JUDGEMENT

          Complainant by filing this complaint has submitted that complainant along with his wife Mamata Agarwal and his son Chirag Agarwal purchased one Family Floatal Policy being No.311400/48/2012/6387 from op for a sum insured of Rs.3,00,000/- on payment of premium and he had been continuing that policy uninterruptedly by paying premium.  Fact remains complainant no.3 was admitted at Park Clinic, Kolkata on 16.10.2012 suffering from high fever under the supervision of Dr. N.K. Taparia on 16.10.2012 where upon checking up complainant was advised to admit complainant no.3 to Delhi or Hyderabad for better treatment being diagnosed with liver disease.  Accordingly complainant carried away complainant no.3 to Delhi by Air India Flight and admitted him to Sir Ganga Ram Hospital, New Delhi under the treatment of Dr. Vibha Varma where it was checked up and it was decided that complainant no.3 would have to be immediately operated and his liver transplantation is required and accordingly he was immediately operated on 19.10.2012 and the complainant no.2 being the mother of the complainant no.3 donated a portion of her liver to the said complainant no.3 and after that on 05.11.2012 complainant no.3 got discharge from the said Sir Gangaram Hospital and he is still under medical treatment of the said Dr. Vibha Varma and the total cost and expenses incurred on account of the said operation and medical treatment was Rs.14,48,775/- and complainant no.1 being the father of complainant no.3 managed to pay by taking loan.

          Subsequently complainant submitted mediclaim policy claim form dated 03.12.2012 along with all the requisite papers and bills and the same duly received by the office of the op no.2 on 04.12.2012.  Thereafter complainant was waiting for the reimbursement but inspite of repeated requests, reminders, op did not dispose of the same and finding no other alternative complainant sent letter to the op dated 21.03.2012 calling upon the ops to make arrangements for payment of the claim amount.  That letter was received by op on 10.04.2013.  But subsequently complainant no.1 received a letter dated 10.05.2013 from the op repudiating the claim of the complainant no.1 stating that the disease is related to genetical disorder which is completely baseless and made without application and with a mala fide intention to deprive the complainants of their legitimate claim have refused to acknowledge the bona fide claim of the complainants on frivolous and unjust ground and for which the complainant has prayed for relief and for disbursement of Rs.3,00,000/- as against that policy with interest.

          On the other hand op by filing written statement submitted that after receipt of the entire material and documents along with claim of Medical Treatment Sheet and also doctors opinion in the said statement reflected that patient was hospitalized for management of Fulminant Willsons disease and the said disease is related to genetical disorder and for which the claim of the complainant was repudiated as per Exclusion Clause-4.15 as op failed to entertain the claim.  So, there was no negligence or deficiency on the part of the op.  Further it was submitted that the repudiation was justified and for which the complainant is not entitled to get any relief.

                                                    Decision with reasons

          After thorough study of the complaint and the written version including the argument and after proper evaluation of the documents that certificate issued by Park Clinic and the other documents and further considering other materials, it is clear that patient was suffering from Acute Chronic Liver disease along with Jaundice and severe pallot and that was the observation and opinion and finally diagnosed of Park Clinic where Chirag Agarwal (son of complainant no.1) was admitted on 16.10.2012.

          Fact remains Chirag Agarwal was admitted to Sir Ganga Ram Hospital for treatment on 18.10.2012 and was discharged on 05.11.2012 and his liver transplantation surgery (Pediatric) was done.  So, it is clear that Chirag Agarwal had been suffering from acute chronic liver disease, severe pallor, Metabolic, Haemolylic and fact remains at the relevant time Chirag Agarwal was aged about 11 years.  It indicates that he had been suffering from acute chronic liver disease for which immediate liver transplantation was necessitated and for which he was admitted to Sir Ganga Ram Hospital and no doubt the disease was not originated recent one and fact remains it was genetically disorder as per Medical Term and as per Exclusion Clause 4.15 genetically disorder is within the Exclusion Clause as enumerated in the said Exclusion Clause 4.15 of the said clause and after considering the material, documents and the sufferings of the patient, it was found that he was suffering from Fulminant Willsons disease and as per Medical Term the said disease is related to genetically disorder and on scrutiny of the entire claim documents by health insurance doctors of the op i.e. Health Insurance Consultation they came to a conclusion that the said disease was a genetically disorder and it is not covered under the policy and after thorough study of the term Fulminant Willsons disease, we have gathered though it is completely genetically disorder and fact remains the said genetically disorder was not originated at the relevant time but it was from the birth for which at the age of 11 years his liver was transplanted and no doubt as per Clause 4.15 of the Mediclaim Policy Bond, complainant is not entitled to get any such relief as same is excluded and it is the provision of law that this Forum cannot go beyond the terms and conditions of the policy at the same time Forum has no legal authority to give any relaxation on the ground of equity but Forum shall be strictly governed by the Policy Condition and no exception and relaxation can be made on the ground of equity and in this regard we have relied upon the ruling reported in 2013 (4) CPR 165 (NC).

          But even after that considering the present situation and also considering the effect of social legislation of Insurance Act and the moral value of the company, we are of opinion that the company ought to have released a certain amount out of the claim considering the huge cost for treatment of Chirag Agarwal was borne by his father.

          Fact remains this complainant and his wife and his son are covered by the Insurance Policy for long period and continuously and in the above particular situation and considering the future of the patient and to give a layer on the pain and sufferings of the patient, we feel that on humanitarian ground, op must have to release a sum of Rs.2,00,000/- in favour of the complainant by treating it as a special case and disposing of the subsequent prayer of the complainant for re-consideration and accordingly we are allowing this complaint in part for the interest of social justice.

          Thus the complaint succeeds in part.

          Hence, it is

                                                              ORDERED

          That the complaint be and the same is allowed on contest with cost of Rs.2,000/-.

          Op nos. 1 & 2 are jointly and severally hereby directed to pay a sum of Rs.2,00,000/- to the complainant Sanjay Agarwal as Mediclaim reimbursement against the claim of the complainant no.1 Sanjay Agarwal as exceptional case and treating it as a social approach within one month from the date of this order along with cost of Rs.2,000/- i.e. total Rs.2,02,000/- to the complainant no.1 and ops are directed to comply the order very strictly so that complainant must not have to suffer much and practically the said amount is a drop of water in respect of complainant’s expenditure amount of Rs.15,00,000/- for the treatment of his minor son Chirag Agarwal.

          Ops are directed to comply the order very strictly failing which for non-compliance and disobeyance of Forum’s order within stipulated time, ops shall be imposed further penalty of Rs.10,000/- each and further penal proceeding may be started against them for which ops are responsible for that.