BANGALORE URBAN DIST.

CONSUMER
DISPUTES REDRESSAL FORUM,
8TH FLOOR,BWSSB BLDG.
K.G.ROAD,BANGALORE
560 009

Complaint Case No. CC/14/209

( Date of Filing : 29 Jan 2014 )

1. Jaya Gowari Balachandran

H 206, Indwin Ecstasy Apts, Hongasandra, 9th Main
Road, Garvebhavi Palya, Bangalore-68. ...........Complainant(s)
Versus
1. Medi Asst. India Pvt. Ltd.
Sri Krishna Arcade, # 47/1, 9th Cross, 1st main Road,
Sarakki Industrial Layout, 3rd Phase, J.P.Nagar,
Bangalore-78. And Others. ............Opp.Party(s)

BEFORE:
HON'BLE MR. SHANKARA GOWDA L. PATIL PRESIDENT
HON'BLE MRS. Shantha P.K. MEMBER

For the Complainant:

For the Opp. Party:
Dated : 17 Nov 2018
Final Order / Judgement

Complaint Filed on:29.01.2014

Disposed On:17.11.2018

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT

BANGALORE URBAN

17 th DAY OF NOVEMBER 2018

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PRESENT:- SRI. S.L PATIL PRESIDENT

SMT. P.K SHANTHA MEMBER

COMPLAINT No.209/2014

Jaya Gowri Balachandran,

#206, Indwin Ecstasy Apts,

Hongasandra 9 th Main Road,

Garvebhavipalya,

Bangalore-560 068.

Karnataka.

COMPLAINANT
Advocate – Sri.N.Kiran.

V/s

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 1) Medi Assist India TPA Private Ltd.,

“Sri Krishna Arcade”, #47/1,

9 th Cross, 1 st Main Road,

Sarakki Industial Layout,

3 rd Phase, J.P Nagar,

Bangalore-560 078.

2) ICICI Lombard General Insurance,

ICICI Lombard House,

# 414, Veer Savarkar Marg.

Near Siddhi Vinayak Temple,

Prabhadevi,

OPPOSITE PARTies Mumbai – 400 025

3) M/s.WIPRO Limited.,

Represented by Senior

Vice President, H R

Mr.Samir Godgil,

‘A’ Block, Doddakanelli,

Sarjapur Road, Sarjapura,

Bangalore-560 003.

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 Advocate for OP-2 –

Sri.Prashant T. Pandit.

ORDER

SRI. S.L PATIL, PRESIDENT

The complainant has filed this complaint U/s.12 of the Consumer Protection Act, 1986 against
Opposite Parties (herein after referred as OPs) with a prayer to direct OPs to pay Rs.97,028
towards portion of the claim, disallowed as policy excess, Rs.6,273/- towards additional
components of the claim to be reimbursed on removing the policy excess, Rs.500/- towards filing
of the complaint, Rs.20,000/- towards litigation cost and Rs.1,00,000/- towards mental agony and
hardship undergone by the complainant, on the allegations of deficiency in service.

2. The brief allegations made in the complaint are as under:

Complainant submits that, on 08.07.2013 she was in her 23 rd week of pregnancy with twin
gestation visited Kauvery Hospital situated at Alwarpet, Chennai for routine checkup. On
examining her condition, the consultant doctor Dr.Rajasri, Obstertrics & Gynecology department
observed that, she suffered with severe pre-Eclampsia and acute Renal failure. That considering
the criticality of her condition, she was immediately admitted in ICU and further treatments were
performed. Her hospital number for the said admission was 1307008915/IPR0002665.
Complainant submits that, thereafter on 09.07.2013, her symptoms worsened and her attenders
were informed that, unless a Medical Termination of Pregnancy (MTP) is done, her survival was
at threat. Hence, her family members consented for an MTP which was planned and done with
Misoprostol anD both the fetuses were expelled on 10.07.2013. That the following procedure the
complainant was shifted to ICU and treated with medications with other supportive measures.
Post obtaining opinions from other experts viz., Cardiologist, physician, Nephrologist,
Ophthalmologist etc., and following their orders, the complainant was finally shifted to normal
ward on 13.07.2013. As a result of all these treatments, she recovered from renal failure and was
finally discharged on 22.07.2013.

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Complainant submits that, the total amount spent towards her hospitalization was Rs.1,52,422/-
and it was paid in full. Considering that the complainant possessed an insurance policy with
above details, she filed a reimbursement claim along with necessary documents in original. The
reference number of the OP-1 for the claim was 8091742 and the OP-1 had acknowledged the
receipt of her claim through mail on 10.09.2013. Later OP-1 settled her claim on 17.10.2013 and
issued claim settlement advice with breakup of payable amount and disallowances. That to the
complainant utter disbelief, the reimbursement was processed only for Rs.24,313/- and the balance
of Rs.1,28,109/- was disallowed by OP-1 citing various reasons. The payable amount is shown as
Rs.1,21,314/- in the settlement advice, Rs.97,028/- was deducted towards policy excess.
Thereafter, the complainant was approached the office of OP-1 through her employer and through
various other sources to explain the inconsistencies and oversight in rejecting a major part of her
claim. As her efforts did not yield any benefit in obtaining the desired result, the complainant
chose to make a representation to explain her reasoning in terms of the amount disallowed.

That complainant explained OP-1 on 09.01.2014 through letter that they had treated her claim as a
maternity related claim and processed in line with sublimit applicable for it. The final diagnosis
as per the settlement advice was mentioned as “Maternal care for other conditions predominantly
related to pregnancy, Eclampsia, Acute renal failure, Medical Abortion”. However, the diagnosis
as per the discharge summary was “primi with DCDA twin gestation at 22 weeks with severe
pre-eclampsia and acute renal failure” and the presenting history states that the complainant came
in for routine checkup. Thus, the purpose of her hospitalization was not ‘maternal care’ as
mentioned in the settlement advice, rather a complication caused out of “severe pre-eclampsia and
actue renal failure”.

That the complainant also added further other points to substantiate her case are as follows:

a. That as per the Insurance policy, maternity benefit was applicable to two live births only,
which is not the case in her hospitalization.

a. That she was not admitted into the hospital and ICU for the purpose of delivering babies as
she was only in her 23 rd week then and her condition was one of failure in other body
organs.

a. That the treatment she underwent was to save her life and it was for this reason that it was
decided to terminate the pregnancy.

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In additional to the policy excess of Rs.97,028/- which was requested for reimbursement, there are
other claim components that were disallowed needing additional supporting from the complainant.

a. Rs.690/- under investigation and Lab charges – X-ray report was required to be submitted.

a. Rs.5,583/- under medicine charges – detailed breakup of medicines was to be provide.

Since reimbursing these items were anyway dependent on clearing the confusion on policy excess,
the complainant assured that she will provide the necessary documents after removing the
applicability of sublimit in her claim. In light of these explanations, complainant requested OP-1
to kindly process her claim in full and not subject it to any of the sub-limits of a regular maternity
related hospitalization. However, the complainant did not receive any reply from either OP-1 or
OP-2 nor any time was sought to resolve the issue. That complainant felt deficiency in service
and caused immense hardship by the OPs in disallowing the amount. Complainant left with no
other alternative option filed a complaint against OPs for seeking relief.

3. Despite service of notice, OP-1 remained absent.

4. In response to the notice issued, OP-2 appeared through their advocate and filed their version
contending in brief, as under:

That the complainant has filed a false, frivolous and vexatious complaint and is liable to be
dismissed in limine by imposing exemplary and punitive costs upon the complainant.
Complainant has filed the present complaint seeking reliefs as per the prayer in his complaint.
That it is true that, the complainant has spent an amount of Rs.1,52,422/- towards the
hospitalization of the complainant and she has made entire payment towards the same.
Complainant is put to strict proof of the same. That it is might be true that, she had filed
reimbursement claim along with the necessary documents. It is not to the knowledge of OP-2 if
OP-1 had acknowledged the receipt of her claim through a mail on 10.09.2013. That it is not to
the knowledge of OP-1 if OP-1 on 17.10.2013 issued claim settlement advice with breakup of
payable amount and disallowances. All the allegations made in paragraphs 4 to 8 of her complaint
are denied as false. That the claim of the complainant fell under the category of the maternity
related claim. It is further submitted that, the complainant has undergone abortion, wherein the
insurance does not cover the claim for abortions i.e., medical termination of pregnancy, by
looking to the insurance papers at page 5, point No.34, it clearly states definition of maternity

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expenses benefit as ‘the term Maternity Expenses benefit wherever appearing/specified in this
policy, means treatment taken in Hospital/Nursing home arising from or traceable to pregnancy,
childbirth including normal caesarean section’. It is clear from this definition that medical
termination of pregnancy is not covered under this Insurance Policy. Therefore, OP-2 has rightly
repudiated the claim of the complainant as it is not covered under this insurance. That even if the
other symptoms fall under the maternity treatment as per the group health insurance policy
obtained by the complainant it is submitted that they are entitled to Rs.30,000/- to Rs.40,000/-
only. The same is mentioned in the policy at point 6. That the amount has been already paid to
the complainant under the two claims on 31.05.2013 under claim No.7825027 an amount of
Rs.15,687/- and another amount of Rs.24,313/- was paid under the claim No.8091742 on
10.09.2013. It is submitted that, for the claim, the complainant has requested, she is entitled for
only an amount of Rs.40,000/- at it comes under the maternity benefit and under the above
mentioned two claims the amount of Rs.40,000/- is already been paid and the complainant is not
entitled to any further claim. That the complainant being aware of the conditions of the insurance
policy cannot make baseless allegations against OP-2. There is no cause of action for filing this
complaint and the cause of action shown in point-3 of the complaint is false and the complainant
is put to strict proof of the same and the cause of action as shown is misconceived with false
statements and allegations. That the complainant is guilty of suppression of material facts before
the Forum and the complainant has not approached this Forum with clean hands and is not entitled
to any of the reliefs as sought in the complaint. In the instant case the OP-2 has acted as per the
conditions of the policy. There is no deficiency of service as alleged by the complainant. The act
of the complainant in filing this complaint is abuse of law and the complainant is misusing and
taking advantage of the process of law. That the complainant is trying to unjustly enriched
himself at the cost of the OPs. All the other allegations which are not herein specifically traverse
specifically denied or contrary to the tenor of this version are all hereby denied as absolutely false
and the complainant is put to strict proof of the same. That the present complaint is frivolous and
vexatious and is liable to be dismissed.

For the reasons mentioned above, OP-2 prays for dismissal of the complaint.

5. OP-3 was subsequently impleaded. Despite service of notice, OP-3 remained absent, hence it
was placed ex-parte.

6. The complainant in support of her case tendered her affidavit evidence reiterating the
allegations made in the complaint. Sri.Jayant S/o Sudheer Inamadar, Legal Manager of OP-2
tendered his evidence by way of affidavit. Both the parties have produced certain documents.
Written arguments have been filed. We have also heard oral arguments.

5. The points that arise for our consideration are:

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 Whether is there any deficiency of service on the part of OPs, if
so, whether the complainant entitled for the relief sought for?
1)

2) What order?

7. Our answer to the above points are as under:

Point No.1:- In the Affirmative

Point No.2:- As per final order for the following

REASONS

8. Point No.1:- We have briefly stated the contents of the complaint as well as the version filed by
OP-2. The undisputed facts which reveals from the pleadings of the parties goes to show that, the
complainant had availed the Mediclaim Insurance Policy for a total sum-assured of Rs.2,00,000/-
with OP-2 i.e., ICICI Lombard General Insurance Company (herein after referred as said policy)
for which a monthly premium of Rs.530/-has been deducted in her pay slip. The said policy with
reference No.4016/74505152/00/000 with effective period from 01.10.2012 to 30.09.2013. It is
also not in dispute that, OP-1 was the TPA for policy reference No.4010730379.

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9. It is also not in dispute that, on 08.07.2013 the complainant was in her 23 rd week of pregnancy
with twin gestation, she visited Kauvery Hospital situated at Alwarpet, Chennai for a routine
checkup. On examining her condition, the consultant Dr.Rajasri of the hospital’s Obstetrics &
Gynecology department observed that, she suffered with severe pre-Eclampsia and Acute Renal
failure. Considering the criticality of the complainant condition, she was immediately admitted in
ICU for her further treatment. It is also not in dispute that, on 09.07.2013 complainant symptoms
worsened and her attenders were informed that unless a Medical Termination of Pregnancy (MTP)
is done, her survival was at threat. Hence, the complainant’s family members consented for an
MTP which was planned and done with Misoprostol and both the fetuses were expelled on
10.07.2013 by following proper procedure. In this context she spent an amount of Rs.1,52,422/-.
The complainant sought for reimbursement which was processes only for Rs.24,313/- and the
balance amount of Rs.1,28,109/- was disallowed by OP-1 citing various reasons. Though the
payable amount is shown as Rs.1,21,341/- in a settlement advice, Rs.97,028/- was deducted
towards policy expenses. Then approached the office of OP-1 through her employer but her
efforts did not yield any benefit. According to the say of the complainant she is entitled for entire
amount of Rs.97,028/- with other benefits. The claim of the complainant was repudiated by OP-2
by invoking point no.34 in the Insurance Policy. The copy of the insurance policy is made
available. For better appreciation we like to extract the said point No.34 reads thus:

Definition of
The term Maternity Expenses Benefit wherever appearing/specified in
this policy, means treatment taken in Hospital/Nursing Home arising
34 Maternity Expenses
from or traceable to pregnancy, childbirth including normal caesarean
section.
Benefit

10. If the above point No.34 is strictly construed the definition of child birth is to be
ascertain as per the dictionary meaning of the child birth/definition of child birth is – Child birth
also known as labour and delivery, is the ending of a pregnancy by one or more babies
leaving a woman’s uterus by vaginal passage or caesarean section . In the instant case when
the complainant in her 23 rd week of pregnancy with twin gestation, visited the Kauvery Hospital,
Chennai, on examining by consultant doctor observed that, she suffered with severe
pre-Eclampsia and acute Renal failure. Considering the criticality of her conditions was
immediately admitted in ICU. On 09.07.2013 her symptoms worsened and her attenders were
informed that unless a Medical Termination of Pregnancy is done, her survival was at threat.
Hence, her family members consented for an MTP which was planned and done with Misoprostol
and both the fetuses were expelled on 10.07.2013 by following the better procedure. In the strict
sense child birth did not indicate as a leaving child or dead born. In the instant case, both the
gestations were expelled. It is settled proposition of law that a child in the mother’s womb is
entitled to all types of rights including right to property. Hence, such being the fact the claim
repudiated by OPs in particularly OP-2 has no legs to stand in the light of following decisions
wherein, it was held as under:

a. 2010 (2) CPR 443, Uttaranchal State Commission in the case of Mahavanand Joshi vs.
Life Insurance Corporation of India and another. Held: Where suppression of material
facts is alleged by the insurance company in relation to a mediclaim policy, the insurer is

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 required to prove that life assured was treated or hospitalized for few days before taking
the policy.

b. 2009 (3) CPR 53 in the case of LIC of India and others vs. Kailash Chandra Kar, Held:
Consumer Protection Act is a beneficial legislation and it cannot allow insurance
company to escape liability on technical grounds to deprive the consumer of benefits to
which he was entitled to.

c) 2009 (3) CPR 53 LIC of India and others vs. Kailash Chandra Kar, Held: Consumer
Protection Act is a beneficial legislation and it cannot allow insurance company to escape
liability on technical grounds to deprive the consumer of benefits to which he was entitled
to.

d) 2010 (1) CPR 114 National insurance company ltd., vs. Nand Lal, Held: insurance
claim must be honestly settled without any delay

11. In the light of the decisions cited supra, we come to the conclusion that, the claim
repudiated by OP-2 for invoking point No.34 is unjust, arbitrary and illegal. When such being the
settled proposition of law the decision cited by the learned counsel for OP-2 reported in;

(1) ICICI Lombard General Insurance Co Ltd Vs Bhaneshwar Dayal Sharma – Hon’ble
National Consumer Disputes Reressal Commission – II (2014) CPJ 17 NC –

(2) Life Insurance Corporation of India Vs Banwari Lal Yadav – Hon’ble National
Consumer Disputes Redressal Commission – IV (2013) CPR 38 NC

are not applicable.

12. Now the question that crops us for our consideration is, what are the reliefs to which
complainant is entitled too. Complainant has sought for an amount for portion of the claim,
disallowed as policy excess of Rs.97,028/-. This amount is to be jointly and severally liable to
pay by OPs.1, 2 and 3. With regard to the additional components of the claim, to be reimbursed
on removing the policy excess with additional documents of Rs.6,273/- and the stationery and
postage expenses of Rs.500/- are negated. Since there is no any positive evidence on record with
regard to the mental agony, hardship undergone by her is for an amount of Rs.1,00,000/-.
Looking to the available materials on record if an amount of Rs.5,000/- is awarded for mental
agony and hardship undergone by the complainant will meet the ends of justice. With regard to
the cost of litigation is concerned, we fix it to Rs.3,000/-. Accordingly we answered the point
no.1 in the affirmative.

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 13. Since the OP-2 is the Insurance Company we passed the liability on it.

14. Point No.2: In the result, we passed the following:

ORDER

The complaint filed by the complainant is hereby allowed in part.

OP No.1, 2 & 3 are jointly and severally liable to pay medical expenses of Rs.97,028/- and
compensation of Rs.5,000/- to the complainant within 4 weeks from the date of this order, failing
which, the said amounts carried interest at the rate of 6% p.a from the date of repudiation till the
date of realization.

OPs are also directed to pay cost of litigation of Rs.3,000/- to the complainant.

Supply free copy of this order to both the parties.

(Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Forum on this
17 th day of November 2018)

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MEMBER PRESIDENT

Vln*

COMPLAINT No.209/2014

Jaya Gowri Balachandran,

Karnataka.
COMPLAINANT

V/s

1) Medi Assist India TPA Private Ltd.,

Bangalore-560 078.

2) ICICI Lombard General Insurance,

Mumbai – 400 025

OPPOSITE PARTies
3) M/s.WIPRO Limited.,

Represented by Senior Vice President, H R

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 Mr.Samir Godgil,

Bangalore-560 003.

Witnesses examined on behalf of the complainant dated 04.04.2014.

Jaya Gowri Balachandran

Documents produced by the complainant:

Document No.1 is copy of ID card issued by complainant’s employer, Wipro

1)
Ltd.

Document No.2 is copy of Kauvery Hospital Discharge Summary dated

2)
22.07.2013.

Document No.3 is copy of Kauvery Hospital bill BIA0002757 dated

3)
22.07.2013 for Rs.1,52,422/-.

Document No.4 is copy of acknowledgement email dated 10.09.2013 for

4)
claim # 8091742.

5) Document No.5 is copy of settlement notice dated 17.10.2013.

Document No.6 is copy of letter dated 09.01.2014 and proof of its dispatch
6)
under Regd post.

Witnesses examined on behalf of the Opposite party-2 dated 05.07.2014.

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 Sri.Jayant.

Document produced by the Opposite party-2.

1) Document No.1 is copy of group health insurance policy.

2) Document No.2 is copy of citation

MEMBER PRESIDENT

Vln*

[HON'BLE MR. SHANKARA GOWDA L. PATIL]

PRESIDENT

[HON'BLE MRS. Shantha P.K.]

MEMBER

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