Smt. Jyoti Agrawal v. The Oriental Insu. Co. Ltd. through Divisional Manager

Dated : 06/04/2015 PER :- HONBLE SHRI JUSTICE R.S. SHARMA, PRESIDENT. This appeal is directed against the order dated 05.08.2014, passed by District Consumer Disputes Redressal Forum, Raipur (C.G.) (henceforth "District Forum"), in Complaint Case No.428/2012. By the impugned order, the complaint of the appellant (complainant) has been dismissed by the District Forum.

2. Briefly stated the facts of the case are that the appellant (complainant) is purchasing Mediclaim Policy from the respondent //2 // (O.P.) since last 4-5 years. She also obtained Mediclaim insurance policy for her husband and children. The respondent (O.P.) issued Mediclaim Insurance Policy No.191100/48/2012/1639 in favour of the appellant (complainant) for the period from 08.10.2011 to 07.10.2012. The appellant (complainant) was admitted in Devi Laxmi Hospital for her treatment for the period from 29.01.2012 to 02.02.2012 and she incurred expenditure on her treatment. She submitted claim before the respondent (O.P.) along with relevant documents, but the respondent (O.P.) has repudiated her claim on the basis of Exclusion Clause 4.12 of the Mediclaim Insurance Policy and denied the claim of the appellant (complainant), therefore, the appellant (complainant) filed consumer complaint before the District Forum and prayed for granting reliefs as mentioned in the relief clause of the complaint.

3. The respondent (O.P.) filed its written statement and averred that under the Exclusion Clause 4.12 of the Mediclaim Insurance Policy, the appellant (complainant) is not entitled to get any compensation from the respondent (O.P.). According to the Exclusion Clause of the Mediclaim Insurance Policy, "the Insurance Company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of : Any treatment arising from or traceable to pregnancy, childbirth, miscarriage, caesarean section, abortion or complications of any of these including changes in chronic conditions as a result of pregnancy." In the instant case the appellant (complainant) Smt. Jyoti Agrawal, was a case of //3 // pregnancy and was admitted in Devi Laxmi Hospital for delivery through LSCS, therefore, the appellant (complainant) is not entitled to get any compensation on the basis of Exclusion Clause 4.12 of the Insurance Policy and the respondent (O.P.) has rightly repudiated the claim of the appellant (complainant) and has not committed any deficiency in service. The complaint is liable to be dismissed.

4. After having considered the material placed before it by both the parties, learned District Forum, has dismissed the complaint.

5. The appellant (complainant) has filed documents. A-1 is Individual Mediclaim Policy Schedule, A-2 is Mediclaim Policy Claim Form, A-3 are Discharge Ticket of Devi Laxmi Hospital, Raipur, birth report, bill of Devi Laxmi Hospital, and bills of medical stores, A-4 is Discharge Ticket of Swapnil Nursing Home and Research Centre, Raipur, A-5 is Cash / Receipt Voucher issued by Swapnil Nursing Home, Raipur, A-6 is letter dated 31.05.2012 sent by Ravi Shankar Agrawal, Advocate to the respondent (O.P.), A-7 is letter dated 04.05.2012 sent by the respondent (O.P.) to Shri Ravi Shankar Agrawal (Advocate), A-8 is reply dated 09.07.2012 sent by Shri P.K Paul, Advocate to Shri Ravishankar Agrawal, Advocate in response to his letter dated 31.05.2012.

6. The respondent (O.P.) has also filed documents. Documents are Individual Mediclaim Policy Schedule with Policy Condition vide Policy No.191100/48/2012/1639, letter dated 14.03.2012 sent by Shri //4 // Ravishankar Agrawal, Advocate to the respondent (O.P.), Discharge Ticket of Devi Laxmi Hospital, Raipur, Discharge Ticket of Swapnil Nursing Home and Research Centre, Raipur, letter dated 30.04.2012 sent by Dolphin Associates to Sr. Divisional Manager, The Oriental Insurance Co. Ltd. Divisional Office I, Raipur (C.G.), letter dated 04.05.2012 sent by the respondent (O.P.) to Shri Ravi Shankar Agrawal, Advocate, reply dated 09.07.2012 sent by Shri P.K Paul, Advocate to Shri Ravishankar Agrawal, Advocate in response to his letter dated 31.05.2012.

7. Shri R.K. Bhawnani, learned counsel appearing for the appellant (complainant) has argued that the impugned order passed by the learned District Forum is erroneous and the District Forum has committed jurisdictional error. The impugned order is suffering from inherent irregularity and illegality and District Forum has wrongly applied provisions of exclusion clause 4.12 of the Insurance Policy. In the instant case Exclusion Clause 4.12 is not applicable but Exclusion Clause 4.1 is applicable, therefore, the appellant (complainant) is entitled to get compensation from the respondent (O.P.) under the Mediclaim Insurance Policy. The impugned order passed by the District Forum, is suffering from irregularity and illegality hence is liable to be set aside.

8. Shri P.K. Paul, learned counsel appearing for the respondent (O.P.) has supported the impugned order passed by the learned District Forum and argued that in the instant case Exclusion Clause 4.12 of the Mediclaim Insurance Policy is applicable and learned District Forum has //5 // rightly applied the Exclusion Clause 4.12 of the Mediclaim Insurance Policy in the instant case. The respondent (O.P.) has rightly repudiated the claim of the appellant (complainant) and the appellant (complainant) is not entitled to get any compensation from the respondent (O.P.).

9. Learned District Forum, has observed in para 7 of the impugned order that from the perusal of the matter we find that the contention of the appellant (complainant) is that the claim was required to be settled as per Condition No.4.1 of the policy, but the respondent (O.P.) has settled the claim as per Condition No.4.12. From the discharge ticket and birth report filed by the appellant (complainant), it is clear that the appellant (complainant) was admitted in the said hospital in respect of pregnancy and she delivered a child on 29.01.2012 at 4.22 minutes. According to Condition No.4.12 of the policy the expenditure incurred in this regard is not included in the insurance policy. In this circumstances, the respondent (O.P.O has repudiated the claim on the basis of Condition No.4.12 and has not committed any deficiency in service.

10. It is not disputed that the case of the appellant (complainant) was case of pregnancy and she was admitted in hospital for delivery through LSCS and she delivered a child on 29.01.2012. Shri Ravishankar Agrawal, who is husband of the appellant (complainant) has sent a letter dated 14.03.2012 to The Officer In Charge, The Oriental Insurance Company Limited, Branch Raipur in which it is mentioned thus :- //6 // "4. That : the above delivery was preterm by a month from the Estimated due date of delivery, hence the baby has been shifted to DR. Anoop Verm's Swapnil Children Hospital, Katora Talab, Raipur for premature care, and the baby was kept there for about a month under care of Doctor, Due to such reason I was unable to inform to your office or agent".

11. It appears that appellant (complainant) was admitted in the Hospital for delivery of child and was case of pregnancy.

12. Exclusion Clause 4.12 of the Mediclaim Insurance Policy runs thus :- "4.12. Any treatment arising from or traceable to pregnancy, childbirth, miscarriage, caesarean section, abortion or complications of any of these including changes in chronic condition as a result of pregnancy."

13. As per Exclusion Clause 4.12 of the Insurance Policy if Any treatment arising from or traceable to pregnancy, childbirth, miscarriage, caesarean section, abortion or complications of any of these including changes in chronic condition as a result of pregnancy, then the insured is not entitled to get any claim under the Mediclaim Insurance Policy.

14. Therefore, the learned District Forum, on the basis of facts and circumstances of the case has rightly applied Exclusion Clause 4.12 of the Mediclaim Insurance Policy in the instant case. The impugned //7 // order passed by the learned District Forum, does not suffer from any infirmity, irregularity, illegality or jurisdictional error.

15. Therefore, the appeal filed by the appellant (complainant) being devoid of any merits, deserves to be and is hereby dismissed. No order as to the cost of this appeal. (Justice R.S. Sharma) (Ms. Heena Thakkar) (D.K. Poddar) President Member Member /04/2015 /04/2015 /04/2015