West Bengal

Bankura

CC/79/2017

Ms Bulbul Pramanic - Complainant(s)

Versus

United India Insurance Co. Ltd. - Opp.Party(s)

Amitava Chatopadhyay

14 Mar 2023

ORDER

IN    THE   DISTRICT   CONSUMER   DISPUTES   REDRESSAL COMMISSION BANKURA

Consumer  Complaint  No. 79/2017

Date of Filing : 27.11.2017

Before:

1. Samiran Dutta                              Ld. President.      

2. Rina Mukherjee                          Ld. Member. 

3. Siddhartha Sankar Bhui            Ld. Member.

 

For the Complainant: Ld Advocate Jayanta Kr. Mukhopadhyay

For the O.P. Ld Advocate Ashim Kumar Mondal

Complainant                                                                                                          

Ms. Bulbul Pramanic, D/o Late Ashit Ranjan Pramanic, at Nutanchati, Lakshmi Mela, Bankura

Opposite Party  

1. United India Insurance Co. Ltd., Bankura Branch, Nutanchati, Bankura & one Or.

 

FINAL ORDER / JUDGEMENT                

                                                                                                                                          

Order No.37                                                                                   

Dt. 14-03-2023

Both parties filed hazira through advocate.

The case is fixed for argument.

After hearing and perusing written argument from both sides the Commission proceeds to dispose of the case as hereunder: -

The complainant’s case is that she has a Health Insurance policy No. being 0315082816P114224059, valid from 02-02-2017 to 01-02-2018 issued by O.P. No.1 and O.P. No.2 is the TPA and O.P. No.3 is the Head Of Office of O.P. No.1. Prior to the issuance of the policy the complainant felt pain in her lower abdomen and she being a single lady overlooked the symptom being normal at her age more than 50 years but when the pain became unbearable in the month of June, 2016 the complainant for the first time consulted Dr. Dipankar Mondal and as per his advice she was to undergo clinical test of MRI of Pelvis and the report showed bulky Uterus with thickened endometrium. Though some medicines were prescribed but the pain did not subside and the said Doctor was consulted at the Mission Hospital and again blood tests were done and medicines continued and as per advice of the Doctor USG test was done.

                                                                                                                                                                                        Contd……p/2

Page: 2

For the first time the problem was detected and immediately thereafter the complainant went to Calcutta and consulted Dr. P. Das Mahapatra and she was under medication for few months under Dr. Das Mahapatra and on 21^st April, 2017 the complainant again consulted Dr. Das Mahapatra who after examination advised to opt for surgery and accordingly the complainant was admitted in the medical facilities under Bhagirathi Neotia Women & Child care on 1^st May, 2017 and surgery was done by the said Dr. Das Mahapatra and she was discharged from the Hospital on 5^th May, 2017.

               The complainant had to pay Rs.1,17,000/- as Doctors’ fees and Rs.70,816/- as Nursing Home charges and Rs.1,160/- as expenses for medicines and in total she had to bear Rs.1,88,976/- for the surgical treatment.

               The claim for reimbursement of the Hospitalization expenses was lodged on 12-05-2017 with O.P. No.1 but by letter dated: 22-08-2017 her claim was repudiated on the ground of pre-existing diseases.              

               O. P. No.1 & 3 contested the case by filing a joint written version contending inter-alia that prior to the issuance of Policy the complainant was suffering from Gynecological problem since 2014 and as such she is not entitled to get the relief as prayed for in this case.

                                                                                          -Decision with reasons-

The Commission has examined the entire facts of the case and the documents relied upon by the parties and gone through the submission and contention on both sides.

               Ld. Advocate appearing for the complainant has referred to the Discharge summary (Annexure 1A) issued by Bhagirathi Neotia Women & Child care wherefrom it reveals that the complainant was diagnosed with Adenonysis with fibroid uterus which is not classified as pre-existing disease in the terms and conditions of the Policy.

               On the other hand Ld. Advocate appearing for the O.P. has referred to the prescription of Dr. Das Mahapatra dated: 26-10-2016 which shows that the complainant had the problem of Menorrhagia with severe pain in lower abdomen since last two years and the USG last done on 14-10-2016 shows bulky uterus with globular shape and relying on this prescription Ld. Advocate for the O.P. has contended that prior to the

                                                                                                                                                                                          Contd…..p/3

Page: 3

commencement of the Policy on 2/2/2017 the complainant had been suffering from uterus complications but the surgical operation was carried out on 1^st May, 2017 for the same disease i.e. within three months from the inception of the Policy. In support of his contention he has submitted two decisions.

               On the other hand Ld. Advocate for the complainant has referred to several decisions to establish his case. The Commission refrains from citing all those common decisions.

               As stated above the disease Adenomyosis with fibroid uterus with which the  complainant was diagnosed before her surgical operation is not a pre-existing disease according to the  terms and conditions of the Policy and so repudiation of  her claim for re-imbursement of medical expenses as prayed for is not justified in the present facts and circumstances of the case.

               In the result the case succeeds and the complainant is entitled to get the relief as prayed for.

Hence it is ordered………

That the case be and the same is allowed on contest but without cost.

The O.P.s are directed to pay to the complainant Rs.1,88,976/- within one month from this date failing which the decretal amount may be realized in due process of law.

Both parties be supplied copy of this order free of cost.

 

   __________________                    ________________                   ________________

HON’BLE   PRESIDENT            HON’BLE    MEMBER          HON’BLE    MEMBER