S. S. ALI, MEMBER
The case of the complainants/petitioners, as projected in the complaint in brief, is that they took a Mediclaim Policy from OP insurance company being policy no. 499033023 after paying requisite premium thereof and the said policy was valid for the period from 29-09-2009 to 29-09-2028. Complainant no. 2 felt ill at her residence in Panskura and therefore, she visited the chamber of Dr. Bhabani Bhattacharya at Tamluk on 10-10-2011. Thereafter, for better treatment complainant no. 2 got admitted at Dewan Medicare, Kolkata on 08-11-2011 under Dr. Indrani Lodh and got operated on 09-11-2011 wherefrom she was discharged on 11-11-2011. It is further stated by the complainants that complainant no. 1 had to incur an expenditure of Rs. 53,029/- for the said treatment and accordingly he submitted a claim form along with relevant documents with OPs on 16-11-2011, however, OPs in an arbitrary manner repudiated their legitimate claim, hence the case.
In support of their contention, complainants’ submitted original insurance policy, Brochure for TPA service, Health Cards issued by OPs in favour of the beneficiaries under the policy in question together with photocopies of Claim Forms, Hospital Treatment Form, Discharge Summary, Repudiation letter, medical bills, pathological report, one prescription etc.
OPs contested the case by filing written version and written notes on argument. Besides, they also took an active part in the entire proceeding. By their written version OPs denied all the material allegations of complainants’ and stated that they were compelled to repudiate the claim of complainants’ as because such surgery was not covered under the said policy. More so, since their TPA is the authorized body to decide about settlement of any claim and their decision is final and binding on all. As such, OPs cannot be held responsible under any circumstances.
In support of their defence OPs filed a blank copy of their Health Protection Plus Plan/Table No. 902 together with a brochure on the conditions and privileges available under the above policy.
Points for consideration
Based on the materials on record and submission of ld. lawyers of both sides, we frame the following points.
- Whether there is any deficiency in service on the part OPs as alleged by the complainants?
- Whether complainant no. 2 is entitled to get reimbursement of medical expenses as sought for under the Health Protection Plus Plan/Table No 902?
- Whether complainants are entitled to any other relief, as sought for?
Decisions with reasons
Point nos. 1,2& 3:
All these points are taken up collectively for the sake of brevity of discussion.
On going through the Policy certificate we find that it clearly stipulates that “policy of assurance shall be subject to the ‘Conditions and Privileges’ attached herewith” and on referring the brochure containing details of Conditions and Privileges we find that it includes a list of surgical procedures of 49 categories. We also find that cl. II(vii) under the heading Major Surgical Benefit Limits of the Conditions and Privileges brochure stipulates that ‘No payment shall be made under this benefit for the operations performed, which are not listed in the Surgical Benefit Annexure ‘.
In the instant case admittedly complainant no. 2 underwent LAVH with BSO under GA surgery for ‘’Multiple Huge Fibroids, Uterus, Morcellated Out’ at Dewan Medicare, Kolkataon 9.11.2011. On going through the list of 49 surgical procedures which are covered under OP’s Health Protection Plus Scheme we do not find any mention of above surgical procedure in the said list and therefore, we do not find any merit in complainant’s claim for reimbursement of medical expenses incurred for the treatment of complainant no. 2 as stated hereinabove.It makes no emphasis that ‘Terms and Conditions’ of a policy is equally binding on both the insurer as well as the insured and for this very reason while the surgical procedure in question which complainant no. 2 underwent is outside the purview of policy condition, in our considered view, complainants’ cannot expect any reimbursement for the same from insurer.
In the light of our foregoing discussion and having regard to the materials on record, we do not find any irregularity or deficiency in service behind repudiation of complainants’ claim by OPs and accordingly hold that complainants’ including complainant no. 2 are not entitled to any relief as sought for.
All these points are, thus, disposed of against the complainants’.
Hence, it is
ORDERED
that the instant C.Case no. 10/13 be and the same is dismissed on contest against the OPs. Parties do bear their respective costs.
S.S. Ali A.K. Bhattacharyya
Member President
