The complainant, Jayantilal Prajapati, had obtained a ‘Hospitalisation and Domici-liary Hospitalisation Benefit Policy’ for members of his family, including his wife Manju. While the policy was in effect, Manju suffered from an ‘incisional hernia’, for which she was hospitalised at Ravi Surgical Nursing Home in Bhayandar (west).
An incisional hernia occurs due to a weakness, separation, gap or opening in the muscles or supporting structures of the abdominal wall directly at, or in the region of a prior surgical incision.
Manju was admitted to the nursing home between November 28 and 30, 2006 and she ran up a bill of Rs 15,597. When the insurance company was informed, it rejected the claim on the grounds that Manju’s condition was the result of a tubectomy conducted a year and a half earlier. The insurance policy clearly stated that pregnancy-related complications would not be covered.
On February 19, 2007, Manju received another communication from the firm stating that her claim now stood rejected because treatment arising from ‘convalescence, general debility, rest cure, congenital external disease or defects or anomalies, sterility, venereal disease, intentional self-injury and use of intoxicating drugs or alcohol’ was not covered by the policy.
A bench comprising president S B Dhumal and member S S Patil of the forum concluded in their order on Wednesday that the company was not justified in rejecting Manju’s claim.
The order stated, “Though tubectomy is an operation for sterility, the patient was not hospitalised for the process. Incisional hernia is altogether different from tubectomy. Therefore, in our candid view, the opposite parties have rejected the claim of the complainant on wrong grounds.” It added that Manju’s ailment did not fall under any of the categories described in the grounds on which her claim was rejected.
The court directed the insurance company to reimburse Rs 15,597 they owed to Prajapati, along with 9 per cent interest from November 30, 2006.An additional Rs 5,000 was awarded to the claimant for mental agony endured, along with an additional Rs 3,000 as costs.
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