State Consumer Disputes Redressal Commission
National Insurance Co. Ltd. vs Abdul Razak on 6 August, 2013
IN THE STATE COMMISSION : DELHI (Constituted under Section 9 of the Consumer Protection Act, 1986) Date of Decision : 06.08.2013 First Appeal No.520/2012 (Arising out of the order dated 10.04.2012 passed by the District Consumer Dispute Redressal Forum-VI, Kasturba Gandhi Marg, New Delhi-110001 in Complaint Case No.1590/2009) National Insurance Co. Ltd. Delhi Regional Office-2 2E/9, Jhandewalan Extension New Delhi-110055 Appellant VERSUS Sh. Abdul Razak H.No.-1/2, Bhagat Singh Road Near Vijaya Bank Rashid Kureji Delhi-110051 ..Respondent CORAM S.A.Siddiqui, Member (Judicial) S.C.Jain, Member
1. Whether reporters of local newspaper be allowed to see the judgment?
2. To be referred to the reporter or not?
S.C.Jain, Member Judgment
1) The present Appeal has been preferred by the Appellant/OP against the order of the District Consumer Dispute Redressal Forum-VI Delhi, in Complaint Case No. 1590/12 directing the Appellant/OP to pay a sum of Rs. 50,056/- to the Complainant with interest at the rate of 9% p.a. from the date of filing of the claim and Appellant/OP was further directed to pay a sum of Rs. 25,000/- as damages for harassment and litigation expenses.
2) The brief facts of the case were that the Respondent/Complainant purchases a Mediclaim Policy Bearing No. 361701/48/08/8500000697 on 11.07.2008 which was operative from 11.07.2008 till 10.07.2009. The sum insured under the above said policy was for an amount of Rs. 1,00,000/-. The Complainant/Respondent in the month of March 2009 felt some pain in his abdomen and got himself examine by the Doctors of Singal Medical Center, a hospital situated at Krishna Nagar, Delhi. After conducting and examining the reports of ultra sound of upper abdomen on 14.03.2009 the Complainant/Respondent was advised to get admitted in the Hospital immediately. But the Complainant/Respondent refused to get admitted in the hospital immediately inspite of pursuance of the Doctors but agreed to take oral medicines and accordingly he was advised certain medicines by the Doctors which he took regularly but when he did not get relief with the oral medicines he got himself admitted to the Hospital on 24.03.2009. As per the version of the Respondent/Complainant the Doctors on the basis of blood reports diagnosed that the Respondent/Complainant was suffering from septicemia (very sever blood infection) as well as worm in gallbladder. The Respondent/Complainant was operated for empyema gallbladder and worm in Gallbladder on 25.03.2009 and remained admitted in the Hospital till 28.03.2009.
3) The Doctor/Hospital filed a pre authorization request form to TPA (Park Medi Claim Consultant Pvt. Ltd.) of the Appellant/OP for pre approval of cashless facility for hospitalization for treating septicemia and operation for worm in gallbladder but the cashless request was refused by the TPA on 25.03.2009 on the ground since the policy does not cover gallbladder and Bile Duct Surgery for two years after inception of the cover/policy the Doctor of the hospital talked to TPA persons and told that the case of the Patient is of septicemia (a very severe infection in blood and body) which is a medical emergency and surgery was to be done due to secondary infection in the gallbladder. A primary diagnosis is septicemia (infection in whole in blood and the body) which is very well covered, but, TPA didnt gave authorization.
4) The Respondent/Complainant after getting discharged from the hospital filed a claim on 12.04.2009 with the insurance company for a sum of Rs. 56,056/- towards the treatment, but the same was repudiated by the Appellant/OP vide their letter in which they stated as per clause 4.3 expenses related to surgery of gallbladder and Bile Duct are not covered for two years after the inseption of the cover.
5) Aggrieved by the repudiation of the claim by the insurance company the Respondent/Complainant filed the complaint before the District Forum and the District Forum decided the complaint in favour of the complainant/respondent and it is against these orders of the District Forum, Appellant/OP had filed the present appeal before this Commission mainly on the ground that the District Forum without properly appreciating the facts of the matter and without going through the exclusion clause 4.3 of the terms and conditions in which the treatment of decease i.e. surgery of gallbladder and bile duct excluding malignancy are not payable for the first two years of operation of the policy has decided the matter erroneously.
6) Registered notice under AD cover was sent to the respondent/complainant who appeared and filed reply to the appeal and contested their case. Arguments of both the parties heard, file perused.
7) Exclusion Clause 4.3 of the insurance cover reads as under
During the first one year of the operation of the Policy the expenses on the treatment of Benign ENT Disorders & Surgeries like Tonsilectomy/Adenoidectomy/Mastoidectomy/Tympanoplasty.
Treatment of diseases such as Cataract, Benign Prostatic Hyperthrophy,Hysterectomy, Hernic,Hydrocele, Congenital Internal Diseases, Fissures/Fistula in anus, Piles Sinusitis and related disorders, polycystic ovarian diseases, Non-infective arthritis, undescended testis, Surgery of Gall Bladder & Bile Duct excluding Malignancy, Surgery of Genito-urinary system excluding Malignancy, Pilonidal Sinus, Gout & Rheumatism, Hypertension, Diabetes, Calculus disease, Surgery Prolapsed intervertebral disc unless arising from accident, surgery of varicose veins are not payable for the first two years of the Operation of the Policy.
Treatment of Joint Replacement due to degenerative conditions, Age related osteoarthristis and osteoporosis are not payable for the first four years of operation of the Policy.
If these diseases are pre-existing at the time of Proposal, will be covered only after four continuous claim free policy years.
8) The above exclusion clause debars payment of medical expenses under the policy in respect of surgery of gallbladder and bile duct excluding malignancy, but from the records of the medical treatment and diagnosis of the Doctor, surgery in question cannot be mixed with gallbladder and Bile Duct surgery conducted in normal course.
Dr. L.P.Duggar consultant surgeon and Dr. Sunil Singhal, Medical Director, of Single Medical Centre vide its letter dt. 10.04.2009 had stated septicemia empyma Gallbladder is a medical as well as surgical emergency which required hospitalization with removal of focus of infection i.e. cholecystectomy in case of empyma gallbladder. This certificate of the Doctor clearly differentiates the operation conducted by the hospital with that of simple surgery of gallbladder which is mentioned in exclusion clause no. 4.3.
9) The district Forum had also observed on the basis of diagnosis of the Doctor at page 18 of the document filed by the complainant with their complaint as well as after going though the meaning of empyema in the medical literature and had stated that empyema means formation of pus in a naturally existing anatomical cavity which is different from pus formation in newly form cavity by collection of pus as in a case of abscess which happens in many parts of the body including brain and gallbladder to uterus joints etc. (source Wikipedia).
10) From the meaning of empyema in Wikipedia as well as certificate of the Doctor Sunil Singhal and L.P.Duggar, it is clear that the treatment and surgery done on the complainant/respondent is not covered under the exclusion clause no. 4.3 of the cover and the surgery done on the Complainant/Respondent cannot be misced with gallbladder and Bile Duct surgery done in normal course. The emergency medical treatment and surgery conducted on the complainant/respondent is inherently covered under any Medi Claim Policy and its control, coverage cannot be disallowed in any event to save the life by septicemia blood infection, which caused it. Accordingly in our view there is no illegality or infirmity in the order passed by the District Forum and we uphold the Judgment of the District Forum VI passed in Complaint Case No. 1590/09 and dismiss the Appeal, no order as to costs.
11) The copy of the order be made available to the parties free of cost as per law and file be consigned to record room.
12) FDR if any be released to the Appellant as per rules.
(S.A.Siddiqui) Member (Judicial) (S.C.Jain) Member fatima