Orissa

Sambalpur

cc/53/2018

Shyam Sundar Pansari - Complainant(s)

Versus

1- United India Insurance Co,Ltd, - Opp.Party(s)

02 Aug 2022

ORDER

PRESIDENT, DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SAMBALPUR

Consumer.Case No.- 53/2018

Present-Dr. Ramakanta Satapathy, President,

  Sri. Sadananda Tripathy, Member

 

Sri. Shyam Sundar Pansari,

Baraipali, Sambalpur                                           …………..Complainant

 

Vrs.

1. United India Insurance Co. Ltd.

Gaity Road, Sambalpur.

2. Heritage Health Services Pvt. Ltd.,

NICCO House, (5^th Floor)

2, Hare Street,

Kolkata 700001.                                         ……….….Opp. Parties

Counsels:-

1. For the Complainant    :-            Self
2. For the O.P No.1           :-            Sri B.K.Purohit, Advocate & Associates.
3. For the O.P. No.2                       :-           None

 

DATE OF HEARING :29.06.2022 DATE OF JUDGEMENT : 02.08.2022

Presented by Dr. Ramakanta Satapathy, PRESIDENT:

1. The Complainant obtained a Mediclaim policy from O.P. No.1 having policy No. 2604002816P116531312 for self and his spouse namely Smt. Prema Pansari Since 1998 and every year renewed the policy. On 01.08.2017 Prema Pansari had undergone a cataract operation of her right eye at care Hospital, Bhubaneswar and spent Rs. 58,627/- including pre and post hospitalization expenses. Under the cashless scheme the O.P. paid only Rs. 40,000/- with a plea that only monofocal lens is payable. The O.P. No.2 is the Third Part Policy Agent(TPA).

Being aggrieved the Complainant filed this complaint.

2. After appearance the O.P. No.1 submitted its version and stated that smt. Prema Pansari is a beneficiary. The policy is admitted to be insured in favour of Complainant and his spouse to the extent of Rs.4,25,000/- and validity period 23.03.2017 to 22.03.2018 MN subject to condition and limitation of the policy terms. In the exclusion clause in connection with clause 4.7 of the policy.  “Cost of spectacles contract lenses and hearing aids” are not payable by the O.P. The Third party administrator paid Rs. 40,000/- to-wards cashless payment but did not pay Rs. 18,607/- as contact lens is excluded from the coverage and deducted Rs. 15,000/- to-wards the amount claimed, Rs. 260/- to-wards registration charges, Rs. 437/- to-wards non submission of prescription of doctor, Rs. 460/- for want of documents and other changes Rs. 825/-. There is no any deficiency on the part of the O.P. No.1 and accordingly complaint is not maintainable.
3. Perused the documents filed by both the parties. In the exclusion clause of the policy clause 4.7 specifically mentioned that for “cost of spectacles, contact lenses and hearing aids” the company shall not be liable to make any payment under the policy. In the complaint the Complainant specifically mentioned that he received Rs. 40,000/- to-wards mono focal lens. The complaint is not specific for which part Rs. 15,000/- claimed. As per version of O.P. the cost of lens has been deducted as it is not payable.

The dispute is relating to payment of cost of lens although no specific prayer has been made by the complainant. The lens cost is excluded from the policy. Accordingly I am not inclined to hold the O.Ps deficient in their service and the complaint is dismissed. No cost.

Order pronounced in open court on this 2^nd day of  August 2022.

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