State Consumer Disputes Redressal Commission
Ashok Kumar vs United India Insu.Co. on 24 November, 2015
Daily Order M. P. STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PLOT NO.76, ARERA HILLS, BHOPAL FIRST APPEAL NO. 280 OF 2011 (Arising out of order dated 06.01.2011 passed in C.C.No.19/2009 by District Forum, Dewas) ASHOK KUMAR S/O LATE CHUNNILAL SHRIVASTAVA, S/O LATE CHUNNILAL SHRIVASTAVA, R/O 35, HIG, VIJAY NAGAR, DEWAS (M.P.) ... APPELLANT. Versus UNITED INDIA INSURANCE CO.LTD. OPPOSITE UNION BANK, 91, STATION ROAD, DEWAS (M.P.) ... RESPONDENT. BEFORE : HON'BLE SHRI SUBHASH JAIN : PRESIDING MEMBER
HON'BLE SHRI S. D. AGARWAL : MEMBER COUNSEL FOR PARTIES: Appellant who himself an advocate is present in person. Shri Mohan Chouksey, learned counsel for the respondent. O R D E R (Passed On 24.11. 2015)
The following order of the Commission was delivered by Shri S. D. Agarwal, Member:
This appeal is by the complainant/appellant (hereinafter referred to as 'appellant'), aggrieved by the order dated 06.01.2011 passed by the District Consumer Disputes Redressal Forum, Dewas (hereinafter referred to as 'Forum'), in CC No. 19/2009 whereby his complaint has been dismissed.
2. Facts of the case in brief, as per the appellant are that the appellant had obtained an Individual Health Insurance Policy no. 191301/48/07/97/00001120 from the opposite party/respondent, the United India Insurance Company Limited (hereinafter referred to as respondent) for the period 01.11.2007 to 31.10.2008. In the month of April-2008, the appellant fell ill, he consulted Dr.R.S.Dubey who treated him for fever and after realizing that the appellant had developed perineal infection, referred him to surgeon. The appellant, therefore, consulted Dr.Alok Shrivastava of Prabhu Prasad Chikitsalaya, -2- Dewas, who diagnosed him suffering from Acute Fissure in Ano with Sentinel pile with Perianal Abscess with suspected pyreliphlebitis i.e. infection of liver venules. Then Dr.Shrivastava decided for operation after controlling the infection. As per appellant he was admitted in the hospital on 16.04.2008 and remained there till 30.04.2008. After discharge when he put up mediclaim to respondent, the same was repudiated. He therefore filed a complaint before the District Forum which was also dismissed. He therefore filed the present appeal.
3. Respondent resisted the complaint before Forum stating that since the appellant was operated for Fistula and the Fistula in Ano is not covered under the policy condition, his claim was repudiated and therefore the respondent insurance company has not committed any deficiency in service.
4. The District Forum dismissed the complaint holding that the respondent insurance company committed no deficiency in service in repudiating the claim as the disease i.e. Fistula for which the appellant was operated, is not covered under the condition no.4.3 of the policy. The appellant has therefore filed the present appeal.
5. We have heard appellant and learned counsel for the respondent and perused the record.
6. On perusal of record, i.e., prescriptions and hospital records filed by the appellant as also the respondent, it is observed that on 16.04.2008 Dr. Alok Shrivastava of Prabhu Prasad Chikitsalaya, Dewas diagnosed the appellant as a patient of Acute Fissure in Ano with Sentinel pile with Perianal Abscess with suspected pyreliphlebitis and advised admission of the patient. The appellant was admitted in the hospital, where different investigations on 20.04.2008 were performed which revealed Ischiorectal abscess with Fistula. It is also clear from the said medical record that Fistulectomy was performed. A certificate dated 30.04.2008 issued by Dr.Alok Shrivastava of Prabhu Prasad Chikitsalaya, Dewas is also on record which reads "This is to certify that Shri Ashok S/O Shri Chunnilalji -3- Shrivastava was operated upon by me for Ischiorectal abscess & Incision & drainage with Fistulectomy was performed. He has recovered completely of his ailment & shall need only Superficial Dressings for the wound protection."
7. We have also gone through the policy filed on record wherein Condition no.4.3 reads as under:
4.3 During the first year of the operation of the policy, the expenses on treatment of diseases such as Cataract, Benign, Prostatic, Hyperthrophy, Hysterectomy for Menorrhagia, or Fibromyoma, Hernia, Hydrocele, Cogenital internal disease, Fistula in anus, piles, Sinusitis and related disorders are not payable. If these diseases (other than congenital internal disease) are pre-existing at the time of proposal they will not be covered even during subsequent period of renewal. If the insured is aware of the existence of congenital internal disease before inception of policy, the same will be treated as pre-existing.
From bare perusal of the above mentioned condition, it is clear that expenses on treatment of Fistula in anus including other diseases are not payable during the first year of the operation of the policy. Appellant placing reliance on the affidavit of the operating surgeon tried unsuccessfully to convince the Forum as also this Commission that he underwent treatment and surgery for fissure and not for fistula. The operating surgeon Dr.Alok Shrivastava in his affidavit dated 03.08.2009 filed before the District Forum tried to say about Fistulectomy that "It is merely the technical term applied to the operation, as stated earlier and it is again stated that patient was not suffering from CHRONIC FISTULA IN ANO," which is contradictory to his own notes dated 20.04.2008 and certificate dated 30.04.2008 issued by him in which he has stated that Fistulectomy was performed. In medical dictionary and Wikipedia term "Fistulectomy" defines a surgical procedure where a fistulous tract is excised (cut out) completely. Fistulae are features of many diseases, but commonly fistulectomy refers to an operation for an anal fistula (fistula-in-ano).
8. In view of the above discussion we find that the insurance company has rightly repudiated the claim of the appellant as medical expenses for the -4- disease (fistula in anus) were not payable under the condition no. 4.3 of the policy. The District Forum has also rightly dismissed the complaint of the appellant. We do not find any reason to take a different view of the matter. The findings of the District Forum are just and proper and do not call for any interference. We do not find any infirmity in the order passed by the District Forum. The appeal is therefore dismissed. Parties to bear their own cost.