Chandigarh

DF-I

CC/255/2018

Maninder Singh - Complainant(s)

Versus

The Regional Manager Kotak Mahindra General Insurance Co. Ltd. - Opp.Party(s)

Jaipal Singh

17 Nov 2020

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

 

                    

Consumer Complaint No.	:	CC/255/2018
Date of Institution	:	04/06/2018
Date of Decision	:	17/11/2020

 

Maninder Singh son of late Sh. Nagar Singh, resident of House No.3108/3, Sector 44-D, Chandigarh.

… Complainant

V E R S U S

1. The Regional Manager, Kotak Mahindra General Insurance Co. Limited, Office at 27-BKC, C-27, G-Block, Bandra Kurla Complex, Bandra (East), Mumbai 400051 Maharashtra.
2. The Branch Manager, Kotak Mahindra General Insurance Co. Limited, SCO No.141-142, Sector 9, Chandigarh.

… Opposite Parties

CORAM :	SHRI RATTAN SINGH THAKUR	PRESIDENT
	SHRI SURESH KUMAR SARDANA	MEMBER

                                               

ARGUED BY	:	None for complainant
	:	Sh. Sachin Ohri, Counsel for OPs

Per Rattan Singh Thakur, President

1.      The long and short of the allegations are, in the year 2016, complainant for himself, wife and children had purchased a health policy namely “Kotak Health Care (Excel)” against premium of Rs.7,129/- which was valid from 8.8.2016 to 7.8.2017. Maintained, the said policy was thereafter renewed from 8.8.2017 to 7.8.2018 on payment of Rs.7,315/-. The sum assured was Rs.3,00,000/- and cumulative bonus of Rs.30,000/-.  Averred, wife of the complainant was pregnant and her expected date of delivery, as per the advice of the doctor, was in the month of August 2017.  She was admitted in the Santokh Hospital, Sector 38, Chandigarh on 24.8.2017 and a child was delivered through caesarian section, but, after two hours, she developed shortness of breath with high fever and was put on ventilator support.  On being suspected as H1N1 disease, she was immediately referred to Max Hospital, Mohali where she was diagnosed as suffering from heart illness and was operated upon. The said hospital raised bill of Rs.3,40,700.07 which was paid by the complainant. The complainant raised claim with the OPs, but, the same was repudiated. Hence, the complainant alleged deficiency in service and unfair trade practice on the part of the OPs and filed the present consumer complaint for directing the OPs to pay Rs.3,30,000/- being the sum assured under the policy alongwith interest, compensation of Rs.2,00,000/- for harassment etc.; Rs.1,00,000/- towards deficiency in service and unfair trade practice and Rs.22,000/- as litigation expenses.
2.     OPs contested the consumer complaint, filed their joint written reply and claimed the policy was valid on the date of admission of the wife of the complainant w.e.f 8.8.2016 to 7.8.2017 and it was further renewed from 8.8.2017 to 7.8.2018. However, the liability was as per terms and conditions of the policy (Annexure R-1).  The case of the OPs is, medical management pertains to post-partum sepsis with cardiomyopathy which is arising due to complication of pregnancy and as per clause 3.4 of the policy there was exclusion clause with regard to expenses incurred on treatment arising from or traceable to pregnancy (including voluntary termination of pregnancy, childbirth, miscarriage etc.).  However, this did not apply to ectopic pregnancy proved by diagnostic means. Maintained, as expenses incurred for the treatment squarely falls in the exclusion clause, therefore, the claim was rightly repudiated. Reference to certain case laws was also made. On these lines, the cause is sought to be defended.
3.     Replication was filed and averments made in the consumer complaint were reiterated.
4.     Parties led evidence by way of affidavits and documents.
5.     We have heard the learned counsel for the OPs and gone through the record of the case. After scanning of record, our findings are as under:-
6.     The sole point in controversy is the disease for which the wife of the complainant, Smt.Ravneet Kaur was treated falls in the exclusion clause of the policy agreed inter se parties.  Per complainant, his wife was admitted in the Santokh Hospital, Chandigarh where through caesarean section a child was delivered and thereafter his wife developed symptom of shortness of breath with high fever and she was put on ventilator support. Subsequently, she was referred to Max Hospital, Mohali where the doctor diagnosed her to be suffering from heart illness and she was operated upon and the bill of Rs.3,40,700.07 was raised which was paid by the complainant. 
7.     Now we shall refer to the document at page 53 issued by Santokh Hospital vide which it was observed, she was suffering from fever spikes and infection and was administered antibiotics and it was also a case of suspected H1N1. The final diagnosis by the Max Hospital where she was treated is jotted down in the discharge summary annexed at page 56 which shows diagnosis settled was post partum sepsis with cardiomyopathy and with the treatment it was improved. In simple terms, diagnosis was bacterial infection of uterus after caesarean section i.e. post partum sepsis and cardiomyopathy allegedly arising due to complication of pregnancy. This diagnosis was not in any way differed with by the complainant and he has not adduced on record any medical opinion to say the treatment of cardiomyopathy and post partum sepsis was not related to pregnancy and the disease sustained of cardiomyopathy and post partum sepsis after the delivery of the child through caesarean section. No such certificate was obtained and produced on record by the complainant.
8.     Contra, OPs have produced on record the certificate dated 22.2.2019 from Dr. Prem Lata S. Bhagat, MD, DGO (Mumbai), Obstetrician, Gynaecologist & Infertility Specialist and the relevant portion thereof is reproduced below :-

          “…… I have been asked to opine on two queries; First whether the episode breathlessness, sepsis and subsequently cardiomyopathy are related to her maternity and delivery to which I opine that Yes.  These are all related to maternity & delivery. Second query is whether this ailment & management falls under ectopic pregnancy; I opine that since pt. reached 38 weeks of gestation & underwent LSCS, it was definitely not an ectopic pregnancy.”

 

9.     The said medical practitioner had opined as per symptoms, this ailment and management pertains to maternity problems and was not an ecotopic pregnancy. For ectopic pregnancy the amount was reimbursable for the treatment as per the terms and conditions of the insurance policy.
10.     The OPs have also produced on record another certificate dated 22.2.2019 issued by Dr.Brajesh K. Kunwar, MD, DM, Cardiology (CMC Vellore) and the relevant portion of the same is reproduced below :-

“Regarding the query whether her cardiomyopathy is related to her maternity and delivery, to which I opine that Yes, the cardiomyopathy is related to maternity and delivery and her respiratory distress was due the cardiomyopathy.”

 

The said doctor had arrived at a definite conclusion that her cardiomyopathy is related to maternity and delivery and her respiratory distress was due to cardiomyopathy.

11.     The OPs have placed on record the affidavit dated 15.3.2019 (Annexure R-5) of Dr. C.H. Asrani, DNB, MBBS, who after taking opinion of aforementioned two doctors opined as under :-

          “That as per the medical records and in the light of the opinion of Dr. Brajesh Kunwar and Dr. Premlata S Bhagat the patient Ravneet Kaur, had a problem of post partum sepsis and Cardiomyopathy, which is related to maternity and delivery and her respiratory distress was due to the Cardiomyopathy. Further, there was no ectopic pregnancy.”

 

12.     This also shows, the problem related to maternity and delivery. The aforementioned evidence furnished by the experts is already on record. There is no rebuttal to this opinion produced by the complainant and as per the terms and conditions referred under clause 3.4(m), there was permanent exclusion of any expenses incurred on treatment arising from or traceable to pregnancy (including voluntary termination of pregnancy, childbirth, miscarriage, abortion or complications of any of these, including caesarean section) and any fertility, infertility, sub fertility or assisted conception treatment  or sterilization or procedure, birth control procedures and hormone replacement therapy.  However, this clause did not apply to ectopic pregnancy proved by diagnostic means and which is certified to be life threatening by the Medical Practitioner. Thus, the treatment for which the complainant has incurred the expenses falls in the permanent exclusion clause.
13.     The contention the said exclusion clause was not explained to the complainant is not convincing at all as 2-3 times the policy was renewed and the terms and conditions are part and parcel of the insurance policy and the complainant was expected to know it or he could have exercised the option to cancel the policy during the free look period as provided by the insurance companies to the customers.
14.     The learned counsel for the OPs have relied on case titled as Suraj Mal Ram Niwas Vs. United India Insurance, Civil Appeal No.1375 of 2003 decided on 8.10.2010 by the Hon'ble Supreme Court in which it was held the terms and conditions of the policy have to be strictly construed to determine the liability of the insurer.  In another case, Export Credit Guarantee Corporation of India Vs. Garg Sons International reported in MANU/SC/0039/2013, 2013 (1) ALT 56 (SC) it was held it was not permissible for the court to substitute terms of contract itself under garb of construing terms incorporated in the agreement of the insurance. No exceptions could be made on the ground of equity. As such, the complainant has failed to prove any deficiency in service or unfair trade practice on the part of the OPs.
15.     In view of the above discussion, we do not find any merit in the present consumer complaint.  Accordingly, the same is hereby dismissed, leaving the parties to bear their own costs.
16.     Certified copies of this order be sent to the parties free of charge. The file be consigned.

	Sd/-	Sd/-
17/11/2020	[Suresh Kumar Sardana]	[Rattan Singh Thakur]
hg	Member	President