BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.

Consumer Complaint No. 375 of 2015

Date of Institution: 08-06-2015

Date of Decision: 03-08-2015  

Sangeeta Kataria, Sr.No.166286 LIC of India, H.G.A.Customer Zone, Amritsar, wife of Manish Kataria, resident of House No. HM-1086, Sector 3, Ranjit Avenue, Amritsar. 

Complainant

Versus

The New  India Assurance Company Limited, through Divisional Manager, 80, Court Road, Post Box No.98, Amritsar.  

Opposite Party

Complaint under section 11, 12 and 13 of the Consumer Protection Act, 1986 as amended upto date.

Present: For the Complainant: Sh. Sanjeet Singh, Advocate

              For the Opposite Party: Sh. P.N.Khanna, Advocate

Quorum:

Sh.Bhupinder Singh, President

Ms.Kulwant Kaur Bajwa, Member

Mr.Anoop Sharma, Member  

Order dictated by:

Sh.Bhupinder Singh, President.

1. This complaint has been remanded by Hon’ble State Commission, Punjab, Chandigarh vide its order dated 13.5.2015, to decide the matter on merits, in accordance with law. 
2. Present complaint has been filed by Smt.Sangeeta Kataria under the provisions of the Consumer Protection Act alleging therein that she is working as H.G.A, LIC of India, Customer Zone, Amritsar and she alongwith other employees of LIC have been medically insured with Opposite Party vide Mediclaim Master Policy bearing No.120700341105000001. Complainant alleges that  in January 2011, she fell ill and had having stomach pain which became severe and serious and complainant was admitted in Smt.Shanti Seth Hospital, 3, Albert Road, Amritsar on 16.2.2011 due to severe stomach pain and further leading to operation of left ovary and amount of Rs.28,814/- was received by the said hospital and the complainant was discharged from the hospital on 23.2.2011. The complainant was re-admitted in same hospital on 26.2.2011 due to stomach pain and the complainant was discharged from the hospital on 1.3.2011. The hospital authorities charged Rs.11,852/- from the complainant. The complainant wrote various letters to Opposite Party  for the reimbursement of the aforesaid medical expenses and the Opposite Party paid Rs.11,612/- vide cheque No. 976467 on 4.5.2011 and wrongly and illegally declined the remaining claim on 6.6.2011 on the false  ground that the complainant is not covered under the policy.        Alleging the same to be deficiency in service, complaint was filed seeking directions to the opposite party to make the payment of Rs.29,054/-  i.e. the balance amount of medical claim. Compensation and litigation expenses were also demanded.
3. On notice, Opposite Party appeared and filed written version in which it was submitted that the LIC of India had obtained Group Mediclaim Policy regarding its employees and the complainant was also covered under the said policy. The claim of the complainant was received through Manager (OS), LIC of India, Amritsar and the same was considered as per terms and conditions and exclusion clauses of the said policy. The matter was referred to Dr. Sunil Grover who submitted his independent expert opinion concluding that as per the medical records including discharge card of the complainant, it was found that the complainant was admitted in Smt.Shanti Seth Hospital, 3, Albert Road, Amritsar with the diagnosis of Ectopic Gestation Left Adnexa (On USG Abdomen) on 15.2.2011 at Randhawa USG Centre and was operated on 16.2.2011 and was discharged on 23.2.2011. After considering this operation, said doctor has given reference of Maternity  Expenses benefits as detailed in clause No. 3.4.1 of the policy which read  as Maternity  Expenses benefits means treatment taken in hospital/ nursing home arising from or traceable to pregnancy, child birth including caesarian section. However, said doctor has further concluded that since the patient has already two children and as such under clause 5.16.3 of the policy, the claim in respect of delivery of only first two children/ or operation associated therewith is payable.  Accordingly, after considering the expert  opinion of the doctor as well as terms and conditions of the mediclaim policy in question, the competent authority of the Opposite Party vide its letter dated 17.5.2011 informed to the Manager (OS) LIC of India in detail that in the light of policy clause 5.16.3 (Special conditions applicable to the maternity expenses benefit extension), the present claim is not payable as the maternity benefits are only available upto first two children only. As the complainant is already having two children, therefore, the Opposite Party is unable to pay any claim to the complainant.  It is further submitted that in fact the complainant was got herself admitted again in Smt.Shanti Seth Hospital, 3, Albert Road, Amritsar on 26.2.2011 and remained admitted in the said hospital till 1.3.2011 on account of sub-acute intestinal obstruction which was an independent ailment having no concern with respect to the pregnancy claim which has been rejected in toto. So, the second claim was  paid to the complainant. While denying and controverting other allegations, dismissal of complaint was prayed.
4. Complainant tendered into evidence her affidavit Ex.CW1 alongwith documents Ex.C1 to Ex.C18 and closed the evidence on behalf of the complainant.
5. Opposite Party tendered into evidence affidavit of Sh.Sunil Mahajan, Divisional Manager Ex.R1, affidavit of Dr.Sunil Grover Ex.R2 alongwith documents Ex.R3 to Ex.R13  and closed the evidence on behalf of the Opposite Party.
6. We have carefully gone through the pleadings of the parties; arguments advanced by the ld.counsel for the parties and have appreciated the evidence produced on record by both the parties with the valuable assistance of the ld.counsel for both the parties.
7. From the record i.e. pleadings of the parties and the evidence produced on record by the parties, it is clear that  the complainant is working as H.G.A, LIC of India, at Amritsar. The complainant alongwith  other employees of LIC have been medically insured with Opposite Party vide Mediclaim Master Policy bearing No.120700341105000001. During the subsistence of this policy, complainant fell ill in January, 2011. She was  admitted in Smt.Shanti Seth Hospital, 3, Albert Road, Amritsar on 16.2.2011 and she was operated for  left ovary and was discharged on 23.2.2011  and she spent Rs.28,814/- on her medical treatment. Complainant further  submitted that thereafter, she was again  admitted in Smt.Shanti Seth Hospital, 3, Albert Road, Amritsar on 26.2.2011 due to stomach pain and was discharged from the hospital on 1.3.2011. This time, she spent a sum of Rs.11,852/- on her medical treatment. The  complainant lodged claim with Opposite Party. Opposite Party paid Rs.11,612/- i.e.  amount of the second claim to the complainant vide cheque dated 4.5.2011, but declined to pay the first claim of Rs.28,814/- vide letter dated 6.6.2011 Ex.C11 on the ground that the complainant is not covered under the policy. Ld.counsel for the   complainant  submitted that all this amounts to deficiency of service on the part of the opposite party.
8. Whereas the case of the Opposite Party is that  on receipt of the claim of the complainant under the Group Mediclaim Policy, the matter was referred to  Dr. Sunil Grover,  who submitted his independent expert opinion Ex.R3 concluding that as per the  medical records including discharge card of the complainant Ex.R4, it was found that the complainant was admitted in Smt.Shanti Seth Hospital, 3, Albert Road, Amritsar with the diagnosis of Ectopic Gestation Left Adnexa (On USG Abdomen) on 15.2.2011 and was discharged on 23.2.2011. Said  doctor has given reference of Maternity  Expenses benefits as detailed in clause No. 3.4.1 of the insurance policy which read  as Maternity  Expenses benefits means treatment taken in hospital/ nursing home arising from or traceable to pregnancy, child birth including caesarian section. Said doctor has further concluded that since the patient has already two children and as such under clause 5.16.3 of the policy, the claim in respect of delivery of only first two children/ or operation associated therewith is payable.  As such, the mediclaim of the complainant was considered being not payable under the aforesaid  terms and conditions of the mediclaim policy. The competent authority of the Opposite Party vide its letter dated 17.5.2011 informed that the present claim is not payable as the maternity benefits are only available upto first two children only, as such, the Opposite Party is unable to pay this claim to the complainant.  Opposite Party further submitted that  the  complainant approached the Opposite Party through its employer LIC for  reviewing of the case stating that this  was not the case of delivery, but just  a case is miscarriage for which immediate operation was done. The complainant has also stated that she is entitled to even compensation for abortion. The case of the complainant was again considered and wrote letter dated 6.6.2011 to the employer of the complainant i.e. LIC of India reconfirming  that as per policy clause  No.3.4.1, the Maternity  Expenses benefits treatment taken in hospital/ nursing home arising or traceable to pregnancy, child birth including caesarian section, but these  benefits are only available upto first two living children. It was also made clear that miscarriage/ Ectopic Pregnancy all relates to traceable to pregnancy and comes under the Maternity  Expenses benefits which  are available upto first two living children. Mrs.Sangeeta Kataria complainant is already having two  children, hence, these benefits are not available to her as per this policy. Thereafter, the complainant approached the office of Insurance Ombudsman who demanded certain documents from the op and Insurance Ombudsman also did not find any justification in the claim of the complainant. As regard second claim, Opposite Party submitted that second claim being an independent claim on account of sub-acute intestinal obstruction,  which was covered  under the policy, so Opposite Party paid this claim for Rs.11,612/- to the complainant on 21.4.2011. As such, this demand has no concern with the treatment relating to maternity of the complainant.   Ld.counsel for the opposite party submitted that there is no deficiency of service on the part of the Opposite Party.
9. From the entire above discussion, we have come to the conclusion that complainant being an employee of LIC of India at Amritsar got Group Mediclaim Policy from the Opposite Party. The complainant became ill in January, 2011 and she was admitted in Smt.Shanti Seth Hospital, 3, Albert Road, Amritsar  on 16.2.2011. She was diagnosed as Ectopic Gestation Left Adnexa  i.e. disease relating to pregnancy as is evident from the discharge slip of the complainant Ex.R4. She was operated on 16.2.2011 and was discharged on 23.2.2011. She spent Rs.28,814/-  on her medical treatment  as per bills Ex.C7 to Ex.C10. The complainant lodged the claim with the Opposite Party who referred the matter to Dr.Sunil Grover for independent expert opinion who submitted his report Ex.R3 which was duly proved by Dr.Sunil Grover through his affidavit Ex.R2. In this report, Dr.Sunil Grover submitted that the complainant was admitted in Smt.Shanti Seth Hospital, 3, Albert Road, Amritsar  on 16.2.2011 with the diagnosis of Ectopic Gestation Left Adnexa considering acute emergency and seriousness, she was operated on 16.2.2011 and was discharged on 23.2.2011. Ectopic Pregnancy as caesarian section is traceable to pregnancy. The patient i.e. complainant has already two children and under clause 5.16.3 of the policy, the claim in respect of delivery of only first two children/ or operation associated therewith will be considered.  So, mediclaim of the complainant  can not be considered  to be payable under the aforesaid  terms and conditions of the mediclaim policy Ex.R13.
10. We have gone through the terms and conditions of the policy. Clause 3.4.1 of the policy Ex.R13 read as under:-

“Maternity  Expenses benefits means  treatment taken in hospital/ nursing home arising or traceable to pregnancy, child birth including caesarian section.”

11. The disease relating to the complainant is traceable to pregnancy. Patient i.e. complainant had already two living children and as such, under clause 5.16.3 of the policy, the claim in respect of delivery   of only first two children or operation associated therewith , is payable.  The complainant could not produce any evidence from the hospital or the doctor concerned that the operation of the complainant conducted on 16.2.2011 at Smt.Shanti Seth Hospital, 3, Albert Road, Amritsar  was not relating  to or traceable to pregnancy, rather the discharge slip of the complainant Ex.R4 fully proves that the complainant was  diagnosed as a case of  Ectopic Gestation Left Adnexa which is related to /traceable to pregnancy and as per clause 5.16.3 of the policy Ex.R13, the claim in respect of any operation associated with Ectopic Gestation Left Adnexa pregnancy/ delivery of 3^rd child is not payable under the policy.  Opposite Party was justified in repudiating the claim of the complainant relating this claim of Rs.28,814/- to the complainant.
12. Consequently we hold that complainant has failed to prove on record any deficiency of service on the part of the Opposite Party.
13. Resultantly the complaint is without merit and the same is hereby dismissed with no order as to cost. Copies of the order be furnished to the parties free of cost. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

Dated: 03-08-2015.                                                   (Bhupinder Singh)                                                                                               President

hrg                                                (Anoop Sharma)     (Kulwant Kaur Bajwa)   

              Member                         Member