1. The present complaint case has been filed by the complaint in settling the medi claim of the complainant in spite of legal notice dated 14.08.2017.
2. The Opposite party illegally in settling the medi claim and this amount to gross negligence and deficiency of services rendered by opposite parties causing mental tension, agony, harassment, injury, loss and damage to the complainant.
3. The Complainant case in brief is that complainant himself and his wife are old medi claim policy holder bearing policy number 171005/48 15/8500000509 valid and effective from 15/03/2016 to 14/03/2017 issued by National Insurance Company Limited on responsibility of payment of premium 11873 covering the complainant and his wife and sons the sum insured is Rs 600,000. During policy period wife of the complainant Sudha Kumari who is also policy holder became ill, and the condition of the wife of the Complainant is not well so Dumka’s doctor refer the wife to higher centre for better treatment. The Complainant admitted his wife in Sefa Nurshing Home, Keshabganj Chatti, G.T. Road, Burdwan. And after the treatment by doctor of Sefa Nurshing Home found the condition of uterus of Sudha is not well so save her life doctor decided operation of uterus. On 30.04.2016 uterus operation successfully held in Sefa Nurshing Home, Burdwan. During treatment complainant informed the said matter to the National Insurance Company by telephone and on 04/05/2016 complainant wrote application to the Branch Manager National Insurance Company Dumka regarding the petition operation.
4.  On 29/06/2016 complainant fillup claim form of National Insurance Company and mention total expenses of Rs 181,082 and also submitted entire original paper. On 02.08/2016 Genins  India Company demanded 64 VB complains and duration of all previous policy were submitted in office of Insurance Company but after long period passed no action was taken by opposite parties. Thereafter on 27/01/2017 the complainant sent a reminder to the opposite parties no. 4 and 5 after receiving the said reminder. Again demanded the entire paper of treatment from the complainant. The complainant send again entire Xerox copy of papers of treatment but opposite parties not paid the claim amount to the complainant and refused to pay the claim. It is important to mention here that the complainant submitted of the relevant original documents before Branch Manager National Insurance Company Ltd. dumka Branch on 29.06.2016 and on same day National Insurance Company sent it to Genins India TPA Patna. As such opposite parties deliberately and intentionally not settled the medi claim in spite of repeated request by the complainant.
5. The Complainant also sent the legal notice on 14.08.2017 in spite of that the opposite parties not settled the medi claim. The Complainant is consumer as defined under act. The Complainant is entitled to get interest amount 18% per annum payable on the claimed amount from the date of losing the claim bill its payment. The Complainant claims the following relief –

1.  Claimed amount – Rs 181,082/-
2.  Compensation – Rs 40,000/-
3.  Allegation Case – Rs 5000/-
4.  Payment of Interest amount 18% per annum

Awarded amount from the date of submitting claim till its payment and any other relief or reliefs for which the complainant is entitled.

6. It is further submitted by the complainant that the cause of action arose in this case since 30/04/2016 when the complainant felt problem and examine by the doctor and it is also arose on subsequent period that treatment was provided bill submitted before OP no. 4 on 26.06.2016 for the payment in respect of medi claim and it is also arose on subsequent period on when request were made to settle the claim and it is however arose on 14.06.2017 when the legal notice was sent to the opposite parties and this case is also within the jurisdiction of this forum.
7.  After the notice the opposite party no. 1 to 4 appeared and filed other written statement on 23.06.2018 but the OP no. 5 did not appeared after the due notice and paper publication as such by order dated 06.07.2018 against him the case was heard exparte.
8. The opposite party no.1 to 4 in their written statement has denied all the allegation of the complainant except what have been specifically admitted by them. Further stated that present petition is not maintainable either in fact or in law and there is no cause of action against this case. It is further stated that OP no. 1 to 4 have no knowledge about the Para no. 4(XI) of the complainant petition against Op no. 5 Genins India Insurance Company TPA( Third party Administrator) Ltd. is main Insurance Company of Medi claim policy. In this connection holder has admitted this claim that OP no. 1 to 4 are received the Medi claim policy of amount and sent to the Genins India Insurance Ltd. for further proceedings and the entire claim payment made in the direction of OP no. 5 Genins India Insurance Company Ltd. It is necessary to mention here that Genins India Insurance Company Ltd. mention that claim pertains to Sudha kumari was covered under National Medi claim Policy bearing Policy no. 171005/48/15800000509, the patient was admitted as a case of uterus rupture with full term pregnancy with Harmatwria and underwent LSCS with subtotal hysterecteomy as per submitted discharge certificate of Sefa Nursing Home, Burdwan District. As per terms and conditions of Insurance Policy expenses related to treatment arising from a traceable to pregnancy/ child birth including caesarean section, miscarriage, surrogate or vicarious pregnancy, abortion or complication thereof including changes in chronic condition arising out of pregnancy other than ectopic pregnancy which may be established by medical report are not payable under exclusion clause 4.7. Hence the claim was repudiated.
9. It is further submitted that answer Ops have no knowledge about the document of the claimant that OP no. 5 Genins India Insurance Ltd. have kept all the original papers of the treatment. It is further submitted that OP no. 1 to 4 are received the Medi claim Policy and amount and sent to the Genins India Insurance Company TPA Ltd. for further proceedings. As such the OP no. 1 to 4 are not responsible for the payment and are not liable to pay any compensation as claimed by the complainant. It is further submitted that the claim of the complainant to be rejected outright.
10. Whether complainant is entitled for any relief or reliefs as   claimed

FINDING

EX-2 Hospitalisation and domiciliary hospitalisation, benefit also claim forum 38 seat

EX-3 letter dated 02.08.2016 of Genins India Insurance TPA Ltd.

EX-4 letter by Nirmal Kumar Das dated 27.01.17 to Branch Manager National Insurance Company, Dumka branch.

EX-5 Reminder letter dated 11.02.2017 to Nirmal Kumar Das.

EX-6 Letter of Branch Manager National Insurance Company Ltd. dated 20.02.2017 to Genins India TPA Ltd.

EX-7 Pleader notice by complainant dated 14.08.2017 to Branch Manager national Company Ltd. Dumka Branch.

12. The opposite parties in support of their case filed oral evidence an affidavit of Gopinath das and also filed EX- A the booklet of National Medi claim Policy.
13. The CW1 Nirmal Kumar das who is husband of Sudha Kumari and also one of the policy holder of Medi claim of the opposite parties company he has stated that he along with his wife has taken a Mediclaim policy from the opposite parties company by policy no. 171005/48/15/8500000509 which was valid from 15.03.2016 to 14.03.2017. He has also paid the premium amount of Rs 11873 along with service tax Rs 1722 to the National Insurance Company and during the tenure of the policy his wife Sudha Kumari’s condition was very critical. She was taken to Sefa Nursing Home, Burdwan West Bengal were she was gone through surgery and her uterus was removed on 30.04.2016 and during the treatment he also informed the national Insurance Company regarding treatment by telephone and thereafter on 04.05.16 he also given written information to the National insurance company, Dumka Branch. Thereafter on 29.06.16 he filled the Insurance claim form on 29.06.16 through National Insurance Company to Genins India Insurance Company i.e; OP no. 5. On 02.08.16 the Genins India ltd. asked the complainant 64 and all the other previous policies and other documents. On 03.08.16 the complainant filed all the original documents relating to previous medical policies and treatment was taken then on 21.02.17. He sent the reminder to the opposite parties then opposite parties no. 5 again demanded all the papers relating to the medical treatment bills etc. But in spite of sending all the papers no action was taken by the Ops. Then on 14.08.17 the complainant a legal notice with requesting to pay the claim amount but no payment was done.
14. CW2 Gyan Kumar Jha has also fully supported the statement of CW1 Nirmal Kumar Das.
15. The CW3 Aastik Khan and CW4 Sudha Kumari has also fully supported the complainant case and the Cw1
16. From the perusal of documentary evidence that is exhibit 1 to 7 clearly shows that complainant within time and within the period of policy period got treatment of his wife Sudha Kumari and filed the a claim form within time and from perusal of exhibit 2 page 3 which is the letter dated 29.06.16 written by Nirmal kumar das to the Branch Manager National Insurance Company Ltd. Dumka in which he has clearly disclosed the history of his medi claim policy which is as under-

1. Policy no. 171005/48/12/8500000436 from 15.03.13 to 14.03.14
2. 171005/48.13/8500000377 from 15.03.14 to 14.03.15.
3. Policy no. 171005/48/14/8500000359 from 15.03.15 to 14.03.16.
4. Policy no. 171005/48/15/8500000509 from 15.03.16 to 14.03.17 and he has claimed mediclaim for the policy no. 17/005/48/15/8500000509 from 15.03.16 to 14.03.16 and he has further stated in his letter that at the time of baby born the uterus was ruptured and due to that Sudha Kumari was taken to the Burdwan west Bengal for better treatment were the operation was done.

Apparently the claim of the complainant is within time and also the relevant papers relating treatment and proper bills were also given to the Ops for the reimbursement of the medi claim policy.

17. The opposite parties no. 1 to 4 who are the National insurance company Ltd. has admitted this fact that complainant got insurance policy from his company in Para 9 of his written statement. The Op no. 1 to 4 has admitted that “In this connection it may be mention here that OP no. 1 to 4 are received a medi claim policy and amount and sent it to Genins India Insurance TPA Ltd. for further proceedings and Para 10 further said that entire claim payment made in the direction of OP no. 5 Genins India Insurance TPA Ltd. In Para 11 he has further stated that Genins India Insurance TPA Ltd. Mentioned that claim pertains to Sudha Kumari was covered under National medi claim policy bearing policy 171005/48/15800000509, the operation was admitted as a case of uterus rupture  with full term pregnancy “treatment arising from traceable to pregnancy/ child birth including caesarean section, miscarriage, surrogate or vicarious pregnancy, abortion or complication thereof including changes in chronic condition arising out of pregnancy other than ectopic pregnancy which may be established by medical report.”

          And says that the complainant claims is regarding this exclusion clause as Sudha kumara was admitted in Sefa Nursing Home Burdwan West Bengal every birth child and rupture of uterus for which the surgery was done and the mediclaim was also claimed for that treatment. As such the complainant is not entitled for Mediclaim and his claim before this forum has not maintainable OP no. 5 has not filed any written statement and OP no. 5 by order dated 06.07.18 against whom the  proceedings was heard exparte.

18. The ruling was filed on behalf of the complainant which is      reported in state commission Delhi appeal no. 115/2004 Ms Laure Brar (applicant) vs Massors Oriental Insurance Comany (Respondent). Decided on 19.04.07 in which the same plea was also advanced by the opposite party that any insured person gone treatment arising from traceable pregnancy child birth including caesarean section condition was not to be liable to make payment. In this case also during pregnancy a severe pain in the abdomen was developed and she was rushed to the clinic and after conducting the ultrasound necessary tests were done and doctor came to the conclusion that it was a life threatening situation which require immedieate hospitalisation and surgery. Thereafter emergency surgical operation was done and the operation was discharged on 12.10.96 a claim of Rs 55556 was lodged and the respondent repudiated the claim on the basis of exclusion clause of the policy. Accordingly to the appellant she was hospitalised for the surgery for ectopic pregnancy which is not the same thing as the pregnancy and therefore exclusion clause is not applicable and after discussion the Learned Court has allowed the Mediclaim Policy rejecting the plea of exclusion clause. Here in this case there is rupture of uterus for which emergency operation was done and the policy is within the sign so far as direction of Consumer Protection Act is concerned. This provides remedy to the consumer for seeking compensation as to the actual loss or injury suffered by him due to the deficiency on the part of the service providers.
19. While dealing with the rule of interpretation of words and phrases and the Insurance Policies for the purpose of Consumer Protection Act, the Supreme Court in Smt. Shashi Gupta Vs. Life Insurance Corporation of India & Another reported as 74 Consumer Protection Reporter V-VI-1995(2) has held that if in a life insurance case two interpretations are reasonably possible, court will accept the one which favours the policy holder, other things being equal.  Merely because the word pregnancy occurs in the phrase ectopic pregnancy does not mean that ectopic pregnancy is the same thing as ordinary pregnancy as referred in the aforesaid exclusion clause. Here in this case it is apparent and we also found that the exclusion clause 4-7 was wrongly invoked by the respondent insurance Company and thereby medical claim of the appellant was illegally repudiated.
20. Admittedly the OP no. 1 to OP no. 4 which is National insurance Company Ltd. who gave the policy of mediclaim of the complainant and is wife since last 4 years and received the money of the installment of the policy and sent it to the OP no. 5 Genins India Insurance TPA Ltd. In this way OP no. 1 to 4 are also equally liable to pay the claim amount along with OP no. 5 Genins India Insurance TPA Ltd.  Simply saying that they have no concern with the medi claim the responsibility of OP no, 1 to OP no. 4 does not make them free from responsibility. As such OP no. 1 to 5 is equally liable to pay the claim amount to the complainant.
21. Heard the Learned Lawyer of both the parties and also gone through the evidence produce by both the parties oral and documentary it is clearly established by the complainant taken to his wife Sudha Kumari and admitted to the Sefa Nursing Home, Burdwan, West Bengal where she got emergency treatment and considering the condition of Sudha Kumari operation was conducted and her uterus was removed. On 30.04.16 the complainant within time informed the opposite parties and also filled the mediclaim form amount of Rs 181082.Although OP no.5 did not appeared in this case because exparte proceedings so done but OP no. 1 to 4 has admitted the plea of the exclusion clause filing Exhibit A but the plea of exclusion clause was not sustainable in this case. Apparently the OP no. 1 to 5 was found guilty for not providing proper service to the complainant and his wife.

In the result

ORDERED

That the case and the same is allowed on contest and OP no. 1 to OP no. 5 were directed to pay the complainant Rs 181082/- as principal amount, Rs 40,000/- as compensation account and also Rs 5000/- as cost of litigation with 12 % interest per annum payable from the date of institution of this case. Office clerk is directed to comply order and to supply the copy of this order to the parties or then counsels free of cost.

                     This case thus disposed off accordingly.