Tamil Nadu

North Chennai

CC/111/2017

E. Yuvarani Medical Research Foundation - Complainant(s)

Versus

The Chairman ICICI Lombard General insurance co Ltd - Opp.Party(s)

M/s.Vasudevan.K.Anand,S.Kavitha

18 Feb 2020

ORDER

 

                                                            Complaint presented on: 08.08.2017

                                                               Order pronounced on: 18.02.2020

 

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHENNAI (NORTH)

2^nd Floor, Frazer Bridge Road, V.O.C.Nagar, Park Town, Chennai-3

 

PRESENT:  TMT.K.LAKSHMIKANTHAM, B.Sc., B.L., DTL.,DCL, DL & AL -  PRESIDENT

 

TMT.P.V.JEYANTHI B.A., MEMBER - I

 

TUESDAY  THE 18^th DAY OF FEBRUARY  2020

 

C.C.NO.111/2017

 

E.Yuvarani,

Medical Research Foundation,

Sri Sankara Nethralaya,

No.18, College Road,

Nungambakkam, Opp. To DPI Campus,

Chennai – 600 006.

                                                                                     …..Complainant

 ..Vs..

1.The Chairman,

ICICI Lombard General Insurance Company Ltd.,

Registered Office at ICICI Lombard House,

414, Veer Sarkar Marg,

Near Sidhi Vinayagar Temple,

Prabhadevi, Mumbai – 400 025.

 

2.The Director,

ICICI Lombard General Insurance Company Ltd.,

Ground and 4^th Floor, Interface II,

Office No.401 and 402, New Linking Road,

Malda (West), Mumbai – 400 064.

 

3.Chief – Underwriting & Claims,

For ICICI Lombard General Insurance Company Ltd.,

Plot No.12, Financial District,

Manakaram Guda, Gachibowli,

Hyderabad – 500 032, Telangana.

 

4.The Manager,

ICICI Lombard General Insurance Company Ltd.,

No.140, Chotabhai Centre, 3^rd Floor,

Nangambakkam High Road,

Nungambakkam, Chennai – 600 034.

 

.....Opposite Parties

Counsel for Complainant                         : M/s.R.Vasudevan, K.Anand, S.Kavitha

 

Counsel for  opposite parties                      : Mrs.Elveera Ravindran, K.Vinod

 

ORDER

 

BY PRESIDENT TMT.K.LAKSHMIKANTHAM, B.Sc., B.L., DTL.,DCL, DL & AL

          This complaint is filed by the complainant u/s 12 of the Consumer Protection Act.1986.

1.THE COMPLAINT IN BRIEF:

          The complainant is a pregnant lady. The complainant took the referred policy vide policy No.41281/IH/117163682/00/000 covering period from 27.05.2016 to 26.05.2017 for a sum of Rs.10,00,000/- by paying an annual total premium of Rs.10,667/-. While so, all of a sudden on 04.08.2016 due to sudden bleeding to the complainant, she was taken to the Apollo Hospital where she was regularly treated by the gynecologist doctor and after observation of the doctors, they advised the complainant to get immediately admitted in the hospital for further observation. The complainant was admitted in Apollo Hospital on 04.08.2016 for the further observation. The doctors advised the complainant’s family and the complainant that the condition of mother and baby was critical. On the same day (09.08.2016) a female baby was born but the condition of the mother (complainant) was very critical and her life was under the threat.  As such she required all sorts of medical administration in order to safeguard the life of the complainant as advised by the treating medical practitioners at Apollo Hospital. After admitting the complainant herein the Apollo First Med Hospital, 154, P.H.Road, Kilpauk,  Chennai – 10,  on 04.08.2016 a cashless request was sent to 1^st and 2^nd opposite parties  through hospital for pre-authorization request, which was denied by 1^st and 2^nd opposite parties.  The complainant states that the medical expenditure bill demanded by the Apollo Hospital for the period from 04.08.2016 to 31.08.2016 was an amount of Rs.21,02,197/-.   The hospital was pleased to discount an amount of Rs.4,00,000/- out of Rs.21,02.197.74 which amounts to Rs.17,02,197.74/-.  On 24.11.2016 the claim was rejected stating as per policy terms and conditions and as per II of the schedule exclusion 3.3. On 17.07.2017,the complainant through her lawyer sent a legal notice to all the opposite parties. Even after the receipt of legal notice no fruitful result was received from the hands of opposite parties. Hence the complaint.

2. WRITTEN VERSION OF THE   OPPOSITE PARTIES IN BRIEF:

           Health Insurance Policy bearing No.4128 i/iH/117163682/00/000 covering the complainant and her daughter Minor KARTHIKA J was issued  for the period from 27.05.2016 to 26.05.2017 for a sum assured of Rs.10 lakhs on payment of the premium of Rs.10,667/-. From the documents submitted it is seen that the complainant was a known case of diabetes, three months on insulin, having a previous surgical procedure LSCS (lower segment caesarean section) done in 2011, which was substantiated by the Discharge Summary issued by Apollo First Med Hospital and such mandatory information was suppressed at the time of inception of the policy, thereby depriving the opposite parties of either rejecting the policy or issuing the policy. The opposite parties submit that they had rightly repudiated  her claim, as per the terms and conditions of the policy of insurance and such terms and conditions are based  on the principles laid down by the IRDA and nothing can be added or deleted there from. The complaint is liable  to be dismissed.

3. POINTS FOR CONSIDERATION:

          1. Whether there is deficiency in service on the part of the opposite parties?

          2. Whether the complainant is entitled to any relief? If so to what extent?

4. POINT NO :1 

          The complainant  availed medical Health Insurance policy bearing No41281/IH/117163682/00/000 for  the period  from 27.05.2016 to 26.05.2017 covering the complainant  and her daughter Minor. Karthika for a total assured sum of Rs.10,00,000/-. The complainant paid the annual premium of Rs.10,667/- for the policy named as ICICI Lombard Nibhaye Vaade (I Health Policy) vide Ex.A1. The case of the complainant is that she had disclosed all her health conditions including her pregnancy and there is no question of suppression of facts. On 04.08.2016 due to sudden bleeding the complainant was admitted immediately at Apollo Hospital as per the advice of the Doctor where she was treated regularly by a Gynecologist.  The complainant was under continuous observation by her doctor for 4 days, thereafter due to the poor condition of the complainant  and as per the advice of the doctor she underwent Caesarian  Operation. She delivered a female baby on 09.08.2016 and she was in need of medical administration further to safeguard of the life of the patient.

             05.  On 04.08.2016 cashless request was made vide Ex.A2 through the hospital for pre-authorisation and the same was denied emphasizing for claim through reimbursement process after discharging from the hospital by their letter dated  15.08.2016  in Ex.A3. The complainant  was discharged on 31.08.2016 with her new born baby  and the  discharge summary  is  Ex.A4. The complainant  was charged with a bill of Rs.17,02,197/- after a discount of Rs.4,00,000/- . The complainant  paid the amount and then  she was discharged. Duplicate bills are submitted under Ex.A11. On 19.09.2016 the complainant  submitted the original bills and the other documents  to the  3^rd opposite party for reimbursement under Ex.A5. On 17.10.2016 the claim was rejected by the opposite parties vide Ex.A6 for the reasons as the “expenses incurred on treatment of hysterectomy within first two years from the commencement of the policy is not payable and also any expenses incurred on treatment arising from or traceable to pregnancy (including voluntary termination of pregnancy, childbirth, miscarriage, abortion or complications of any of these,  including caesarean section) and any fertility, infertility, sub fertility or assisted conception treatment or sterilization or procedure, birth control procedures and hormone replacement therapy” are excluded. E-mail correspondence to the opposite parties by the complainant  dated  22.11.2016 and the objections forwarded to the concerned team are Ex.A7 & Ex.A8. Finally it was rejected by the opposite parties  under Ex.A9. Legal notice was issued by the complainant on 15.12.2016 and on 17.07.2017. Copy of the notice with acknowledgement card are under Ex.A10 & Ex.A13.  Policy documents are in Ex.A12.

           Terms and conditions of policy as in Ex.B2 in section3.3 and Sub-clause iii, reads as “Any Medical Expenses incurred by you on treatment of following illnesses within the first two (2) consecutive years of period of Insurance  Start Date: i. Cataract*  ii. Benign Prostatic Hypertrophy   iii. Myomectomy. Hysterectomy unless because of malignancy”

As per the above terms of policy, in simple words the exclusion does not apply to ectopic pregnancy proved by diagnostic means and is certified to be life threatening by the medical practitioner. As per the discharge summary in Ex.A4 the complainant was diagnosed as 1.G2P1L1 with previous LSCS  at 35 weeks GA with GDM on insulin with placenta Previa and Accreta 2. Massive post partum haemorrhage. 3. Diffuse SAH with Intracranial Haemorrhage. The complainant underwent surgery of 1.Ceserean Subtotal Hysterectomy 2. Relaparotomy, Exploration, completion of subtotal Hysterectomy. This does not constitute an ectopic pregnancy and from the discharge summary the patient underwent the above said surgery only for postpartum Haemorrhage complications due to placental abnormalities  (placenta Previa & placenta accreta) and not due to ectopic pregnancy. In Medical terminology, “ectopic pregnancy” means “a pregnancy in which the fertilized egg implants outside the uterus” but here is not the case as per the medical report submitted by the complainant.

  06. The learned counsel for complainant had presented the citations which are totally based on ectopic pregnancy. Hence those case studies are not applicable to the circumstances of the present case.  The focusing point on the side of the complainant  is towards the emergency and accidental admission due to bleeding  and for safe delivery of the complainant, , but the exclusion clause means only for ectopic pregnancy proved by diagnostic means and is certified to be life threatening by the medical practitioner. Ex.A15 only reveals that there is a complicated delivery for the complainant but it is not an ectopic pregnancy as per the policy clause 3.3. Sub clause xiii and excluded the medical expenses incurred within the first two consecutive years of period of insurance start date such as Myomectomy, Hysterectomy unless because of malignancy. Here the claim is for Hysterectomy with no Malignancy. Therefore the claim is repudiated and on the terms and conditions of the policy based on the principles laid down by IRDA.

             07. As put forth by opposite parties the contract of Insurance is a contract of Uberrimaefidei and both the contracting parties are bound by the terms and conditions of the policy of insurance and having agreed the terms and conditions the complainant is bound to adhere to the terms and conditions. Hence the claim repudiation is based on the terms and conditions of the policy by the opposite parties  and  does not amount to deficiency in service.  It is concluded that there is no deficiency in service on the part of opposite parties.

08. POINT NO.2:

         In the light of aforesaid discussions in the absence of deficiency in service on the part of opposite parties, the complainant is not entitled to any relief against opposite parties and the complaint is liable to be dismissed.

          In the result, this complaint is dismissed. No costs.

          Dictated to the Steno-Typist transcribed and typed by her corrected and pronounced by us on this 18^th  day of February 2020.

 

MEMBER – I                                                                PRESIDENT

LIST OF DOCUMENTS FILED BY THE COMPLAINANT:

Ex.A1 dated 27.05.2016          Policy No.41281/IH/117163682/00/000

Ex.A2 dated 04.08.2016          Cashless request

Ex.A3 dated 15.08.2016          Denial of cashless access

Ex.A4 dated 31.08.2016          Discharge Summary

Ex.A5 dated 09.09.2016          Submission of reimbursement (all original bills & documents forwarded)

Ex.A6 dated 17.10.2016          Rejection of claim on hyper technical ground

Ex.A7 dated 22.11.2016          E-mail to opposite party to consider the reimbursement claim

Ex.A8 dated 23.11.2016          Forwarding the objection to concerned team for consideration

Ex.A9 dated 24.11.2016          Rejection of claim stands valued

Ex.A10 dated 15.12.2016        Legal notice to opposite parties with a acknowledgement card

Ex.A11 dated NIL                   Duplicate bills

Ex.A12 dated NIL                   Policy documents

Ex.A13 dated 17.07.2017        Legal notice with AD card

Ex.A14 dated 18.08.2017        Letter issued by Apollo Hospital

Ex.A15 dated 22.02.2018        Letter issued by Apollo Hospital       

LIST OF DOCUMENTS FILED BY THE OPPOSITE PARTIES:

 

Ex.B1 dated NIL                      Policy of insurance

Ex.B2 dated NIL                      Terms and conditions of the policy

Ex.B3 dated NIL                      Cashless request

Ex.B4 dated NIL                      Denial of cashless request

Ex.B5 dated NIL                      Letters sent by opposite parties to complainant

Ex.B6 dated NIL                      Letters sent by opposite parties to complainant

 

 

 

MEMBER – I                                                               PRESIDENT