Order No.  16  dt. 15/06/2017

       The case of the complainant in brief is that the complainant had mediclaim policy with o.p. and the policy was valid on and from 5.1.13 to 4.1.14 and the assured sum was Rs.5 lakhs. The complainant suffered heart ailment on 3.9.13 and he was admitted to R.N. Tagore Hospital. He underwent operation and he had to pay an amount of Rs.1,83,075/-. The complainant after recovery from the said operation submitted medical bills to the tune of rs.1,83,075/- to M/s Vipul Medcorp TPA Pvt. Ltd. The TPA did not allow the reimbursement on the ground that the complainant was a patient of diabetes and subsequently the insurance company vide their letter dt.8.10.13 declined the claim of the complainant referring the clause 4.1 of their insurance policy. The said clause excludes reimbursement of expenses of diabetic angiopathy for preexisting diabetic patient whereas the complainant’s artery blockage was due to calcification of artery. Calcification (stone formation) in the body is attributed to unknown reason and not to diabetes mellitus. On the basis of the said fact since the claim of the complainant was repudiated the complainant filed this case praying for direction upon the o.p. insurance company for releasing the medical expenses bill of the complainant to the tune of Rs.1,83,075/- along with compensation of Rs.50,000/- for deficiency in service.

            The o.p. insurance company contested this case by filing w/v and denied all the material allegations of the complaint. It was stated that the complainant filed the complaint in order to raise a pre mediated false and frivolous claim to harass the o.p. insurance company. The o.p. stated that the complainant suffers from diabetes mellitus and the same has been declared in the proposal form at the time of taking insurance policy. According to the terms and conditions of the policy being clause no.4.1 the complainant is not eligible to get any compensation for any ailment relating to the diseases which are mentioned in the table in clause 4.1. It was further stated that cardio vascular diseases represent over one half of all the deaths in both type 1 and type 2 diabetes mellitus. In diabetic patients, vascular calcifications are more frequently observed than in people without diabetes. Even the treating Dr. Binayak Deb concluded and diagnosed with calcified artery and proximal segment shows 99% stenosis (blockage), unlike usual blockage due to cholesterol and triglyceride where DM is regarded as a contributing factor and considering the said fact the claim of the complainant was repudiated. There was no deficiency in service on the part of o.p. insurance company, thereby o.p. insurance company prayed for dismissal of the case.

            On the basis of the pleadings of parties the following points are to be decided:

1. Whether the complainant underwent heart surgery at R.N. Tegore Hospital?
2. Whether the denial of the medical reimbursement of the complainant was in terms of the policy?
3. Whether there was any deficiency in service on the part of o.p.?
4. Whether the complainant will be entitled to get the relief as prayed for?

Decision with reasons:

            All the points are taken up together for the sake of brevity and avoidance of repetition of facts.

            The complainant himself conducted the case and he in support of his contention filed the documents including the medical; papers. The complainant also filed the policy wherefrom it is found that the policy was valid at the relevant point of time while the complainant took admission in the said hospital. It is also an admitted fact that the complainant had to undergo coronary angiogram on 4.9.13 and stent was inserted. After release from the hospital the complainant submitted a medical bill to the TPA appointed by insurance company to the tune of Rs.1,83,075/-. The claim of the complainant was denied by the insurance company as per clause 4.1 and as such the complainant filed this case praying for reimbursement of the said amount along with compensation.

            Ld. lawyer for the o.p. insurance company argued that the complainant suffered from diabetes mellitus at the time of undergoing the said treatment. The complainant himself at the time of obtaining the policy disclosed that he was suffering from diabetes mellitus and before completion of 4 years of the policy the complainant went for the surgery and thereby the claim of the complainant was not entertained. There was no deficiency in service on the part of o.p.

            Considering the submissions of the respective parties it is an admitted fact that the complainant had the policy under the o.p. at the relevant point of time and the complainant at the time of applying for obtaining the policy disclosed that he was suffering from diabetes mellitus and he underwent treatment within 4 years from the disclosure of the said disease. On perusal of the policy and as per the terms and conditions of the policy being clause no.4.1 ld. lawyer for o.p. emphasized that the complainant is not eligible to get any compensation for any ailment to the diseases which are mentioned in the table in clause 4.1 in heading pre existing health condition or disease or ailment / injuries before completion oif 4 years of the policy. It also appears from the materials on record that the complainant only completing 2 years of policy and during the 3^rd year he underwent for the said treatment. The complainant filed the documents wherefrom it is evident that he was suffering from diabetes mellitus and since he underwent treatment before completion of 4 years and as per clause 4.1 in heading pre existing health condition or disease or ailment the insurance company rightly refused to accept the claim of the complainant for reimbursement of the medical bill as claimed by the complainant. In view of the facts and circumstances of the case and considering the evidence on record we hold that there was no deficiency in service on the part of o.p. insurance company and the complainant will not be entitled to get the relief as prayed for.        Thus all the points are disposed of accordingly.

            Hence, ordered,

            That the CC No.33/2014 is dismissed on contest without cost against the o.p.      

            Supply certified copy of this order to the parties free of cost.