State Consumer Disputes Redressal Commission
United India Insurance Co.Ltd. vs Amit Kumar Roy & Anr. on 27 January, 2018
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Formation of calculi is known as lithiasis. Stones can cause a number of medical conditions. fpfdRlh; nLrkostksa esa fMLpktZ lejh Hkh 'kkfey gS ftlesa ifjoknh ds iq= dh chekjh dk fooj.k Li"V :Ik ls ;qfjujh Vsªd esa bUQsD'ku of.kZr gSA vukosndx.k }kjk ifjoknh ds iq= dh chekjh dks chek nkok Hkqxrku djus ls cpus ds nqjk'k; ls xyr rjhds ls of.kZr dj chek nkok [kkfjt fd;k x;k gS tks lsok esa deh ,oa vuqfpr O;kikj izFkk dh Js.kh esa vkrk gS ftlds dkj.k ifjoknh dks ;g ifjokn ykus dh vko';drk iM+h gSA vr% ifjokn&i= esa of.kZr vuqlkj vuqrks"k fnykbZ tkosA 03- vihykFkhZ@vukosnd dz-1 dh vksj ls ftyk Qksje ds le{k fyf[kr dFku izLrqr djrs gq, ;g vfHkopu fd;k x;k gS fd vukosnd dz-1 chek daiuh }kjk ifjoknh ds uke ij esfMds;j ikWfylh fnukad&10- 11-2015 ls fnukad&09-11-2016 rd dh vof/k gsrq fu;e] 'krksZa o vioknksa ds rgr tkjh fd;k x;k FkkA ikWfylh ds ,DlDywtu DykWt 4-3 ds rgr Illness Calculus diseases ikWfylh ds rgr nks o"kZ rd doj ugha gksrk gSA // 5 // vFkkZr~ nks yxkrkj fjU;qvy esfMDyse ikWfylh ds Ik'pkr~ gh mDr chekjh doj gksrh gSA vukosnd dz-2 FkMZ ikVhZ ,MfefuLVsªVj gS ftlesa fo'ks"kK MkWDVjksa dh Vhe ds }kjk nkos dk voyksdu dj mlds laca/k esa vfHker~ fn;k tkrk gS rFkk vko';drk gksus ij fujkd`r Hkh fd;k tkrk gS ftlds vk/kkj ij vukosnd dz-1 }kjk nkok dks fujkd`r djrk gSA ifjoknh }kjk izLrqr nkok Hkh vukosnd dz-2 }kjk tkap dj ;g ik;k x;k fd ifjoknh ds iq= dks Calculus diseases gS vkSj mDr chekjh dk [kpZ ikWfylh ds izkjaHk ds 02 o"kZ esa ns; ugha gksrk gS vkSj uk gh bl laca/k esa dS'kysl QsflfyVh iznku fd;k tk ldrk gS ftldh tkudkjh fnukad&27-08-2016 dks gkWfLiVy dks fn;k x;k gSA vukosnd dz-1 }kjk nkok izkIr gksus ij tkap Ik'pkr~ ;g ik;s tkus ij fd ifjoknh ds iq= dks Calculus diseases gksus ds dkj.k ifjoknh ls yxkrkj nks o"kksZa dh iwoZ ikWfylh dh ekax dh xbZ tks izLrqr uk fd;s tkus ij ifjoknh dk nkok DykWt 4-3 ds rgr ns; uk gksus ls jsiqfM,V dj mldh lwpuk ifjoknh dks iznku fd;k x;k gSA vukosnd dz-1 }kjk lsok esa dksbZ deh ugha dh xbZ gSA ifjoknh] vukosnd dz-1 ls dksbZ vuqrks"k izkIr djus dk vf/kdkjh ugha gSA vr% ifjoknh dk ifjokn lO;; fujLr fd;k tkosA 04- uksfVl rkehyh ds ckn Hkh mRrjoknh dz-2@vukosnd dz-2 ftyk Qksje ds le{k vuqifLFkr Fkk vkSj mldh vksj ls dksbZ fyf[kr dFku ,oa nLrkost izLrqr ugha gSA // 6 // 05- mRrjoknh dz-1@ifjoknh dh vksj ls vius i{k leFkZu esa ftyk Qksje ds le{k chek ikWfylh dh Nk;kizfr ¼,usD'pj ,&1 ,oa ,&2½] Li'kZ eYVh Lisf'kfyVh gkWfLiVy dh bZykt iphZ dh Nk;kizfr ¼,usD'pj ,&3½] ;wfju tkap fjiksVZ fnukad&26-08-2016 dh Nk;kizfr ¼,usD'pj ,&3@,½] foMky VsLV fjiksVZ fnukad&26-08-2016 dh Nk;kizfr ¼,usD'pj ,&3@ch½] lh- ch- lh- fjiksVZ fnukad&26-08-2016 dh Nk;kizfr ¼,usD'pj ,&3@lh½] dYpj ,.M lsaflfVfoVh fjiksVZ fnukad&28-08-2016 dh Nk;kizfr ¼,usD'pj ,&3@Mh½] vYVªk lksuksxzkQh fjiksVZ fnukad&28-08- 2016 dh Nk;kizfr ¼,usD'pj ,&3@b ,oa ,Q½] fMLpktZ lejh dh Nk;kizfr ¼,usD'pj ,&4½] fizfLdzI'ku isM fnukad&28-08-2016 ls 29-08- 2016 dh Nk;kizfr ¼,usD'pj ,&5 ls 5@,Q½] nokbZ iphZ dh Nk;kizfr ¼,usD'pj ,&5@th ls 5@;w½] vukosnd dz-2 dk i= fnukad&27-08-2016 dh Nk;kizfr ¼,usD'pj ,&6½] vukosnd dz-2 dk i= fnukad&27-08-2016 dh Nk;kizfr ¼,usD'pj ,&7½] nkok QkeZ dh Nk;kizfr ¼,usD'pj ,&8½] jsiqfM,'ku ysVj fnukad&20-10-2016 dh Nk;kizfr ¼,usD'pj ,&9½ rFkk fyVjspj dh Nk;kizfr ¼,usD'pj ,&10½ izLrqr fd;k gSA 06- vihykFkhZ@vukosnd dz-1 dh vksj ls vius i{k leFkZu esa ftyk Qksje ds le{k chek ikWfylh fnukad&10-11-2015 ls 09-11-2016 dh Nk;kizfr ¼,usD'pj ,u,&1½] nkok QkeZ dh Nk;kizfr ¼,usD'pj ,u,&2½] vukosnd dz-2 dk i= fnukad&27-08-2016 dh Nk;kizfr ¼,usD'pj // 7 // ,u,&3½ rFkk jsiqfM,'ku ysVj fnukad&20-10-2016 dh Nk;kizfr ¼,usD'pj ,u,&4½ izLrqr fd;k gSA 07- ftyk Qksje us mHk;i{kksa dh vksj ls izLrqr vfHkopu ,oa nLrkosth lk{;ksa ds ifj'khyu ds Ik'pkr~ ifjoknh ds ifjokn dks Lohdkj djrs gq, Åij dafMdk&1 esa of.kZr vuqlkj vuqrks"k iznku fd;k gS ftlds fo:} ;g vihy gSA 08- vihykFkhZ@vukosnd dz-1 dh vksj ls milatkr gksus okys fo}ku vf/koDrk Jh ih- ds- ikWy dk rdZ gS fd ifjoknh }kjk Lo;a ,oa viuh ifRu Jherh jkS'kuh jkW; rFkk iq= jkSud dqekj jkW; ds fy, QSfeyh esfMds;j ikWfylh fy;k x;k Fkk vkSj jkSud dqekj jkW; dh chekjh dk bZykt djk;k x;k Fkk rFkk jkSud dqekj jkW; ds iFkjh ¼Calculas½ dk bZykt gqvk Fkk tks fd chek 'krksZa ds viotZu [k.M&4 ds varxZr vkrk gS vkSj ftlds vuqlkj nks o"kZ dh vof/k ds Ik'pkr~ gh esfMds;j ikWfylh ns; Fkk rFkk nks o"kZ dk osfVax ihfj;M O;rhr ugha gqvk Fkk vkSj blfy, vukosnd dz-1 chek daiuh dksbZ Hkh jkf'k Hkqxrku djus gsrq mRrjnk;h ugha gS vkSj pwafd ifjoknh ds iq= jkSud dqekj jkW; dks xaHkhj Advance Calculas Disease Fkk] ,slh fLFkfr esa viotZu [k.M dks ns[krs gq, chek daiuh dk dksbZ nkf;Ro ugha gS vkSj blfy, chek daiuh fdlh izdkj ls nkf;Rok/khu ugha gS vkSj ftyk Qksje us tks vkns'k ikfjr fd;k gS og iw.kZr% =qfViw.kZ gSA vr% vukosnd dz-1 dh vihy Lohdkj fd;k tkos vkSj ftyk Qksje }kjk ikfjr vkyksP; vkns'k vikLr fd;k tkosA vukosnd dz-
// 8 // 1 dh vksj ls vius rdZ ds leFkZu esa Dr. Bihari Lal Singhania Vs. United India Insurance Co. Ltd. & Ors. II (2017) CPJ 68 (NC) dk voyacu fy;k gSA 09- mRrjoknh dz-1@ifjoknh dh vksj ls milatkr gksus okys fo}ku vf/koDrk Jh vuqjkx Bkdj dh vksj ls ;g rdZ izLrqr fd;k x;k gS fd ifjoknh ds iq= jkSud dqekj jkW; dks ;qjhujh bUQsD'ku Fkk tks fd ;qjhujh Vsªd esa gksrk gS vkSj mls iFkjh ;k dSydqyl dh chekjh ugha ekuk tk ldrk gSA jkSud dqekj jkW; dks cq[kkj ,oa is'kkc esa tyu dh rdyhQ gqvk Fkk rc mls Li'kZ eYVh Lisf'kfyVh gkWfLiVy fHkykbZ esa tkap ds fy, yk;k x;k Fkk vkSj MkW- iqyd tSu }kjk tkap dj ;qjhujh bUQsD'ku crk;k x;k Fkk vkSj vYVªk lkÅ.M tkap djkus ij iFkjh dh tkudkjh gqbZ Fkh ysfdu iFkjh dk dksbZ bZykt ugha gqvk Fkk vkSj tgka rd ;qjhujh Vsªd esa bUQsD'ku dk laca/k gS og cSDVhfj;k ls gksrk gS vkSj blesa viotZu [k.M dz-&4 ykxw ugha gksrk gS vkSj ftyk Qksje us tks vkns'k ikfjr fd;k gS og iw.kZr% mfpr gSA vr% vukosnd dz-1 dh vihy fujLr fd;k tkos vkSj ftyk Qksje }kjk ikfjr vkyksP; vkns'k dks ;Fkkor~ j[kk tkosA 10- uksfVl rkehyh ds ckn Hkh mRrjoknh dz-2@vukosnd dz-2 dh vksj ls dksbZ milatkr ugha gq, gSaA 11- geus mHk;i{k ds fo}ku vf/koDrkx.k dk rdZ Jo.k fd;k rFkk ftyk Qksje ds vfHkys[k ,oa vkyksP; vkns'k dk Hkh ifj'khyu fd;k x;kA // 9 // 12- vihykFkhZ@vukosnd dz-1 us tks U;k; n`"Vkar Dr. Bihari Lal Singhania Vs. United India Insurance Co. Ltd. & Ors. (Supra) dk voyacu fy;k gS mlesa ;g crk;k x;k gS fd%& "6. It was contended during arguments by the learned Counsel for the petitioner that the complainant's case was of removal of gall bladder, which is called cholecystectomy. There was no removal of any stone, and hence, the case was not hit by the Exclusion Clause 4.3, as being alleged by the Insurance Company.
7. The learned Counsel for the respondent Insurance Company, however, stated that the case was hit be Exclusion Clause 4.3 as gall bladder had been removed with stone. ... The learned counsel has drawn attention to the report made by the Chaudhari Digital Imaging and Research Centre, in which it is stated that small calculi were observed. In the discharge summary of Shri Ram Hospital as well there is mention of gall bladder calculi.
9. ....The Exclusion Cluase 4.3 of the InsurancePolicy makes it clear that if the Gall Bladder Stone removal is done during the first two years of the operation of the policy, the expenses on such treatment are not payable. The version of the complainant in the present case is that the gall bladder was removed without stone, as per the evidence brought on record.... The discharge summary given by Shri Ram Hospital at Patna also mentioned about 'gb calculi' under the heading 'diagnois'. In the ultrasonography done at Bombay Hospital and Medical Research Centre, it has been stated as follows :-
"Conclusion : Thick irregular walled gall bladder with dense echoes within".
10. In the report of Department of Histopathology, at the Bombay Hospital, it is mentioed, 'No calculi are received'. However, in the conclusion of Medical Research Centre, Bombay Hospital Trust, it is stated that 'small calculus extracted'. In the discharge summary given by Bombay Hospital and Medical Research Centre, although the final // 10 // diagnosis have been stated to be acute Cholscystitis, but it has also been stated that small calculus was extracted." 13- vc ;g ns[kuk gS fd D;k mDr U;k; n`"Vkar ds rF; bl izdj.k esa ykxw gksrk gS\ 14- ;g Lohd`r gS fd ifjoknh vfer dqekj jkW; us vius ,oa viuh ifRu Jherh jkS'kuh jkW; vkSj vius iq= jkSud dqekj jkW; ds fy, vukosnd dz-1 ds ikl QSfeyh esfMds;j ikWfylh fy;k Fkk tks fd fnukad&10-11-2015 ls fnukad&09-11-2016 rd dh vof/k ds fy, FkkA ifjoknh us ;g vfHkopu fd;k gS fd **mlds iq= jkSud dqekj jkW; dks ekg vxLr 2016 esa cq[kkj ,oa is'kkc esa tyu dh rdyhQ vkus ij vkosnd }kjk vius iq= dks Li'kZ eYVh Lisf'kfyVh gkWfLiVy fHkykbZ esa tkap gsrq yk;k x;k vkSj MkWDVj }kjk tkap Ik'pkr~ vkosnd ds iq= dks fnukad&26-08-2016 dks gkWfLiVy esa HkrhZ djus dh lykg nh xbZA** ifjoknh }kjk ;g Hkh vfHkopu fd;k x;k gS fd ifjoknh ds nkos dks dsoy bl vk/kkj ij fujLr dj fn;k x;k fd Calculas Disease gksus ds dkj.k viotZu [k.M ds varxZr vkrk gSA 15- ifjoknh dh vksj ls Li'kZ eYVh Lisf'kfyVh gkWfLiVy dk ULTRA SOUND WHOLE ABDOMEN [TAS & TVS] fjiksVZ dh Nk;kizfr izLrqr fd;k x;k gS ftlesa fdMuh ds ckjs esa crk;k x;k gS tks fuEukuqlkj gS%& "KIDNEYS: Both kidneys are of norml shape, size and position.
Cortical thickness is normal.
Corticomedullary differentiation is maintained.
// 11 // There is no evidence of hydronephrosis.
ECHOGENIC FOCUS OF 3 MM IS SEEN AT THE MID POLE OF LEFT KIDNEY.
gkykafd bEizs'ku esa TINY LEFT RENAL CALCULUS gSA 16- LOYAL'S Medical Dictionary, Dr. S. N. Bansal, 2002 Edition ds i`"B dzekad&164 esa Calculas ds laca/k esa crk;k x;k gS tks fuEukuqlkj gS%& "Calculas ¼dSYdqyl½& [kfut yo.kksa dk o`Dd ;k xqnsZ] ew= uyh] ew=k'k; ;k ew= ekxZ esa vlkekU; :Ik ls tek gks tkuk] v'ejh ;k iFkjh dgykrk gSA mlh izdkj v'kksd fpfdRlh; foKku 'kCndks"k esa MkW- cyoar flag fl}w ds i`"B dzeakd&149 esa dSYdqyl dks ifjHkkf"kr fd;k x;k gS ftlesa Hkh Åij of.kZr vuqlkj gh vFkZ crk;k x;k gSA 17- ifjoknh dh vksj ls tks ULTRA SOUND WHOLE ABDOMEN [TAS & TVS] fjiksVZ izLrqr fd;k x;k gS mlesa RENAL CALCULUS vFkkZr~ o`Dr ;k xqnsZ esa iFkjh gksuk crk;k x;k gS tcfd Li'kZ eYVh Lisf'kfyVh gkWfLiVy ds fMLpktZ lejh ¼,usD'pj ,&4½ esa jkSud jkW; dh chekjh ds laca/k esa tks Diagnosis ¼jksx fu.kZ;½ fd;k x;k gS mlesa ;qjhujh Vsªd esa bUQsD'ku vFkkZr~ ew= ekxZ esa ladze.k crk;k x;k gS vkSj blls Li"V gS fd jkSud jkW; dk tks bZykt gqvk gS og dSYdqyl ¼iFkjh½ dk bZykt ugha gS vfirq tks ;qjhuVh Vsªd bUQsD'ku Fkk] mldk bZykt fd;k x;k gSA // 12 // 18- tcfd tks chek 'krZ izLrqr fd;k x;k gS mlds viotZu [k.M 4-3 ds vuqlkj%& "4.3 Unless the Insured has 24 months of continuous coverage, the expenses on treatment of diseases such as Cataract, Benigr Prostatic, Hyperthrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Congenital intemal disease, Fistula in anus, piles, Sinusitis and related disorder, Gall Bladder Stone removal, Gout & Rheumatism, Calculus Diseases are not payable." 19- bl izdkj mijksDr viotZu [k.M 4-3 ds ifj'khyu ls Li"V gS fd ;fn Hysterectomy, Hydrocele, Hernia, Gall Bladder Stone removal fd;k x;k gS ;k Calculus Diseases dk bZykt fd;k x;k gS rHkh viotZu [k.M ykxw gksxk] tcfd bl izdj.k esa tks bZykt gqvk gS og ;qjhujh Vsªd bUQsD'ku ls lacaf/kr bZykt gS tks fd dSYdqyl ls fHkUu gS vkSj lkekU;r% ;qjhujh Vsªd bUQsD'ku ew=k'k; ;k ew= ekxZ esa cSDVhfj;k ds }kjk tc bUQsD'ku gksrk gS rc mRiUu gksrk gS vkSj QyLo:Ik vukosnd dz-1 }kjk ;g cpko fy;k tkuk fd jkSud jkW; ds iFkjh dk bZykt fd;k x;k gS vkSj blfy, viotZu [k.M&4-3 ykxw gksrk gS] Lohdkj ;ksX; ugha gS vkSj QyLo:Ik ifjoknh esfMds;j ikWfylh ds varxZr mlds }kjk O;; dh xbZ jkf'k izkIr djus dk vf/kdkjh gSA 20- ftyk Qksje us mDr 17]951@&¼l=g gtkj ukS lkS bD;kou :Ik;s½ ij tks 09 izfr'kr okf"kZd dh nj ls C;kt ,oa ekufld {kfriwfrZ ds fy, 25]000@&¼iPphl gtkj :Ik;s½ rFkk okn O;; dk // 13 // 10]000@&¼nl gtkj :Ik;s½ fnyk;k gS] og izdj.k dh ifjfLFkfr dks ns[krs gq, mfpr gS vkSj mlesa fdlh izdkj ds gLr{ksi dh vko';drk ugha gSA 21- vr% vihykFkhZ@vukosnd dz-1 dh vksj ls izLrqr vihy lkjghu gksus ls fujLr fd;k tkrk gSA ftyk Qksje }kjk ikfjr vkyksP; vkns'k fnukad&22 vxLr 2017 dh iqf"V dh tkrh gSA bl vihy dk O;;
i{kdkj viuk&viuk ogu djsaxsA
¼U;k;ewfrZ vkj- ,l- 'kekZ½ ¼Mh- ds- iksn~nkj½ ¼ujsUnz xqIrk½
v/;{k lnL; lnL;
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