Smt. Syeda Shahnur Ali, President-in-Charge

This is a case over repudiation of Complainant’s claim by the OP.

Briefly narrated, case of the Complainant, is that he took a mediclaim policy from the OP, namely, Jeevan Arogya (Table 903) being policy no. 49962 1784 and the said policy started w.e.f. 28-08-2011.  His other family members, viz., his wife and two daughters were the other beneficiaries covered under the said policy.  While the said mediclaim policy was in vogue, his wife suffered Sinus Tract, high grade squamous intraepithelias lesion of cravix and got admitted at Apollo Hospital, Chennai on 21-12-2013. To undergo excision of Sinus Tract, Colposcopy and Large Loop excision of transformation zone was done and was discharged on the very same day and he had to incur an expenditure of Rs. 60,000/- for this purpose. Subsequently, his wife experienced some problems which was diagnosed as unspecified open wound of abdominal wall, unspecified quadrant with penetration into peritoneal cavity, for which she again got admitted at the said hospital on 10-02-2014 and was discharged from there on 13-02-2014 after undergoing curative surgery.  The hospital charged Rs. 1,10,000/- for performing the second surgery.  It is stated that necessary claim, along with all relevant medical papers, was lodged with the OP vide Claim No. T1209141964.  It is alleged that the OP illegally and malafidely repudiated the claim on 12-12-2014. Hence, this case.

Short case of the OP, on the other hand, is that the Complainant took a health insurance policy being no. 499621784 with DOC on 28-08-2011.  According to the OP, it is actually a benefit purchase plan with limited facilities and not a mediclaim policy. Under the health insurance policy, only for some defined treatments, certain percentage of sum assured is reimbursed irrespective of the actual costs.  It is stated that the first surgery, performed on the wife of the Complainant, does not fall within the category of major surgery of the health insurance policy.  However, Rs. 5,000/- is payable under the category of day care surgery in normal suitable cases.  It is admitted by the OP that the second surgery performed on the wife of the Complainant belongs to the category of major surgery and according to the OP, in suitable cases, this type of surgery qualifies for reimbursement of 60% of the sum assured. Moreover, for staying in the hospital for two days, reimbursement @ Rs. 1,100/-per day, i.e., Rs. 2,200/- would have been payable to the Complainant.  As such, Rs. 67,200/- would have been reimbursable in similar type of surgeries under normal suitable conditions.  It is stated by the OP that the claim of the Complainant was repudiated for non-supply of treatment papers for her previous operation that she underwent in the year 2011. It is claimed by the OP that the said operation has got direct bearing on the present operations and therefore, it needed the said papers.  Allegedly, the Complainant did not satisfy its need in this regard and as such, the claim has been rightly repudiated.

We are to decide, whether the Complainant is entitled to any relief, or not.

Decision with reasons

In order to arrive at a judicious decision over the bone of contention, we have perused all the relevant documents on record, including medical papers.  We have also given a thoughtful consideration to the arguments advanced by the Ld. Lawyers of both sides.      

It transpires from the repudiation letter dated 12-12-2014, issued by Medicare TPA Services (I) Pvt. Ltd. that the claim in question did not cut ice with the OP due to non-availability of treatment papers related to ligation. 

From the discharge certificate dated 23-08-2010 on record, issued by the Medical Officer, Khejurberia Block Primary Health Centre, Nandakumar, Purba Medinipur it appears that Complainant’s wife underwent Minilap sterilization on 23-08-2010.  However, it is mentioned in the discharge summery of Apollo Hospital dated 13-02-2014, that tubal ligation was performed on Complainant’s wife in the year 2011. As we know, the most common surgical sterilization procedure for women is called “tubal ligation”.  There are two common types of tubal ligation surgeries - the mini-laparotomy and the laparoscopy. It all likelihood, by mistake, the year of minilap sterilization/tubal ligation has been wrongly mentioned as 2011 in the discharge summary of Apollo Hospital. Against such backdrop, the preliminary objection of the OP of non-receipt of medical papers pertaining to ligation appears totally misplaced. 

Besides, it is contended by the OP that the tubal ligation performed on the Complainant’s wife has got direct bearings on the operations done in the year 2013 and 2014.

In an article, published in the Oman Medical Journal (2012) Vol. 27, No. 4: 326-328, under the title, ”Is Previous Tubal Ligation a Risk Factor for Hysterectomy because of Abnormal Uterine Bleeding?”, the authors duo, Sanam Moradan, Department of Obstetrics and Gynecology, Amir Hospital, Semnan University of Medical Sciences, Semnan, Iran and Raheb Gorbani, Faculty of Medicine. Semnan University of Medical Sciences ,Iran found that previous tubal sterilization is not a risk factor for undergoing hysterectomy because of abnormal uterine bleeding.

That apart, on a reference to the Claim Intimation Form, submitted on record by the Complainant, it transpires that the treating doctor has opined in unequivocal terms that the surgery performed on 21-12-2013 did not develop out of any pre-existing condition that the patient was suffering from.

On the other hand, although the OP has linked the two operative procedures, for some obscure reasons, it has not come up with any authentic medical text to drive home such point.  The notion, as articulated from the side of the OP, appears to be a complete misnomer and as such, the same is not acceptable to us.

Thus, we find that the OP did not apply its mind prudently before repudiating the claim of the Complainant.  We, therefore, hold that the Complainant is justifiably entitled to reimbursement of his claim.

Now, let us consider the quantum of relief, the Complainant is entitled to.  Complainant has claimed reimbursement of cost to the tune of Rs. 1,10,000/- besides other relief, such as, compensation, litigation cost.  On the other hand, the OP has figured out the entitlement of the Complainant to the tune of Rs. 67,200/- and placed on record a specimen copy of OP’s Jeevan Arogya Conditions and Privileges for our reference.  On a tour through the same vis-à-vis the method of calculation to figure out the compensation figure as illustrated by the OP in it’s WV, we find the same is in consonance with that of the terms and conditions of the health insurance policy in question.   

We, thus, hold that the Complainant is entitled to the reimbursement of Rs. 67,200/- towards full and final settlement of his claim.  Besides, taking into consideration the facts and circumstances of the case, in the interests of justice and equity, we award a compensation of Rs. 20,000/-  and another sum of Rs. 10,000/- as litigation cost in favour of the Complainant.

Thus, the present complaint case succeeds in part.

Hence,

O R D E R E D

that C. C. No. 41/2016 be and the same is allowed on contest against the OP.  The OP is directed to pay, within 40 days hence, a sum of Rs. 67,200/- to the Complainant towards full and final settlement of the claim amount together with compensation and litigation cost for a sum of Rs. 20,000/- and Rs. 10,000/-, respectively, i.d., Complainant would be at liberty to execute this order in accordance with law in which case, OP shall be liable to pay interest @ 8% p.a. over Rs. 97,200/- from this day till the order is complied with in toto.