Decided on May 10,2013

Pradeep Damodar Sonawane Appellant
Manager, Oriental Insurance Co Ltd And Ors Respondents


- (1.)THIS appeal takes an exception to an order dated 28/02/2011 passed in consumer complaint No. 273/2010; Mr. Pradeep Damodar Sonawane v/s. Manager, Oriental Insurance Co. Ltd. and another; passed by District Consumer Disputes Redressal Forum, Nasik. It was a consumer complaint pertaining to wrongful repudiation of insurance mediclaim vis -a -vis deficiency of service on that count on the part of respondents' opponents. The consumer complaint stood dismissed and, feeling aggrieved thereby, complainant preferred this appeal. Undisputed facts are that complainant had taken mediclaim policy for his family including his wife Sonal. Mediclaim policy for the first time was taken in the year 2003 and it was subsequently renewed from year to year. Last policy was for the period 10/07/2009 and 09/07/2010 and as far as wife of the complainant -Sonal is concerned, she was covered with the risk to the extent of Rs. 1,00,000/ -. On 27/02/2010, wife of the complainant was admitted to the hospital of Dr. Ramesh Desle with a complaint of bleeding from vagina. On her examination, she was found pregnant of 22 weeks. However, wife of the complainant was ignorant of the said pregnancy. Considering her condition, her history of previous two caesarian operations, and the continuous bleeding; it was decided to remove the fetus by caesarian. During the said caesarian operation, it was also noticed that the placenta was stuck to the scar of previous two caesarian deliveries and, as such, surgeon took decision, which was necessary for saving life of wife of complainant to remove her uterus. It was done accordingly. She was discharged from the hospital on 09/03/2010. She had incurred expenditure for treatment in the hospital including medicines, total amounting to Rs. 71,216/ -. Mediclaim was raised for the said amount, which stood repudiated by the Insurance Company referring to clause No. 4.12 of the policy and stating that since the treatment undertaken and received by wife of complainant was 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, is excluded from risk covered. Branding this action of the respondent/opponent/insurance Company and its agent -opponent No. 2 as arbitrary and improper, the consumer complaint came to be filed. In their written version, opponent No. 1 justified the repudiation referring to the above referred clause in the policy.
(2.)HEARD both the parties. It is submission of the appellant that since the removal of uterus vis -a -vis hysterectomy undergone by complainant's wife was for saving her life as per the policy of the Insurance Company reflected in their circular dated 17/04/2001 the claim ought not to have been rejected. Before proceeding further we would like to produce exclusion clause 4.12 on the basis of which claim stood repudiated. It reads as under: -
"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"

(3.)IT is well settled principle that the Consumer Fora cannot rewrite the insurance mediclaim policy contract or cannot substitute anything in it. Important document to which even the Insurance Company referred is the discharge card of complainant's wife Sonal and the affidavit of treating surgeon Dr. R.T. Desle From these documents it is clear that complainant's wife Sonal was admitted of the hospital of Dr. Desale was for a complaint of bleeding from vagina. On her examination she was found to be pregnant of 22 weeks and after this particular finding, it was decided to remove the fetus by caesarian. Thus, whatever is carried out thereafter is a part of treatment received by the complainant's wife Sonal is the one referring to her pregnancy and related complications and her condition as a result of said pregnancy. Complications of bleeding was thus referring to her pregnancy. Hysterectomy was done not as initially planned but only when it was found that the placenta was stuck to the scar of previous caesarian. No doubt it was necessary to stop the bleeding and save life of complainant's wife Sonal but certainly, every description referred above is within the scope of exclusion clause 4.12. A reference has been made to circular dated 17/04/2001 but said circular refers to the treatment claim arising out of treatment relating to Ectopic/Tubular pregnancies i.e. fetus developed outside the womb. Such is not a case before us. Under the circumstances, the circular would not come to any help of the appellant/complainant. Thus, we find that the forum rightly observed that since the repudiation of the claim validly refers to an exclusion clause in the policy, the action on the part of the Insurance Company in repudiating the claim cannot be faulted with and, as such, there is no deficiency in service on the part of Insurance Company vis -a -vis respondent No. 1. Hence, finding the appeal devoid of any substance, we pass the following order: - -

Appeal stands dismissed. However, in the circumstances of the present case, both the parties to bear their own costs.


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