This is an application u/s.12 of the C.P. Act, 1986.

          Complainant is the Mediclaim Policy holder No.510100/34/12/06/ 00000670 of New India Assurance Company Ltd. and it is continuing since November, 2003.

          During validity of the said policy complainant was admitted to Kalpataru Jubiliant Hospital at Barasat on 08-01-2013 due to a minor operation of left ring finger and he had already spent Rs.22,230/- for the purpose of operation but he did not get cashless benefit even after existence of the said mediclaim policy.  So, subsequently, complainant submitted claim application for reimbursement of the said amount for hospitalization and treatment cost but it was informed by the OP that the history of the disease is genetically disorder.  So, 2^nd time he sent a letter to the S.D.M, The New India Assurance Co. Ltd. with a request to settle the claim and 3^rd time sent a letter by regd. post to the authority of Medicare T.P.A Services (I) Pvt. Ltd. along with medical certificate of the doctor who operated his said finger at the hospital and certified that Neurofibroma of left finger is not a genetical disorder.  Subsequently, the complainant complained before the Consumer Affairs Department and they tried a lot but mediation and tripartite meetings failed and entire decision of the OP is uncalled for and without any foundation so the complainant has prayed for redressal and compensation.

          On the other hand OP by filing written statement submitted no doubt complainant is a valid mediclaim policy holder for the period from 03-11-2012 to 02-11-2013 covering the risk of reimbursement of hospitalization expenses of the complainant, his wife and his daughter for sum insured value of Rs.50,000/- each subject to terms, conditions, limitations and exceptions thereof as per the said policy.  Fact remains complainant submitted a claim along with medical papers for disbursement of Rs.22,230/- and after scanning the medical papers and after evaluation of the same by the panel doctor of TPA they came to a conclusion that the complainant suffered from Neurofibroma which is genetically disorder and accordingly as per terms and conditions of the policy in respect any genetic disorder no insured is entitled to any benefit and OP further submitted that after thorough examination of the papers and including the definition of the medical science and etc. as applied TPA repudiated the claim which is correct and valid and there is no arbitrary act on the part of the OP and for which the present complaint should be dismissed.

Decision with Reasons

On proper study of the complaint including the written statement and also hearing the complaint personally in open Forum including the argument as advanced by the OP it is found that only question is whether Neurofibroma is a genetic disorder or not.  In this regard complainant himself has filed a page of Harrison’s Volume – 1, 18^th Edition, Chapter-53, Page No.417 and tried to say Neurofibroma are soft papules or modules that exhibit the ‘button-hole’ sign, that is, they invaginate into the skin with pressure in a manner similar to a hernia.  Single lesions are seen in normal individuals and further complainant has tried to convince that it is not genetic disorder.  Further complainant submitted that Dr. Prabir Kumar Jash, Plastic Surgeon who operated the left ring finger of the complainant certified that Neurofibroma of left ring finger is not a genetic disorder and that was issued by the doctor on 10^th March, 2013 and complainant has relied upon and submitted that it is not a genetic disorder.  On the contrary OP submitted one report of Dr. Kaushik Sil, MBBS, MS, DNB(Neurosurgery), MNAMS, PDCC, Consultant Branch and Spine Surgeon of Medica Superspeciality Hospital who has submitted in his certificate that Neurofibroma is especially NF1 type usually a genetic disorder with abnormalities involving nervous system.  However, it may not be a congenital disorder.  NF2 is purely genetic disorder.  That doctor after considering the biopsy report of Amit Kumar Roy, 46 years, Male who has underwent surgery of left ring finger Neurofibroma and his opinion is Neurofibroma, NF1 type is usually a genetic disorder with abnormalities involving nervous system.  Considering two conflicting opinions of two doctors we have gone through a research paper written by Sarah Thornton, MS, reviewed by Kim Nichols, MD, Kristin Zelley, Ms, Michael Fisher, MD of November, 2013 and query from that through internet we have collected the answer – Neurofibroma type 1 (NF 1) is a genetic disorder and affected individuals are also at increased risk to develop certain benign tumors of the nervous system, especially, Neurofibromas (benign or malignant tumors of the nerves that form on or under the skin) and it is especially mentioned that answer against what causes neurofibroma type 1 is NF1 is caused by alterations (mutations), at specific areas within a person’s genetic information.  Each of us has a large amount of genetic information that is organized into smaller segments known as “genes”   Genes provide the necessary instructions that our cells require to perform their different functions within our bodies.  In the vast majority of patients with neurofibromatosis type 1, the disorder develops as the result of alterations in a specific gene known as NF1, which is located on chromosome 17 at position q11.2. NF1 is the only gene known to be associated with neurofibromatosis type1.  The protein produced by the NF1 gene acts as a “tumor suppressor”, which means that it helps to keep cells from growing and dividing too quickly and it promotes cell death.  This protein functions by “turning off” a second protein that stimulates cell growth and division.

          It is specifically mentioned that Neurofibroma Type 1 is hereditary, the risk to develop the features associated with NF1 may be passed from generation to generation in a family, however, the disorder can vary widely to effect family process.  As per said observation all those doctors approximately 50% of patient with Neurofibromatosis Type 1 inherit an altered copy of the NF1 gene from a parent who also has NF1.  in the remaining 50% of patients, Neurofibromatosis Type 1 results from the development of a ‘new’ mutation in the NF1 gene in one of the father’s sperm, mother’s eggs, or in a cell of the developing fetus.  In the latter scenario, the affected individuals will be the first ones in their family to carry this genetic change.  All individuals who carry an alteration in one copy of the NF1 gene in all the cells of their body have a 50% or in 1 in 2 chance of passing this same alteration on to each of his or her children.  Children who inherit the altered gene copy will have Neurofibromatosis Type 1 and will, therefore, be at risk to develop the features associated with this disorder.

          As per findings of those doctors almost all individuals with Neurofibromatosis Type 1 (NF1) eventually develop Neurofibromas benign (non-cancerous) tumors that form along nerves on the skin, or elsewhere in the body.  The tumors may be removed for cosmetic or medical reasons if needed.  In some cases, however, these tumors undergo malignant changes and behave like cancers.  Approximately, 10% of individuals with Neurofibromatosis Type 1(NF1) develop cancerous Neurofibromas, called malignant peripheral nerve sheath tumors.  Those doctors recommended for clinically services to the adults who have neurofibromatosis type 1(NF1) to contact the Medical Genetics Team at the Hospital of the University of Pennsylvania over phone also.

          Considering the research study of the aforesaid foreign doctors we are confirmed that the present disease is genetic disorder no doubt and this view has been already published in National Library of Medicine Genetics Home Reference-NF1 and it is also circulated in Neurofibromatosis Network.  So, considering the above fact and materials we are convinced to hold that Neurofibroma especially Type 1 (NF1) type is usually a genetic disorder and that has been confirmed by the above doctors of Sarah Thornton and reviewed by the doctors also noted above. 

          In the light of the above observation we are convinced to hold that OP rightly repudiated the claim as the present disease in which the operation was made by the doctors on the present complainant is a genetic disorder and invariably as per terms and conditions of the policy complainant is not entitled to get any mediclaim reimbursement. 

          In view of the above fact and no doubt for that reasons OP repudiated the claim which is justified and legal in view of the terms and condition of the policy and no doubt in this regard there is no laches, negligence or deficiency on the part of the OP and for which the complaint fails.

Hence,

Ordered

That the case be and the same is dismissed with contest against the OP but without any cost.