr.Sabitha Nithyanandan who is a Gynaecologist of Baby Memorial Hospital, from where complainant underwent the treatment for pancretatits. The relevant portion of Ext.A6 reads as under: “It may be noted that acute pancretatitis is a disease affecting the pancreas and it is not related to pregnancy. It is co-incidental that she acquired the disease while she was pregnant.”
Ext.A6 sufficiently proves and establishes the contention of the complainant that she was not admitted and treatment for any disease related to pregnancy and child birth. Except the nebulous affirmation in the counter affidavit opposite party has failed to adduce any evidence to substantiate that the illness is related to pregnancy and child birth. We therefore have no hesitation to conclude that the disease, for which treatment was undertaken is not related to pregnancy and child birth and will not come within the purview of exclusion 4.12 of the policy. The repudiation of policy on such flimsy grounds without due application of mind amounts to deficiency in service. We therefore find opposite parties deficient in service. 7. Point (ii):- Complainant claim Rs.88,898.85/- towards expenses incurred for treatment, Rs.25,000/- as compensation for mental agony and hardships and Rs.1,000/- towards cost. It was submitted by counsel for opposite party Smt.Pushpakumari that the liability if any is limited as per condition in clause 1.2 of the policy. Ext.B1 is the condition of policy and clause 1.2 reads as under: In the event of any claim becoming admissible under the scheme, the company will pay through TPA to the Hospital/Nursing Home or insured person the amount of such expenses as would fall under different heads subject to limits mentioned below and as are reasonably and necessarily incurred thereof by or on behalf of such insured person.
Hospitalisation Benefits Limits A. (i) Rooms, Boarding expenses as provided by i) Upto 0.5% of Sum Hospital/Nursing Home. Insured per day
If admitted in IC Unit ii) Upto 1% of Sum Insured
per day.
B. Surgeon, Anesthetist, Medical Practitioner, Upto 15% of Sum Insured Consultants, Specialists, Fees, per illness/Injury. Nursing Expenses.
C. Anesthesia, Blood, Oxygen, OT charges, Surgical appliances, Medicines, Upto 15% of Sum Insured drugs, Diagnostic material & X-Ray, per illness/Injury
Dialysis, Chemotherapy, Radiotherapy, cost of pacemaker, artificial limbs.
N.B. (a) Total expenses incurred for any one illness is limited to Rs.15,000/-.
(b) Company's Liability in respect of all claims admitted during the period of Insurance shall not exceed the Sum Insured of Rs.30,000/- per person or family as mentioned in the Schedule.”
Thus as per the said stipulation the liability of opposite party shall not exceed Rs.30,000/-. Complainant is definitely entitled to this amount of Rs.30,000/-. She is to be compensated for the deficiency meted by her. For the illegal retention of legitimate amount by opposite party, we hold that complainant is entitled to interest @ 9% per annum upon the above amount from the date of complaint till payment, together with costs of Rs.2,000/-, which according to us would meet the ends of justice. 8. In the result we allow the complaint and order both opposite parties to jointly and severally to pay to the complainant Rs.30,000/- (Rupees thirty thousand only) along with interest @ 9% per annum from the date of complaint till payment within three months from the date of this order failing which opposite parties shall be liable to pay interest @ 12% per annum from date of this order in addition. Opposite parties shall also pay to complainant Rs.2,000/- as costs of this proceedings.
Dated this 13th day of January, 2009.
Sd/- C.S. SULEKHA BEEVI, PRESIDENT
Sd/- MOHAMMED MUSTAFA KOOTHRADAN, Sd/- MEMBER E. AYISHAKUTTY, MEMBER
APPENDIX
Witness examined on the side of the complainant : Nil Documents marked on the side of the complainant : Ext.A1 to A11 Ext.A1 : Policy Certificate from 18-4-2007 to 17-4-2008 Ext.A2 : Policy Certificate from 18-4-2006 to 17-4-2007 Ext.A3 : Universal Health Insurance Policy (Policy conditions Book-let). Ext.A4 : Letter dated,03-10-2007 of Duroflex (Pvt.) Ltd. Ext.A5 : Photo copy Ext.A6 : Treatment Certificate. Ext.A7 : Photo copy of the letter dated, 11-7-2007 by opposite party to Dr.Sabitha Nithyanandan. Ext.A8 : Policy Certificate from 18-4-2007 to 17-4-2008 Ext.A9 : Medical Certificate. Ext.A10series : Bills (14 Nos.) Ext.A11series : Bills (41 Nos.) Witness examined on the side of the opposite parties : Nil Documents marked on the side of the opposite parties : Ext.B1 to B4 Ext.B1 : Photo copy of the Universal Health Insurance Policy (Policy conditions Book-let) Ext.B2 : Photo copy of the Prospectus Universal Health Insurance Scheme (Individual) Ext.B3 : Photo copy of the Medical certificate. Ext.B4 : Photo copy of the Universal Health Insurance Claim Form submitted by complainant.
Sd/- C.S. SULEKHA BEEVI, PRESIDENT
Sd/- MOHAMMED MUSTAFA KOOTHRADAN, Sd/- MEMBER E. AYISHAKUTTY, MEMBER
......................C.S. SULEKHA BEEVI | | 
