By Smt. C.S. Sulekha Beevi, President,<br /> <br /> 1. Complainant availed a mediclaim policy under opposite party. During the currency of the policy on 21-01-2004 she experienced severe palpitation and difficulty in breathing and so consulted a doctor at Nilambur. She was advised to approach a hospital with better facilities and was taken to Vijay Speciality Hospital at Manjeri. On the next day she was referred to Medical College Hospital, Kozhikkode for expert treatment. Complainant was admitted and treated in the Cardiology department of Medical College from 22-01-04 till 29-01-04. After discharge her condition became bad again and she was further admitted and treated from 11-02-04 till 15-02-04 in the Medical College Hospital. Since her condition did not improve upon medications she was again admitted on 10-5-2004 till 15-5-2004 and under went Radio Frequency Catheter Ablation. She spent huge amount for hospitalization expenses and for treatment. Though a claim was preferred before opposite party along with all relevant documents opposite party repudiated the claim on unsustainable grounds. Hence this complaint alleging deficiency in service.<br /> 2. Opposite party has filed version admitting the issuance of Hospitalization and Domiciliary Hospitalization Benefit Policy for the period 15-9-2003 to 14-9-2004. It is submitted that the policy expressly excludes from it's purview maternity, pregnancy and related hospitalization. That on scrutiny of the medical records submitted by complainant it was found that the entire series of hospitalization were for management of Pregnancy Induced Hypertension (PIH) which resulted intrauterine death of the baby at 8 months gestation Supraventricular tachycardia is also an ailment encountered during pregnancy. That the ailments for which complainant underwent treatment were directly or indirectly related to pregnancy which is expressly excluded as per policy. Thus Third Party Administrator (TPA) officially appointed by Company to deal with Mediclaims repudiated the claim on sufficient grounds and that there is no deficiency in service. <br /> 3. Evidence consists of affidavit filed by complainant and Exts.A1 to A13 marked on her side. Opposite party has filed counter affidavit. No documents marked on the side of opposite party. Either side has not adduced any oral evidence.<br /> 4. Points for consideration:-<br /> (i) Whether opposite party is deficient in service.<br /> (ii) If so, reliefs and costs.<br /> 5. Point (i):-<br /> The vital point that arises for consideration in this case is whether the ailments for which complainant underwent treatment were directly or indirectly related to pregnancy so as to bring it within the exclusion under 4.12 of the policy. According to complainant she was admitted from 21-01-04 to 22-01-04 in Vijay Hospital at Manjeri from where she was referred to Medical College Hospital for expert management. Ext.A7 is the discharge card issued from Vijay Hospital. In Ext.A7 the diagnosis is noted as “ ? RVOT – PIH”. The other details noted in Ext.A7 are as follows:<br /> “Patient came with history of chest discomfort. G2P1L1 (Gravida-2, Para-1, Living-1) LMP June 13th EDC (Expected date of confinement) 20/03<br /> On examination palpitation with syneope, Patient was kept in ICU. Treated with antibiotics and analgesic with antidepresents. 2nd day no relief and send to IMCH., Calicut for further management in Cardiology at Request (ECG – VT)”.<br /> 6. It can be seen that though complainant was pregnant she was admitted for discomfort in chest. It is also seen that she was referred for management in Cardiology and not for any complications in relation to her pregnancy. Ext.A8 is the photo copy of Reference Card issued from Medical College Hospital, Kozhikkode. As per Ext.A8 she was admitted and treated from 22-01-04 till 29-01-04 and further on 11-02-04 till 15-04-04. The diagnosis noted in Ext.A8 is VT – RVOT -- PIH -- IUD (Ventricular Tachycardia – Right Ventricular outflow Tract, Pregnancy Induced Hypertension – Intrauterine Death). Ext.A9 is the discharge summary issued from the department of Cardiology of Medical College Hospital, Kozhikkode. As per Ext.A9 complainant was admitted from 10-5-2004 till 15-5-2004. On 12-5-2004 the procedure of CAG/L Vangio/RHC was done. From these treatment records it is clear that complainant was treated for some cardiac problem. Exclusion 4.12 in Ext.A1 policy is as follows:<br /> “treatment arising from or traceable to pregnancy (including voluntary termination of pregnancy) and child birth (including caesarian section)”. <br /> In the present case there is nothing to show that the ailment or treatments were related to pregnancy. In our view the whole issue for denial of policy might have arose due to the doctors noting PIH (in the medical records). This doubt has been clarified by Ext.A5 which is the Certificate issued by Dr.Kader Muneer Cardiologist of Medical College Hospital, Kozhikkode who has treated the complainant. Ext.A5 is reproduced as under:<br /> “This is to certify that Mrs.Rukiya had Ideopathic Right Ventricular Outflow (RVOT) Tachycardia. This is a disease of the heart and not a complication of pregnancy. She later underwent successful radio frequency ablation of RVOT Tachycardia”.<br /> Ext.A6 is the letter issued by Dr.Noushad Pandharappadan, Medical Director, Vijay Hospital, Manjeri. The relevant portion of Ext.A6 reads as follows:<br /> “I would like to bring to your notice that the patient by name Mrs. Rukiya came to our casualty on January, 2004. Complains of chest pain. It was true that she was pregnant that time. Diagnosis was ? RVOT (Right Ventricular Out Flow). This is a disease of heart and not a complication of pregnancy/PIH (Pregnancy Induced Hypertension). The Cardiologist who treated her also given the same opinion”.<br /> Ext.A5 and Ext.A6 which are opinions given by experts sufficiently prove and establish that the ailment and treatment for which complainant underwent treatment was not related to pregnancy and therefore does not come within exclusion 4.12 of the policy. Except the affirmation in the affidavit there is no evidence adduced by opposite party to controvert the case put forward by complainant. We have no doubt to conclude that opposite party has repudiated the claim on unsustainable grounds. The act of Insurance Company repudiating the claim on flimsy and unreasonable grounds is not only unjustifiable but ethically indefensible. For the foregoing reasons we find opposite party deficient in service.<br /> 7. Point (ii):-<br /> The prayer in the complaint is to allow Rs.15,000/- as monetary loss, Rs.25,000/- as compensation and to pay interest @ 18%. The benefit payable under the policy is Rs.15,000/-. Complainant is definitely entitled to this amount. Ordinarily insurance company should settle the claim within a period of three months. The delay in settling the claim indisputably causes inconveniences and hardships to the insured. Ext.A13 series are the Medical bills produced by complainant. It shows that Rs.5,000/- was paid to the Cardiac Catheterisation Lab alone. According to us payment of interest @ 12% per annum from date of complaint upon the above sum of Rs.15,000/- would be sufficient compensation to complainant for the deficiency, inconvenience and hardships.<br /> 8. In the result we allow this complaint and order opposite party to pay Rs.15,000/- (Rupees Fifteen thousand only) to the complainant along with interest @ 12% per annum from the date of complaint till payment together with costs of Rs.1,500/- (Rupees One thousand, five hundred only) within one month from the date of receipt of copy of this order.<br /> <br /> Dated this 17th day of September, 2008.<br /> <br /> Sd/-<br /> C.S. SULEKHA BEEVI, PRESIDENT<br /> <br /> <br /> Sd/-<br /> E. AYISHAKUTTY, MEMBER<br /> <br /> <br /> <br /> <br /> <br /> APPENDIX<br /> <br /> Witness examined on the side of the complainant : Nil <br /> Documents marked on the side of the complainant : Ext.A1 to A13<br /> Ext.A1 : Prospectus Mediclaim Insurance Policy(Individual) issued by <br /> opposite party to complainant. <br /> Ext.A2 : Photo copy of the receipt for Rs.639/- dated, 15-9-2003 from <br /> opposite party to complainant.<br /> Ext.A3 : Letter dated, 13-10-2003 from Family Health Plan Ltd. to complainant.<br /> Ext.A4 : Photo copy of the claim form submitted by complainant to <br /> opposite party.<br /> Ext.A5 : Certificate dated, 26-11-2003 issued by Dr.Kader Muneer Cardiologist <br /> of Medical College Hospital, Kozhikkode to complainant. <br /> Ext.A6 : Letter dated, 27-11-04 by Dr.Noushad Pandharappadan, <br /> Medical Director, Vijay Hospital, Manjeri to CRM Deptt., Family<br /> Health Plan, Cochin.<br /> Ext.A7 : Photo copy of the discharge card issued from Vijay Hospital, Manjeri<br /> to complainant..<br /> Ext.A8 : Photo copy of Reference Card issued from Medical College Hospital,<br /> Kozhikkode to complainant. <br /> Ext.A9 : Photo copy of the CAG Discharge summary issued from department <br /> of Cardiology of Medical College Hospital, Kozhikkode.<br /> Ext.A10 : Photo copy of the letter dated, 15-7-2004 by complainant to<br /> 1st opposite party.<br /> Ext.A11 : Letter dated, 22-6-2004 from CRM Department, Family Health Plan<br /> Ltd. to complainant.<br /> Ext.A12 : Photo copy of the letter dated, 28-10-2004 from 1st opposite party<br /> to complainant.<br /> Ext.A13(series): Photo copy of the Medical bills. <br /> Witness examined on the side of the opposite parties : Nil<br /> Documents marked on the side of the opposite parties : Nil<br /> <br /> Sd/-<br /> C.S. SULEKHA BEEVI, PRESIDENT<br /> <br /> <br /> Sd/-<br /> E. AYISHAKUTTY, MEMBER