FINAL ORDER/JUDGMENT
Presented by:
Minakshi Chakraborty, Presiding Member.
Brief facts of the case: This case has been filed U/s. 35 of the Consumer Protection Act, 2019 by the complainant stating that the complainant No.1 is the proposer and complainant no.2 is the insured person of the Medical insurance policy, vide policy no.153600592110000011, dt. 05.04.2021 of National Insurance Co. Ltd. i.e. OP no.1 and the aforesaid medical insurance policy is issued from Branch office Chandannagar of National Insurance Co. Ltd., situated at Bhudeb Mukherjee Road, PO & PS – Chandannagar, Dist-Hooghly, Pin-712136, which is within the jurisdiction of this forum and complainant no.1 being the proposer of aforesaid medical insurance policy, vide policy no. 153600592110000011 dt. 05.04.2021 of National Insurance Co. Ltd is regularly paying premium and hence falls under the perview of the definition “CONSUMER’’ under Sec 2(7) of Consumer Protection Act, 2019 and the brief fact of the case is that the insured, mentioned hereinabove was suffering from heavy vaginal bleeding. She consulted with local gynecologist, who advised her to undergo USG of Lower Abdomen. Accordingly she went to Dr. Datta’s Clinic at Chandannagar and undergone USG. In the said USG primary impression of the Technician Doctor “Gravid Bulky uterus having well outlined empty G. Sac without any definite viable foetal pole – G sac of 6 week duration with surrounding minimal area of fluid collection in subchorionic space please correlate with features of threatened abortion.” After that complainant no.2 went to the concerned Doctor and said Doctor relying on the USG report dt.19.04.2021 advised the complainant no.2 to abort the fetus by taking pills. As per the advice of concerned Doctor complainant took pills but the bleeding continues, hence for second opinion the complainant no.2 went to Cradle Fertility Center and visited Dr. Syed Monajatur Rahman, who advised to have a further USG report, accordingly on 06.05.2021 his complainant conducted USG from Accucare Diagonastic Centre, wherein it was for the first time it was detected as “Ectopic Pregnancy”, however they suggested to undergo TVS and Beta HCG titer for confirmation. Another USG of Pelvis was done on 6.05.2021 wherein it was the impression of Doctor / USG technician that “Bulky uterus with incomplete abortion with probable myometrial invasion by chronic tissue”. Thereafter on 24.05.2021 USG-TVS was conducted Dr. H. Qureshi at Cradle Diagnostic Center, wherein it has been confirmed that it is a case of “SCAR ECTOPIC PREGNANCY” and after TVS and considering the health condition of complainant no.2, it has been advised to go through operation immediately, accordingly Dr. H. Qureshi conducted Laparoscopy surgery to remove the “Ecotopic Pregnancy” on 24.05.2021 at Kasturi Medical Centre Pvt. Ltd. and she was discharged on 26.05.2021 with final diagnosis of “CESARIAN SCAR ECTOPIC PREGNANCY”.
Complainant No.1 paid the bill of hospitalization and submitted claim Form to OP no.2 (TPA) for reimbursement of Rs.73,566/- on 14.07.2021 at the office of OP no.1. On 02.07.2021 complainant no.1 send one reminder mail to OP no.1 and stated that he came to know from his agent that their claim is not accepted by TPA but it has not been officially communicated to the complainant and seeks for an opportunity to clarify and query raised by TPA. Thereafter the complainant no.1 send one certificate issued by treating doctor to the TPA but even after providing all necessary documents their claim remain unsettled, hence on 07.02.2022 the complainant no.1 sent several e-mail to OP no.1 on 07.09.201** OP no.1 informed complainant through e-mail that OP no.2 is of the opinion that the claim is not related with Ectopic Pregnancy, hence OP no.1 is going to issue repudiation mail shortly. Accordingly on 07.09.2021 OP no.1 issued claim repudiation letter with a final observation that on 21.04.2021 “Patient has bleeding per vaginum so she took MTP pills for abortion on 21.04.2021, report dt.16.05.2021 showed bulky uterus with incomplete abortion…. Hence it is not an Ectopic Pregnancy”.
The real fact is that complainant no.2 was initially diagnosed as threatened abortion in USG and she took some medication on abortion, depending on USG report but as she was having continuous heavy bleeding P/V for which she was undergone TVS and it was detected that gestational sac implanted on previous casesarian Scar, which in medical terminology known as Ectopic Pregnancy. This was missed on initial USG. As Ectopic pregnancy is a uncommon phenomenon so there was diagnostic dilemma. Taking advantage of diagnostic the OP-2 misinterpreted the USGH reports and arbitrarily repudiated genuine claim of Complainant.
Complainant filed the complaint petition praying direction upon the opposite party to pay a sum of Rs. 73566/- and to pay a sum of Rs. 2,00,000/- for sufferings and mental agony and to pass any other order or orders as deem fit and porper.
Evidence on record
The complainant filed evidence on affidavit which is nothing but replica of complaint petition and supports the averments of the complainant in the complaint petition.
Argument highlighted by the ld. Lawyers of the parties
Complainant has filed written notes of argument. As per BNA the evidence on affidavit and written notes of argument of complainant shall have to be taken into consideration for disposal of the instant proceeding.
Heard argument of complainant at length. In course of argument ld. Lawyer of complainant have given emphasis on evidence and documents produced by the him.
From the discussion hereinabove, we find the following issues/points for consideration.
Issues/points for consideration
- Whether the complainant is the consumer?
- Whether this Forum has territorial/pecuniary jurisdiction to entertain the case?
- Whether there is any deficiency of service on the part of the opposite parties?
- Whether the complainant is entitled to get relief?
DECISION WITH REASONS
Issue no.1:
In the light of the discussion hereinabove and from the materials on record, it transpires that the complainant is a Consumer as provided by the spirit of Section 2 (7) of the Consumer Protection Act, 2019.The point is thus answered in the affirmative.
Issue no.2:
Both the complainants and the opposite parties are residents/having their office addresses within the district of Hooghly and the claims do not exceed the pecuniary limit of this commission. This point is thus disposed of accordingly.
Issue nos. 3 & 4:
Both the issues are taken up simultaneously for the sake of convenience. The specific case of the O.P (national insurance company, to be addressed as the O.P) as has been reported in its letter dated 07.09.2021 that on 21.04.2021 petitioner no. 2 has bleeding her vagina so she took MTP pills for abortion. Report dated 16.05.2021 showed bulky uterus with incomplete abortion with myometrial invasion of retained product of conception and written report dated 06.05.2021 showed bulky uterus with ROPC in cavity and invasion of RPOC in previous LSCS scar. It further appears therein that on the bases of the above documents the O.P concluded the chapter stating, “implantation occurred within cavity of uterus not in caesarean scar and only RPOC extension has been seen in previous scar and in that view of the matter the O.P has concluded the chapter by saying, “it is not an ectopic pregnancy” and as such petitioner’s clam has been repudiated.
In such juncture this commission can not close its eye to the valuable document of Dr. Syed Monajatur Rahman dated 12.08.2021 wherein it appears that petitioner no.2 was under his care and after confederation of the entire case this Dr. Rahman concluded on finding of the previous reports she (petitioner no.2) was diagnosed to have Scar Ectopic Pregnancy and was advised surgery for the same. Scae Ectopic Pregnancy is an uncommon phenomenon so there may be Diagnostic Dilemma on USG which led to discrepancy between initial USG report and latter one.
This certificate in question has referred to discrepancy between initial USG report and latter one and also diagnostic dilemma.
In support of their case the petitioners have submitted one reference being apple no A-115/2004 with its decision 19.04.2007 wherein it has been observed the definition of Ectopic Pregnancy as “ectopic pregnancy is any pregnancy that occurs outside the uterus. The vast majorities of these are in the fallopian tubes……………………………It is very serious because when the pregnancy grows in these abnormal areas it can easily cause massive , rapid bleeding, which can result in a decrease in fertility and even death.” On consideration of the above facts the previous USG and the opinion of the Doctor dated 19.04.2021 to abort the fetus by taking pills can not be the reason for repudiation of the clam of the petitioner no.2 .
In this connection this commission is fortified with the observation“ it is the universal rule of interpretation of statutes or contract that contract has o be taken as a whole and interpreted in consonance with its aims and objects. The predominant object of mediclaim insurance policy is to reimburse the insured as to the medical expenses incurred by him towards hospitalization and operation or treatment in the hospital.
Admittedly taking assistance of the certificate issued by Dr. Rahman dated 12.08.2021 stated Supra we should keep in mind that where two interpretations are possible the interpretation promote the object of the contract and serving the interests of the consumer should be resorted to it is also rule of interpretation that the terms, words and phrases in the contract should not be given literal and verbatim meaning. “ they should be provided lateral, liberal meaning so as to fulfill the object of the contract and not with a view to frustrate the object and jeopardize the interests of the person for whose benefit the statute or the contact was made .
In view of the observation this commission is of the view that the petitioner no. 2 be provided with the remedy of compensation about the actual loss suffered by petitioner no.2 Dr. Sufua Khatun due to the deficiency on the part of the National Insurance Company Ltd.
Both the issues are thus disposed of.
Hence,
Ordered
The complainant case no. 42 of 2022 is decreed ex parte against the National Insurance Company Ltd. and against branch manager Medsave health insurance (TPA) Ltd.
The petitioner no.2 do get the clam amounting to Rs.73,566/- she also do get Rs.20,000/- for sufferings pain and mental agony. The O.P no. 1 do pay the aforesaid quantum of money within 45 days from date failing which the petitioner no. 2 be at liberty to take recourse to law.
Let a plain copy of this order be supplied free of cost to the parties/their ld. Advocates/Agents on record by hand under proper acknowledgement/ sent by ordinary post for information and necessary action.
The Final Order will be available in the following website www.confonet.nic.in.
