State Consumer Disputes Redressal Commission
United India Insurance Co., Ltd., And ... vs M.Naresh Kumar S/O Late M.Gowrishankar ... on 27 April, 2010
BEFORE THE A BEFORE THE A.P.STATE CONSUMER DISPUTES REDRESSAL COMMISSION: AT HYDERABAD. F.A.No. 704 OF 2008 AGAINST C.C.NO.902 OF 2007 DISTRICT CONSUMER FORUM-III HYDERABAD Between 1. United India Insurance Co., Ltd., Branch Office, 2-4-1/4, 1st Floor, M.G.Road, Secunderabad 2. United India Insurance Co., Ltd., Having its Companys Registered Head Office at 24, White Road, Chennai-600 014 Appellants/opposite parties A N D 1. M.Naresh Kumar S/o late M.Gowrishankar aged about 53 years, Occ: Advocate 2. Smt M.Sadalaxmi W/o M.Naresh Kumar Aged about 43 years,House Wife Both are R/o H.No.3-2-332, Somasundaram Street Secunderabad Respondents/complainants Counsel for the Appellants Sri Ravishankar Jandhyala Counsel for the Respondents Sri Md Yousufuddin QUORUM: SRI SYED ABDULLAH, HONBLE MEMBER
& SRI R.LAKSHMINARSIMHA RAO, HONBLE MEMBER TUESDAY THE TWENTY SEVENTH DAY OF APRIL TWO THOUSAND TEN Oral Order ( As per R.Lakshminarsimha Rao, Member) *** The appeal is challenge to the order passed by the District forum-III Hyderabad, in C.C.No.902 of 2007.
Briefly stated the facts of the case as represented by the complainants are that they are the holders of individual mediclaim policy bearing NO.051501/48/06/20/000000691 dated 10.08.2006 issued by the opposite parties for a sum of Rs.2 lakh after collecting premium amount of Rs.3,500/-. In the first week of November 2006 Gynaecologist advised the complainant no.2 to go for colonoscopy test at Swapna Nursing home. On 14.11.2006 after having been conducted the tests she was diagnosed with chronic cervicits with abnormal cellular pattern. Subsequently on 11.2.2007 the complainant no.2 was admitted to the Kirloskar Hospital where laproscopic hysterectomy was conducted by Dr.Padmini Gandham. The complainant submitted claim for hospitalization expenses through their agent Medsave was repudiated by the opposite parties.
The opposite party resisted the claim and it was contended that as per the terms of the conditions of the insurance policy particularly clause IV Point No.3 of the policy the claim of the complainant was excluded from the coverage. Hysterectomy as per clause 4.3 of the insurance policy is not covered in the first year of the inception of the policy.
The complainant no.1 has filed his affidavit and Exs.A1 to A9 have been marked on behalf of the complainants.
The Asst. Manager, Mrs Indira Rani of the opposite party no.1 company has filed her affidavit and got marked Exs.B1 to B10.
The District Forum has allowed the complaint opining that there is a mention of none as against the column, clause 4.3 of the insurance policy and as such the clause will not have any binding on the claim of the complainant.
The points for consideration are:
1) Whether hysterectomy and chronic cervicitis are covered by the terms of the insurance policy?
2) Whether there was any deficiency in service on the part of the opposite parties?
3) To what relief?
POINTS NO.1 AND 2 The parties are not at dispute on the issue of the insurance policy bearing no.051501/48/06/20/000000691 dated 10.08.2006 for a sum of Rs.2 lakh. It is also not in dispute that the complainant no.2 was diagnosed to have suffered from chronic cervicitis with abnormal cellular pattern. There is no disagreement between the parties with the laproscopic hysterectomy conducted by Dr.Padmini Gandham on the complainant no.2 on 11.2.2007 and the complainant lodged claim for indemnification of expenses stated to have been incurred during hospitalization of the complainant no.2.
The complainants have submitted that their claim was repudiated arbitrarily and that the disease was not a pre-existing disease. Even if it is a pre-existing disease, it has to be covered as per the direction of the IRDA.
The opposite parties have contended that as per clause 4.3 of the insurance policy the expenses incurred on hysterectomy are not covered during the first year of the operation of the policy. A perusal of the of Clause 3 of the policy shows that diseases such as cataract, benign prostatic, hyperthropic etc., are excluded from the coverage of the policy during the first year of its operation. Clause 4.3 of the policy reads as under:
During the first year of operation of the policy, the expenses on treatment of diseases such as cataract, benign prostatic, hypertrophy, hysterectomy for hemorrhage or Firbromyoma, Hernia, Hydcrocele, Congenital internal disease, Fistula in anus, piles, sinusitis and related disorders are not payable. If these diseases (other than congenital internal diseases) 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.
Having extracted clause 3 of the policy, we will proceed to consider the disease the complainant has suffered from and the treatment she had undergone therefor. The discharge card of Kirloskar Hyderabad indicates that laproscopic hysterectomy with BSO was done under general anesthesia and the complainant was diagnosed to have suffered from Chronic Cervicitis. The clause 4.3 of the policy has excluded from the scope of its coverage cataract, benign prostatic and hysterectomy during the first year of the operation of the policy. The second part of the clause excludes from its coverage all pre-existing diseases and congenital internal diseases during the term of the insurance policy.
Admittedly, the complainant no.2 had undergone hysterectomy for chronic cervicitis. The insurance policy was issued for the period commencing from 13.8.2006 to 9.8.2007. The complainant no.2 was admitted to the Kirloskar Hospital on 11.2.2007 and she was discharged on 14.2.2007 from the hospital. The claim was lodged within the first year of its inception. The hysterectomy having been covered by the exclusionary clause of the insurance policy cannot be said to give rise a claim in terms of the insurance policy.
The first part of clause 4.3 has been invoked by the opposite parties in repudiating the claim of the complainants. The complainants contended that the pre-existing disease are also covered within the fold of coverage of the insurance policy issued by the opposite parties. The repudiation of the claim was made on the ground that hysterectomy was not covered by the terms of the insurance policy but not for the reason that hysterectomy was a consequence of preexisting disease. In the circumstances, we are inclined to accept the contention of the opposite parties that repudiation of the claim was based on the terms and conditions of the insurance policy and as such hold it justified. The impugned order does not stand to the scrutiny of fact or law. The appeal deserves to be allowed.
In the result the appeal is allowed by setting aside the order dated 13.2.2008 passed by the District forum. Consequently the complaint is dismissed. In the circumstances of the case there shall be no order as to costs.
Sd/-
MEMBER Sd/-
MEMBER Dt.27.04.2010 KMK*