Hanumantharayappa vs Goetze (India) Limited

THIS appeal is by the complainant challenging the order of the DF dismissing his complaint. The facts in this case are as follows: The complainant is an employee of OP1. OP3 is the Insurance Company which has undertaken to reimburse the medical expenditure incurred for himself and his family members as per the terms and conditions of the policy. The wife of the complainant by name Smt. Bhagyalakshmi was suffering from severe abdominal pain and, therefore, approached K.K. Hospital for check-up on 12.6.2004. The doctor in the K.K. Hospital conducted certain tests and found the patient was pregnant. But since the wife of the complainant continue to suffer severe pain in the abdomen she was referred to Bhagwan Mahaveer Jain Hospital. In the said hospital, she was admitted as an in-patient from 12.6.2004 to 18.6.2004. In the Bhagwan Mahaveer Jain Hospital, it is found on examination, she has to undergo surgery for Ectopic Pregnancy. Accordingly, emergency Laparotomy was conducted. In respect of this, the complainant had spent a sum of Rs. 30,000. Thereafter, the complainant made a claim with the Insurance Company for reimbursement of medical expenditure. The Insurance Company refused to reimburse the medical expenditure on the ground the policy obtained by the complainant specifically excludes the 3rd pregnancy. THIS has made the complainant to file the complaint before the DF.

THE DF accepting the defence put forward by the Insurance Company dismissed the complaint. This order is under challenge by the complainant in this appeal. It is not in dispute that the patient i.e., the wife of the complainant had 2 children who were aged about 17 years and 14 years respect

The present pregnancy was noticed in the K.K. Hospital on 12.6.2004 when she approached the K.K. Hospital with a complaint of abdominal pain. Ultimately, she was referred to Bhagwan Mahaveer Jain Hospital since she continued to have the abdominal pain. In the BMJ Hospital, after conducting several tests, found that she was suffering from Ectopic Pregnancy and, therefore, she requires immediate surgery and accordingly on the very day the emergency Laparotomy was conducted.

THE Learned Counsel appearing for the complainant submitted that Ectopic Pregnancy, no doubt, arises out of third pregnancy which is not a normal pregnancy and it is a disease which requires immediate surgery. In support of this contention, the learned Counsel appearing for the complainant relied upon the literature relating to Ectopic Pregnancy. As per this medical literature, it is stated as follows: Normally, the fertilised egg moves along the tube to enter the. uterus and to implant in its mucosa. But the conditions for the movement of the egg may by some causes be upset and the fertilized ovum may implant elsewhere to cause extrauterine, or ectopic pregnancy (graviditas extrauterina) the consequence of which results in rupture in the tube. THE literature further states as follows: Bearing in mind the special danger to which the woman is exposed during extrauterine pregnancy, she should be examined by a specialist immediately when suspicion arises. If sings of terminated extrauterine pregnancy appear, the patient should immediately be delivered to the hospital by any possible means (by air, car, etc.). An obstetrician should accompany her to the hospital. From the literature referred to above, we find that the ectopic pregnancy is not a normal pregnancy and it is a disease which requires immediate surgery. If that were be the case, there is no reason for the Insurance Company to repudiate the claim. Therefore, in our view, the complaint of the complainant is to be allowed. Accordingly, we pass the following: ORDER Appeal is allowed. Impugned Order is set aside. The respondent/OP No. 3 is directed to pay Rs. 30,000 to the complainant with interest @ 6% p.a. from the date of the complaint till realisation. The parties are directed to bear their own costs. Appeal allowed.