This case has arisen out of an application U/s 35 of the Consumer Protection Act, 2019.
The case of the complainant is that she, her husband Kamal Ch. Biswas and son are holder of policy No:-0314032819P116448436, Name and ID Kamal Ch. Biswas/23081334826 valid for the period from 21.03.2020 to 20.03.2021, under Individual Health Insurance Policy of O.P/Insurance Company. During policy period she became a patient of abdominal wall fistula & was admitted to Appollo Women’s Hospital, Chennai and surgery was done on 16.12.2020 under supervision of Dr. Alpa Khakhar, discharged on 17.12.2020.
After return to her house at Kaliyaganj her husband met with agent Tanmoy Choudhury and verbally applied for refund the money spent and as per agent’s instruction her husband submitted written application along with all original bill of medical treatment and surgery but no receipt was given.
That on 05.03.2021 O.P.No-1 replied to her husband that as per policy terms and condition claim is not payable under Clause No:4.14. Hence this complaint praying for Rs.1,63,652/- for cost of medical treatment, Rs.50,000/- for mental agony & harassment, Rs.20,000/- for litigation cost.
O.Ps contested the case by filing W.V stating that on 16.12.2020 the complainant was admitted to Appollo Women’s Hospital, Chennai and discharged on 17.12.2020 due to abdominal wall fistula. As per discharge certificate patient was admitted for Abdominal Fistulectomy, as c/o pain and stained to discharge from previous scar and patient had surgical H/o LSCS 04 yrs back. So this complication arises due to surgical procedure. Hence as per policy terms & conditions claim is not payable under Clause No:-4.14, as such on 21.03.2021 O.P/Insurance Company repudiated the claim.
Points for consideration are:-
- Whether there was any deficiency in service on the part of the O.Ps which gives rise cause of action to file the complaint and the complainant is entitled to get the claim?
D e c i s i o n w i t h r e a s o n s
Admittedly, proposer Mr. Kamal Ch. Biswas/ID 23081334826 purchased individual Health Insurance Policy No:-0314032819P116448436, for the period from 21.03.2020 to midnight of 20.03.2021, from O.P/Insurance Company, covering self (salaried), Joyashree Majumdar (Spouse-Housewife) & Kinjal Biswas (Son-student), plan- Platinum, sum insured Rs.3,00,000/- each.
It is also admitted that during policy period complainant was admitted to Appollo Women’s Hospital, Chennai and surgery was done on 16.12.2020 under supervision of Dr. Alpa Khakhar, discharged on 17.12.2020.
Discharge Summary, Dept. of URO GYNAECOLOGY of said Hospital shows:-Diagnosis-Abdominal Wall Fistula, Surgery-Abdominal Wall Fistulectomy, Chief complaints-C/o pain and blood stained discharge from previous scar X2 months. Diagnosed to have Abdominal Wall Fistula. Admitted for surgical management. Normal and bladder habits, Surgical History-LSCS-4 Yrs back (Induction:cord around neck), Menstrual History-Menarche-11th year, Obstetric History P1L1-Previous lscs – lcb 4 Yrs.
It appears that discharge request of Joyashree with TPA-ID-HHS4.0701604148 dated 17.12.2020 with two attachments i.e Discharge Summary.pdf and Final Bill. Pdf, for approval was/were forwarded to Heritage Health Insurance TPA Pvt. Ltd, but the TPA regretted their inability to sanction cashless authorization and informed O.P.No-1 by letter dated 21.01.2021 that as per the instruction of Head Office of United India Ins. Co. Ltd and subsequently by the Kolkata Regional Office vide letter dated 24.07.2007 with opinion to repudiate the claim file. Accordingly, O.P.No-1 by letter dated 05.03.2021 informed the insured/proposer Kamal Ch. Biswas that “as per discharge certificate patient was admitted for Abdominal Fistulectomy, as c/o pain and stained discharge from previous scar. According to Discharge Certificate patient had surgical h/o LSCS 04 Yrs back so this complication arises due to surgical procedure. Hence, as per policy terms and conditions the claim is not payable under Clause No:-4.14.
Exclusion Clause 4.14 runs as-Treatment arising from or traceable to pregnancy, child birth, miscarriage, abortion or complications of any of these including caesarean section, except abdominal operation for extra uterine pregnancy (Ectopic Pregnency) which is proved by submission of Ultra Sonographic Report & Certificate of Gynaecologist that it is life threatening one if left untreated.
In this case Ultra Sonographic report and/or certificate of Gynaecologist as to life threatening if left untreated is/are not submitted. According to Course in the Hospital: after obtaining informed consent and pre anesthetic clearance, she was taken up Abdominal Wall Fistulectomy. Post operative period uneventful. She is being discharged with stable vitals.
Under above facts and discussion, we are of the considered view that there was/ is no deficiency of service on the part of O.P/Insurance Company or Branch Manager, Raiganj Branch of O.P/Insurance Company, in not paying complainant’s claim or in repudiating her claim in terms of Exclusion clause No:4.14 of the terms & condition of the policy schedule. Consequently, the complainant is not entitled to get relief as prayed for.
In the result the case fails.
Hence, it is
O R D E R E D
that the C.C-13/2021 be and the same is dismissed on contest but without any cost.
Let a copy of this order be given to the parties free of cost.
