District Consumer Disputes Redressal Commission, Hooghly
PETITIONER
VS.
OPPOSITE PARTY
Complaint Case No.CC/12/2019
(Date of Filing:-21.01.2019)
- Sri Tanmoy Dutta
Mallick Lane, Kharua Bazar,
P.O. & P.S. Chinsurah
Dist. Hooghly, Pin:- 712101.…..complainant
- The Divisional Manager,
New India Assurance Company Ltd.
Chinsurah Division, G. T. Road, Khadina More,
P.O. & P.S. Chinsurah, District:-Hooghly, Pin:- 712101.
- The Vice President,
Medicare Insurance TPA Services (India) Pvt. Ltd.
Flat No. 10, Paul Mansions,
6B, Bishop Lefroy Road, Kolkata-700020
Before:-
Mr. Debasis Bhattacharya, Member
Mrs. Babita Choudhury, Member
-
Final Order/Judgment
Debasis Bhattacharya:- PRESIDING MEMBER
Being aggrieved by and dissatisfied with the repudiation of a claim by the OP Insurance Company, for reimbursement of medical expenses incurred by the Complainant in a medical institution, towards the medical treatment of his wife, the instant case has been filed by the complainant, u/s 12 of the Consumer Protection Act 1986.
The fact of the case in a nutshell is as follows.
The complainant, during the material period was a holder of the Health Insurance Policy bearing No. 51250034189500000017 of the OP Insurance Company.
OP 2 is the Third Party Administrator i.e. agent of the OP 1 Insurance Company.
The sum insured for the policy was for Rs.5,00,000/- and the policy covered his wife also. The Complainant had to pay premium against the said policy for Rs.20,508/- for the period 22.04.2018 to 21.04.2019.
Reportedly, on 22.08.18 the wife of the complainant had to be admitted in one Spectrum Clinic and Endoscopy Research Institute and had to undergo a surgery on 23.08.18 for removal of tumour/fibroids from her uterus, cyst from her left ovary and for clearing of blockages from her fallopian tubes. However she was discharged on 26.08.18.
The medical expenses incurred towards the entire process was to the extent of Rs 1,61,844/-. The complainant claims to have sent a prior intimation to the OP Insurance Company regarding the medical condition of his wife and the anticipated surgery. The said intimation was reportedly received by the OP Insurance company on 20.08.2018.
However subsequently on 31.08.2018 the Complainant lodged a claim with OP 1 for reimbursement of the medical expenses of Rs.1,61,844/- along with corroborating documents related to the treatment.
It is further mentioned that prior to this treatment, the wife of the Complainant had to go through certain tests and procedure but the claim for reimbursement of the expenses in connection with those tests and medical procedure was repudiated by the OP Insurance Company on the ground that the medical procedures were related to a case of infertility and it was not covered under the policy.
The Complainant at this point claims that the admission in the medical institute and the surgery were not related to infertility.
However, so far as the lodging of the claim by the Complainant is concerned, the OP Insurance Company was unresponsive.
Finding no other alternative, the Complainant was compelled to send a ‘demand notice’ in the form of a legal notice on 18.12.18 and the same was received by OP 1 on 19.12.18 and by OP 2 on 20.12.18.
On receipt of the same, OP 1 sent a reply to the concerned Advocate with a copy to the patient concerned, stating that the patient was presented with secondary infertility and underwent diagnostic hysteron laparoscopy on 23.08.18, a procedure, primarily to diagnose the exact cause of infertility and it was further stated that the TPA being the OP 2 had observed that the insured in this case was a patient of secondary infertility and the treatment in question was related to secondary infertility. OP 1 clarified that Secondary infertility was not covered under the Policy under the clause 4.4.6 and accordingly the claim was repudiated.
From this, the Complainant drew the inference that the OP Insurance Company and OP TPA committed ‘mischief’ intentionally to make a wrongful gain and committed unfair trade practice by repudiating the claim. The Complainant claims to have received no proper service from OPs and thus suffered physically, mentally and financially due to no fault on his part.
Considering the treatment extended by the OP Insurance Company as deficiency of service and unfair trade practice, the Complainant approaches to this Commission with a prayer to impose direction upon the opposite parties, particularly OP 1 to reimburse the medical expenses of Rs.1,61,844/- with interest @12% from due date to the actual date of payment, compensation of Rs.12,00,000/-, a sum of Rs.50,000/- towards litigation cost and cost of the case which is not specified and any other relief which the Complainant is entitled to get according to law.
The Complainant along with his petition has annexed certain related documents viz. premium receipt, policy schedule, prospectus related to the mediclaim policy, related test reports and corresponding bills, money receipts, bills raised by the medical institute where the treatment and surgery were done, discharge certificate and discharge summary and copies of legal notice and reply thereof and the communication of OP 1 repudiating the claim.
Evidence on affidavit and brief notes of argument filed by the Complainant are almost replicas of the Complaint petition. The Complainant argues in the brief notes of argument that removal of tumor/fibroids from the uterus and removal of cysts from an ovary cannot in medical parlance be equated with the treatment of infertility.
Apparently in the instant case the OP Insurance Company was a service provider.
Thus, in view of the above discussion and on examination of available records it transpires that the complainant is a consumer as far as the provisions laid down under Section 2(1) (d) of the Consumer Protection Act 1986 are concerned.
The complainant is a resident within the district of Hooghly. OP 1 is also having their office within the district of Hooghly.
The claim preferred by the complainant does not exceed the limit of Rs.50,00,000/-.Thus, this Commission has territorial as well as pecuniary jurisdiction to proceed in the instant case.
The issues related to the questions whether there was any deficiency of service and whether the complainant is entitled to get any relief, being mutually inter-related, will be taken together for convenient disposal.
Defence case
OP Insurance Company has contested the case by filing written version, evidence on affidavit and brief notes of argument.
However, the OP Insurance Company points out in their written version, evidence on affidavit and brief notes of argument that the policy of insurance is a contract and on the proposal as executed by the proposer the insurance policy is issued on the terms and conditions, exceptions and limitations as stipulated therein.
Now, referring to the discharge certificate issued by the medical institute where the insured one underwent treatment and surgery, the OP Insurance Company mentions that the wife of the Complainant underwent a diagnostic hysteroscopy and laparoscopy with indication of secondary infertility, here with left ovarian chocolate cysts and right tubal block. Here reference is also made to the clause 4.4.6 of the terms and conditions of the policy where it is stated that ‘No claim will be payable under this policy………for any treatment relating to infertility, sterility……’ The OP Insurance Company in all their representations puts stress on the sole issue that primarily the medical treatment was in connection with infertility and claim for reimbursement of medical expenses incurred for medical treatment of infertility is excluded under this policy.
Decision with reason
Materials on records are perused. The key document here, which appears to be the deciding factor is the discharge summary issued by the medical institute.
The attending doctor inter alia mentions the following issues.
- The wife of the Complainant had a consultation with the doctor on 02.01.2017 with secondary infertility.
- She had spontaneous miscarriage on 08.10.16 and had evacuation of retained products of conception.
- Her left ovary had lemon sized chocolate cyst with maturing follicle.
- The relevant history of her husband was normal and had no conjugal problem.
- She was advised hysteroscopy and laparoscopic conservative surgery after routine pre-operative investigations.
While counseling, the Complainant and his wife were told that after conservative tubal surgery the pregnancy chance would be around 30%.
In view of the above the Commission is of the opinion that the entire medical treatment and surgery were in connection with infertility and unfortunately the exclusion clause incorporated in the terms and conditions of the policy prevents the OP Insurance Company from considering the reimbursement claim.
Thus, any sort of deficiency of service or unfair trade practice on the part of the OP Insurance Company in the instant case cannot be established in unequivocal terms.
Hence it is
ORDERED
that the complainant case no.12/2019 be and the same is dismissed on contest.
However there is no order as to costs.
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 website www.confonet.nic.in
