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Showing contexts for: Liposuction in Romy Singh & Anr. vs . The Oriental Insurance Co. Ltd. on 16 October, 2012Matching Fragments
2. As per the case of the plaintiffs, plaintiff no. 1 was issued a Mediclaim Policy bearing no. 215200/48/07/01778 for the period 30.10.06 to midnight 29.10.07, with sum insured of Rs. Three Lakhs, each family member, covering reimbursement of medical expenses. Plaintiff no. 1, Romy Singh was the person insured. Plaintiff no. 2, Gurmeet Kaur Singh, is the wife of plaintiff no. 1, other family members were their two sons, Samir Singh and Karan Singh. Defendant no. 1, The Oriental Insurance Company Ltd. had issued the policy and defendant no. 2, Raksha TPA Pvt. Ltd. is third party administrator providing services to both insured and insurer. Plaintiff no. 2 on 27.03.07 was admitted in Indraprastha Apollo Hospitals, Delhi and was diagnosed Localised truncal obesity with fat deposits upper lateral chest and flanks. Plaintiff no. 2 underwent abdominoplasty with liposuction of flanks and Romy Singh & Anr. Vs. The Oriental Insurance Co. Ltd.
liposuction upper lateral chest. Plaintiff no. 2 on the next day, had complained of breathlessness and after examination, a single small bowel perforation was detected and perforation was repaired in layers. Second procedure was done on 29.03.07. Plaintiff no. 2 was discharged from the hospital on 05.04.07. On 20.09.07 plaintiffs filed their claim with defendant no. 1 for reimbursement of expenses of Rs. 2,58,888/ being the expenses incurred on treatment. The claim of the plaintiffs was made nonpayable and was repudiated on the ground that insured underwent surgical treatment (Abdominoplasty with liposuction for cosmetic purpose) as per Clause 4.5 of the policy. The request of the plaintiffs to deduct the amount of Rs. 93,553/ being the cost of abdominoplasty surgery, from the total claim was not agreed to by defendant no. 1. Defendant no. 2 also held as communicated vide letter dated 10.04.08 that claim was nonpayable as per Clause 4.5 of the policy and original file had already been sent to defendant no. 1 on 02.04.08. Claim has been filed for recovery of Rs. 1,64,027/, damages of Rs. 50,000/ and interest has been claimed @ 18% per annum.
6. Arguments were heard on behalf of both the parties and I hold as under:
7. Issues no. 1 and 2 .
Both the issues are disposed of together as issue no. 1 is as regard the entitlement of the plaintiff to the amount and issue no. 2 is whether Romy Singh & Anr. Vs. The Oriental Insurance Co. Ltd.
the procedure undergone by plaintiff no. 2 was only a cosmetic surgery and a related complication. As per the discharge summary dated 05.04.07, Ex. PW1/2 plaintiff no. 2 had a history of liposuction done 2/3 weeks ago at IAH, New Delhi and it is not a situation where plaintiff no. 1 is diagnosed with the alleged problem of localised truncal obesity on 27.03.07 itself. Plaintiff no. 2 underwent abdominoplasty with liposuction of flanks etc, on 27.03.07 and on second post operative day, complained of breathlessness. On exploration, a single small bowel perforation was detected and perforation was closed in layers. Subsequent procedure was done on 29.03.07. As regards the complications being not related to the procedure undergone by plaintiff no. 2 on 27.03.07, a certificate Ex. PW1/3 in that regard has been given by Dr. Lokesh Kumar, Senior Consultant Plastic Surgen, who had operated plaintiff no. 2 for abdominoplasty on 27.03.07 and it is his certificate to the effect that perforation in intestine of plaintiff no. 2 was incidental and not related to the previous surgery. Apart from the certificate given by the doctor himself who had performed abdominoplasty of plaintiff no. 2. No evidence whatsoever had been brought on record to show that the condition of plaintiff no. 2 noted on 28.03.07 was not related to the surgery performed on 27.03.07. Prima facie, it appears to be something related to the surgery performed on 27.03.07 as it was liposuction for reducing fat deposits and similar procedure had been done on plaintiff no. 2 at IAH, New Delhi 2/3 weeks prior. There is nothing in the documents in the medical report or the discharge summary Ex. PW1/2, the reasons or the circumstances, in which such conditions may develop if it was not Romy Singh & Anr. Vs. The Oriental Insurance Co. Ltd.