National Consumer Disputes Redressal
Dr. Bihari Lal Singhania vs Branch Manager, United India Insurance ... on 21 September, 2016
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI REVISION PETITION NO. 1414 OF 2015 (Against the Order dated 26/02/2015 in Appeal No. 112/2014 of the State Commission Bihar) 1. DR. BIHARI LAL SINGHANIA S/o. Late Chhedi Lal Singhania, Akharaghat Road, Muzaffarpur, Bihar ...........Petitioner(s) Versus 1. BRANCH MANAGER, UNITED INDIA INSURANCE COMPANY LIMITED & 3 ORS. Kalyani Chowk, Muzaffarpur, Bihar 2. Shri Rajesh Kumar Sub Regional Manager, Regional Office. R-Block, 3rd Floor, United India Insurance Co. Ltd. Chanakya Complex, B Patel Marg, Patna Bihar 3. Paresh Kashmakar United India Insurance Co. Ltd., Head Office, 24, Whites Road, Chennai - 600014 Tamil Nadu 4. Claim Executive, Heritage Health Services Pvt. Ltd. Heritage Health TPA Pvt. Ltd., NICCO House, 5th Floor, 2, Hare Street, Kolkata - 700001 West Bengal ...........Respondent(s)
BEFORE: HON'BLE DR. B.C. GUPTA,PRESIDING MEMBER
For the Petitioner : Mr. Ravi Agrawal, Advocate For the Respondent : Mr. Kishore Rawat, Advocate, R-1 to 3
R-4, NEMO
Dated : 21 Sep 2016 ORDER
This revision petition has been filed u/s 21(b) of the Consumer Protection Act, 1986, against the impugned order dated 26.02.2015, passed by the Bihar State Consumer Disputes Redressal Commission (hereinafter referred to as the State Commission) in appeal No. 112/2014, "Branch Manager, United India Insurance Co. Ltd. vs Dr. Bihari Lal Singhania," vide which, while allowing the appeal, the order passed by the District Forum Muzaffarpur in consumer complaint case No. 06/12 dated 23.12.2013, allowing the said complaint, filed by the present petitioner, was set aside.
2. The facts of this case are that the petitioner/complainant Dr. Bihari Lal Singhania obtained a medi-claim policy from the respondent/OP United India Insurance Company for a sum of ₹5 lakhs, valid from 08.10.2009 to 07.10.2010 (midnight). During the currency of the said policy, the complainant suffered from breathlessness and stomach pain for which he was admitted in Shri Ram Hospital, Patna on 22.12.2009 where he was made to stay in the ICU upto 30.12.2009, after which he was transferred to Bombay Hospital and Medical Research Centre, Mumbai for further treatment. At that hospital, surgery was performed upon him for removal of his gall bladder, after which he was kept in the ICU for treatment of the problem of breathlessness. The complainant claimed expenditure from the insurance company of ₹3,74,701/- for the said treatment, but the Insurance company paid a sum of ₹98,536/- only, on 14.12.2010. The balance amount was not paid on the ground that as per exclusion clause 4.3 in the terms and conditions of the policy, if the removal of gall bladder was done "with stone" within a period of 2 years from the date of issue of the policy, the claim was not payable. The OP Insurance company stated that they had made payment for treatment towards lung infection and breathlessness.
3. The complainant filed the consumer complaint in question, seeking directions to the respondents to make payment of the remaining amount of ₹2,76,165/- alongwith interest and compensation for mental agony and harassment.
4. In their reply filed before the District Forum, the Insurance Company stated that there was no deficiency in service or negligent act on their part. The balance claim of ₹2,76,165/- made on the treatment/operation for Cholecystectomy was not payable, as there was a locking period of 2 years in the terms and conditions of the policy.
5. The District Forum after taking into account the averments of the parties, held that the exclusion clause 4.3 of the Insurance policy was not applicable in the case, since the gall bladder had been removed 'without stone'. They directed vide their order dated 23.12.2013 to pay the balance claim amount to the complainant alongwith a compensation of ₹20,000/- for mental agony and litigation cost of ₹5,000/-. Being aggrieved against the said order, the Insurance Company challenged the same by way of an appeal before the State Commission. Vide impugned order, the State Commission held that the claim was not permissible, because the expenditure had resulted from the removal of gall bladder 'with stone'. Being aggrieved against the impugned order of the State Commission, the petitioner/complainant is before this Commission by way of the present revision petition.
6. It was contended during arguments by the Ld. 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. From the discharge summary made by the Bombay Hospital and Medical Research Centre, it was clear that it was a case of acute Cholecystitis, which means, 'inflammation of gall bladder'. Even the TPA, Heritage Health Private Limited had mentioned it to be a case of Cholecystitis. The report made by the Department of Histopathology at the Bombay Hospital, dated 31.12.2009 also clearly mentioned, "no calculi are received". It was, therefore, wrong on the part of the Insurance Company to deny the genuine insurance claim.
7. The Ld. Counsel for the respondent Insurance company, however, stated that the case was hit by exclusion clause 4.3, as gall bladder had been removed with stone. The order passed by the State Commission was, therefore, in accordance with law and should be upheld. The Ld. 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. The Ld. Counsel further argued that in the endoscopic findings made by the Medical Research Centre, Bombay Hospital Trust, it was clearly mentioned that small calculi had been extracted. The discharge summary of Bombay Hospital and Medical Research Centre also stated that small calculi had been extracted. The Ld. Counsel argued that the claim for the expenditure incurred on the removal of gall bladder had been rightly denied by the insurance company.
8. I have examined the entire material on record and given a thoughtful consideration to the arguments advanced before me.
9. As stated in the impugned order as well, the main issue for consideration in the present case is whether the gall bladder of the complainant was removed alongwith stone, or there were no stones removed during surgery. The exclusion clause 4.3 of the insurance policy 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. However, the State Commission stated in their order that in the report of the Chaudhari Digital Imaging and Research Centre, it was stated that the gall bladder contained small calculi. The discharge summary given by Shri Ram Hospital at Patna also mentions about 'gb calculi' under the heading, 'diagnosis'. 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 mentioned, "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 the Bombay Hospital and Medical Research Centre, although the final diagnosis have been stated to be acute Cholecystitis, but it has also been stated that small calculus was extracted.
11. Based on the reports stated above and the documentary evidence, the State Commission concluded that the claim was not admissible as during removal of gall bladder, stones were also extracted and hence, the exclusion clause was applicable. I do not find any irregularity, infirmity or jurisdictional error in the order passed by the State Commission, which may merit any interference at the revisional stage. This revision petition is, therefore, ordered to be dismissed and the impugned order passed by the State Commission is upheld. There shall be no order as to costs.
...................... DR. B.C. GUPTA PRESIDING MEMBER