ORDER

V. K. DABAS, MEMBER

The complainants are the beneficiaries under mediclaim policies purchased by them from OP1. The policy was first purchased in the year 2007 and had been renewed year after year. The last policy was effective from 19.5.2012 to 18.5.2013. It is alleged that complainant number 2 was pregnant and had also suffered from incisional  hernia.  She was got admitted in Max Hospital on 1.12.2012 and was operated upon for hernia as well as for LSCS. A sum of Rs. 1,32,503.76 was spent on her treatment out of which the   OP1 had paid a sum of Rs. 58500/-  and had refused to pay the balance amount of Rs. 74003.76 which was allegedly spent on the surgery relating to incisional hernia.   The complainants have alleged that this act of the OP was unjust and uncalled-for and amounts to deficiency in service. They have, therefore , approached this forum for redressal of their grievances. 

     The Ops have contested the complaint. They have claimed that the complaint is devoid of any merits and is liable to be dismissed. They have also claimed that the complaint has been filed with a malafide intention. 

     Paras 1 to 6 of the preliminary submissions of the written statement are relevant for the disposal of the complaint and are , therefore, reproduced as under:-

1.     That it is submitted that the complainant had lodged a false and frivolous claim and is maliciously trying to mislead this Ld. Forum. The treatment undergone by the wife of the complainant was for the disease/ailment which is excluded according to the terms and conditions of the policy.

2.     That it is submitted that surgery done upon the wife of the complainant was related to her pregnancy. The complainant no. 2 was operated for her emergency delivery and caesarian section was performed upon her to get her delivery done. Since she was suffering from Incisional Hernia due to her prior Caesarian Sections (Twice earlier during the delivery of her two children), the Hernia was also treated by repairing the abdominal wall.

3.     That it is submitted that since the complainant no 2 was having a mature pregnancy of about 38 weeks and she had already undergone two LSCS surgeries, the delivery was supposed to be done through LSCS methods as in almost all the cases where two LSCS had already been done the third delivery is done only through the LSCS method and the same was successfully done.

4.     That it is submitted that the surgery performed upon the complainant no. 2 was for Incisional Hernia. It is further submitted that an Incisional hernia is one that is located at the site of a previous surgical incision. These can develop weeks, months or even years after the initial surgery. These are often repaired with a mesh patch. It is called an incisional hernia because it generally occurs as a bulge in abdomen at the site of an old surgical scar. It is caused by thinning or stretching of the scar tissue, and occurs more frequently in people who are obese or pregnant. It is pertinent to mention that the Complainant no. 2 i.e. the wife of the complainant no. 1. Had undergone two LCSC's surgery earlier also(1st8 years back and 2nd4 years back). Thus it is clear from the above that the surgery for the Incisional Hernia was done as a result of complication/ailment arising out of prior surgeries done upon her in the co -urse of her delivery.

5.     That it is crystal clear from the above discussion that the surgery undergone by the complainant no. 2 was the result of the complications/ailments suffered due to the treatment of her past pregnancy as well as the present pregnancy. The complainant is hereby trying to mislead this Ld. Forum by falsely submitting that the Hernia in the present case has no relation with pregnancy, childbirth, miscarriage or complication of pregnancy (LSCS).

6.     That it is submitted that the claim of the complainant clearly comes under the exclusion clause 4.4.13 of the terms and conditions of the Insurance Policy and was rightly rejected. The Opposite Party herein does not bear any liability to pay any amount to the complainant.

    In the evidence, the complainant have reiterated the contents of the complaint by way of affidavit.  The OP has also filed his evidence by way of affidavit and has corroborated the contents of the written statement.

   We have heard arguments advanced at the bard and have perused the record.

     On perusal of the record, it is clear that the surgery performed on complainant number 2 was for incisional hernia and LSCS for pregnancy i.e. delivery of the baby.  It is also clear that complainant number 2 (wife  of complainant no. 1) had undergone two LSCS surgeries  earlier also i.e. first surgery was performed  8 years back whereas the second surgery was performed four years back  The incisional hernia can develop week, months or even years after the initial surgery due to thinning or stretching of scar tissues and more frequently during pregnancy and since the incisional hernia is located at the site of the previous surgical incision indications are that the incisional hernia had developed as a result of complication/ ailment arising out of prior surgeries done upon the complainant number 2 for LSCS.  Exclusion clause 4.4.13 of the terms and conditions of the policy is relevant for arriving at a decision in this complaint and is reproduced as under:

Exclusion no. 4.4.13 :- Treatment arising from or traceable to pregnancy, child birth, miscarriage , complication of pregnancy (LSCS) not payable.

In the case of United India Insurance Co. Ltd. vs. Harchand Rai Chandan Lal (2005 ACJ 570), the Hon’ble Supreme Court has held that the terms and conditions of the contract have to be strictly construed and no variation can be made there from.

 The case of the complainant is covered under the aforesaid exclusion clause as incisional hernia had developed at the site of the previous surgeries done for LSCS. In view of the judgment cited above by us and facts and circumstances of the case  we are of the constrained to hold that there are no merits in this complaint and the claim was rightly repudiated by the OP. We hold that there is no deficiency in service on the part of the OP in repudiating the claim of the complainant.  Accordingly, the complaint is hereby dismissed. 

Copy of the order be made available to the parties as per rule.   File be consigned to record room.

     Announced in open sitting of the Forum on.....................