IN THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,
MURSHIDABAD AT BERHAMPORE.
CASE No. CC /129/2013.
Date of Filing: 14.11.2013. Date of Final Order: 16.03.2016
Complainant: Siddhartha Ghosh, S/O Jitendra Nath Ghosh, Vill.& P.O Palsonda, P.S. Nabagram,
Dist. Murshidabad.
Vs
Opposite Party: Branch Manager, United Insurance Company Ltd.,
3/20, A. K. Banerjee Road, Berhampore, Dist. Murshidabad.
Present: Sri Anupam Bhattacharyya ………………….President.
Sri Samaresh Kumar Mitra ……………………..Member.
Smt. Pranati Ali ……….……………….……………. Member
FINAL ORDER
Sri Anupam Bhattacharyya, Presiding Member.
The instant complaint has been filed by the complainant u/s 12 of C. P. Act, 1986 praying for payment of Surgery charges of Rs.14,300/- payable under the policy and compensation of Rs.5,000/- and cost of Rs.5,000/-.
The complaint’s case, in brief, is that the complaint had a family Medicare Policy with OP-Insurance Co. for the period from 5.12.12 to 4.12.13. The complaint finding eye problem availed the treatment of Disa, Barrackpore but could not be cured and thereafter, complainant undergone eye treatment at E.L.V.Y. Prasad Eye Institute at Bandare Hills, Hyderabad for last 6 months and ultimately he underwent eye surgery namely anterior Retinal Cryopexy with intravitral Avestin Injection in the left eye having diagnosis of O.S. V.H at the said institute as indoor patient on 22.8.13 and the complaint had to pay surgery charges of sum of rs.14,300/- of the said hospital authority. The complainant claimed the said amount of Rs.14,300/- from OP-Insurance payable under the policy but OP-Insurance Co. repudiated the said claim by letter dt. 16.09.13 being the claim is not admissible as per Clause 2.3 of the policy. The provision of Clause 2.3 as to time limit for admission in case of eye surgery is not applicable and for that the repudiation by the OP-Insurance Co. is illegal and unfair. Such non-payment is an act of deficiency in service on the part of Insurance Co. .For such non-payment the complainant has filed this instant complaint. Hence, the instant is complaint case.
The written version filed by OP-Insurance Co., in brief, is that there is no deficiency in service on the part of the OP-Insurance Co. and they have correctly repudiated the claim of the complainant . The complainant was admitted for interior Retinal Cryopexy which is an outpatient procedure. In the instant case the complainant went to L.V. Prosad Eye Institute on 22.08.2013 and discharged on the same day at 12.07 hours. The surgery column speaks “Left Eye Anterior Retinal Cryopexy-IV Avastin Inj” but the treatment was not a surgery, but only an injection was applied to the left Eye of the complainant. The Medical term “Anterior” means “In Anatomy refers to ventral Portion of the Body”. So, the complainant is not entitled to get any amount from this Insurance Company as per Clause 2.3 of the Policy and for that the complaint is liable to be rejected. Hence, the instant written version.
Considering the pleadings of both parties the following points have been framed for the disposal of the case.
Point for Consideration
- Whether the case is maintainable in its present form and law?
- Whether the complainant is a consumer under the C.P. Act, 1986?
- Whether the case is barred by law of limitation?
- Whether the complainant is entitled to get relief as prayed for?
- To what other relief/reliefs the complainant is entitled?
Decision with Reasons.
Point Nos. 1 to 5.
All the points are taken up together for the sake of convenience.
The complainant’s main case is that the instant treatment of eye of the complaint at L.V. Prosad Eye Institute, Hyderabad as done is surgery and not a mere injection and the same is exempted in Cl. 2.3 of the Policy where admission for more than 24 hrs is not required and for that the complainant is entitled to get relief and as such the repudiation of the claim by the OP-Insurance Co is illegal.
On the other hand, the OP’s case is that in the discharge summary of L.V. Prosad Eye Institute in Surgery Column it is clearly mentioned as Left Eye: Anterior Retinal Cryopexy with Intravitreal Avastin Injection. This being injection the instant treatment will not come under surgery and for that the instant claim will not come under exemption category of Cl. 2.3 of the Policy. The repudiation of the claim is thus correct and for that there is no deficiency in service.
To prove the case the complainant has adduced evidence-on-affidavit and the relevant documents in support of his case, including the bills/receipt of L.V. Prasad Eye Institute, discharge summary of the Institute including the policy certificate, one certificate issued by L.V. Prasad Eye Institute in favour of Intravitreal Avasin Injection costs Rs.10, 000/- and Anterioor retinal Cryopexy for Rs.4300/- totaling Rs.14,300/- .
This complaint is for realization of these medical charges towards eye treatment particularly the injection claiming as an Eye Surgery in the said hospital at Hyderabad.
As per the terms and conditions of the Insurance Policy towards Medi Claim in case of Eye Surgery admission for more than 24 hours is not mandatory.
Admittedly the treatment for which claim has been raised is provided in the particular hospital for less than 24 hours.
Admittedly, the injection was administered in the Eye of the complainant and the treatment of that injection was for Anterior Retinal Cryopexy .
From the Journal regarding Retinal Cryopexy obtained from Net submitted by the Ld. Lawyer for the complainant wherefrom under the head “Description” it appears that usually, retinal cryopexy is administered under local anesthesia. The procedure involves placing a metal probe against the eye.
Further under the heading “Aftercare” wherein it provides that after the procedure, patients are taken to a recovery room and at the last of the paragraph –Day surgery patients are usually allowed to go home two hours after the surgery is complete”.
Considering the above materials provided in the Journal also particularly the admitted case as to the problem in the eye for Anterior Retinal Cryopexy Injection we can safely conclude that the treatment is not a simple injection. Also from the documents, discharge certificate under the column surgery it is written as Left eye: Anterior Retinal, Cryopexy, IV Avastin InJ from that we find that though the treatment provided in the hospital by administering injection in the eye but it was for Anterior Retinal Cryopexy
Further from the bill of the Institute, it has also clearly reflected under the printed head - Procedure/Surgery Performed as below:-
Surgery: ANTERIOR RETINAL C RYOPEXY (ARC) IN MAIN OR plus INTRAVITREAL AVASTIN IN.
Considering the particular facts and circumstances as to nature of treatment in the eye with the observation in medical journal for Anterior Retinal Cryopexy Injection and also considering the description in the Discharging Certificate and bill as surgery we can safely conclude that this is a case of surgery and as such the complainant is entitled to get the said amount of Rs.14, 300/- towards expanse for such treatment.
On the basis of the above discussions we find that all the points are disposed of in favour of the complainant in part.
The repudiation being on the point of interpretation of the terms of the Policy relying upon medical science we are of view that the complainant is not entitled to get any compensation.
Hence,
Ordered
that the Consumer Complaint No. 129/2013 be and the same is hereby allowed on contest . There will be no order as to cost.
The complainant is entitled to get Rs.14, 300/- for the treatment of his eye from the OP.
The OP is directed to pay Rs.14,300/- to complainant within two months from the date of this order failing which the OP is to pay Rs.100/- as fine for each day’s delay and the amount so accumulated shall be deposited in the “Consumer Legal Aid Account”.
Let a plain copy of this order be made available and be supplied free of cost, to each of the parties on contest in person, Ld. Advocate/Agent on record, by hand under proper acknowledgment / be sent forthwith under ordinary post to the concerned parties as per rules, for information and necessary action.
