1.                     The brief facts of the case of the complainant are that, he obtained an insurance policy bearing No.52709289 for 5 members of his family from the Ops on 24.11.2016 for a sum assured of Rs.3, 00,000/- for the period covered from 28.11.2016 to 27.11.2017.  It is submitted that the wife of the complainant who was an insured under the said policy suffered from N20.1 – CALCULUS URETERIC (URETERIC STONE) as diagnosed by the Urologist, Dr. N. Naidu Ch., Apollo Hospital, Visakhapatnam.  She was advised for operation on 22.3.2017 and the complainant was admitted in the said hospital as tagged by the Ops and after operation she was discharged on 24.3.2017.  It is further submitted that the complainant being the proposer of the policy advanced the claim before the Ops for the expenditure of Rs.37, 081/- incurred towards treatment of his wife but in spite of written grievance, the Ops are not responding.  Thus alleging deficiency in service on the part of the Ops, he filed this case praying the Forum to direct the Ops to pay Rs.37, 081/- towards treatment expenditure with interest @ 18% p.a. and to pay Rs.20, 000/- towards compensation to the complainant.

2.                     The Ops filed counter in joint denying the allegations of the complainant but admitted about the Family Health Protector Policy vide No.52709289 issued in favour of the complainant-proposer for period from 28.11.2016 to 27.11.2017 for covering the risk up to the basic sum assured of Rs.3.00 lacs.  It is contended that the cashless request was received from Apollo Hospital, VSP with respect to Mrs. A. Gouri Parvati on 23.3.2017 and the Ops sent a discrepancy letter to the said hospital.  On receipt of report of the hospital it was found that the patient was taking treatment for Ureteric Calculus and waiting period of 2 years is applicable for the same.  As the policy was running in its first year, they denied the request on 24.3.2017.  It is also contended that the complainant has submitted claim documents which were examined and found that the claim was not admissible as per policy terms and conditions and hence the claim was repudiated through their letter dt.05.05.2017.  Thus denying any deficiency in service on their part, the Ops prayed to dismiss the case of the complainant.

3.                     Parties have filed certain documents in support of their cases.  The complainant only filed affidavit.  The Ops also filed written argument.  Heard from the parties through their respective A/Rs and perused the materials available on record.

4.                     In this case, Family Protection Health Plan bearing No.52709289 covering the period from 28.11.2016 to 27.11.2017 issued by the Ops in favour of the complainant and 4 other members of his family for a sum assured of Rs.3.00 lacs as admitted by the parties.  The complainant submitted that, his wife Smt. A. Gouri Parbati suffered Ureteric Calculus (Ureteric Stone) problem as diagnosed by Urologist, Dr. N. Naidu Ch. At Apollo Hospital, VSP and was admitted in the said hospital for stone removal on 22.3.2017 and discharged on 24.3.2017.  The case of the complainant is that he submitted claim related documents before the Ops who have neither reimbursed nor replied to the complainant.

5.                     According to the Ops, after receipt of cashless request in respect of insured, A. Gouri Parbati from the Apollo hospital on 23.3.2017, they immediately sent a discrepancy letter to the said hospital to provide documents to process the cashless request and on receipt of documents they found that the claim of the complainant was not admissible as per policy terms and conditions.  The Ops intimated the fact of repudiation on 05.05.2017 to the complainant inter alia citing the exclusion clause at 4(a) under the policy. We have carefully gone through the extract of clause 4(a) of the policy which says that, any expenditure incurred in the first two continuous years of operation of the insurance cover on treatment of Gall Bladder, Billiary, Renal & Urinary Stones comes under exclusion clause.  As admitted by the parties, the insured was diagnosed for Ureteric Calculus (Ureteric Stone).  Now the sole question emerges importance for consideration is whether Ureteric calculus (Ureteric stone) and Urinary stone as mentioned in the policy clause are one and same or it differs to each other.

6.                     In order to know the basic facts of the Ureteral Stone, we have followed the Medical Glossary and found that Kidney stones are rocklike accumulations that form from naturally occurring mineral salts in the urine and can become lodged in the Ureter (Kidney Tube).  Such Stones form in the Kidney and migrate in to the Kidney tubes or ureters.  Those are called Ureteral Stones.  Further stones can remain in the kidney for years without causing any problems.

7.                     The exclusion clause of the insurance policy says about urinary stones which blocks urinary track and as such we found a visible difference in the meanings between urinary stone and Ureteral stones as per medical glossary.  In the present case, the complainant has advanced claim for treatment of his wife in connection with Ureteric stones but not urinary stones.  As we find two different meanings after studying the nature of cases between Ureteric and urinary stones, it can be safely held that the disease for which the insured received treatment is not coming under exclusion clause and the Ops without application of their mind have repudiated the claim of the complainant which in our opinion, amounts to deficiency in service on their part.  Therefore, the repudiation is arbitrary as done by the Ops.

8.                     In view of above facts, the complainant is entitled to get the claim of Rs.37, 081/- with interest @ 12% p.a. from the date of discharge from the hospital i.e. 24.3.2017, the claim documents for which have already been submitted before the Ops.  Further due to such inaction of the Ops, the complainant must have suffered some mental agony and has also come up with this case incurring some expenditure.  Considering the sufferings, we feel, a sum of Rs.5000/- towards compensation and costs in favour of the complainant will meet the ends of justice.

9.                     Hence ordered that the complaint petition is allowed in part and the Ops being jointly and severally liable are directed to pay Rs.37, 081/- with interest @ 12% p.a. from 24.3.2017 and to pay Rs.5000/- towards compensation and costs to the complainant within 30 days from the date of communication of this order.

(to dict.)