By Sri. Mohandasn.K, President
1.The complaint in short is as follows:
The first complainant took a Medicare policy from the opposite party through their agent who enticed the complainant to take policy stating that the entire family iscovered by the policy. The second complainant is the wife of the first complainant and as per the policy, the complainant, his wife and his son are covered. The complainant is the policyholder of opposite party since 2010. The present policy is valid from 06/12/2017 to 05/12/2018 and the policy number is 101900/28/17/P1/11556347. The second complainant, Pankajavalli was detected with glaucoma to her right eye with cataract. Immediately surgery was advised and the complainant took her to Puthalath Eye hospital, Mini bypass road, Kallthumkadvu, Puthiyara, Kozhikode on 28/10/2016 and the surgery was done. The opposite party denied cash less insurance facility and directed to submit the bill along with claim form. After the discharge the claim form along with all records submitted before the opposite party.
2. The complainant contacted the opposite party and requested to sanction the entire insurance amount which was not paid by the opposite party. It was stated that, the opposite party entrusted another third party to process the claim and they sanctioned only a sum of Rs. 10,000/- which is already paid to the complainant. The complainant was not aware of such arrangements with third party and the policy is silent about such authority. The opposite party officials and agents stated that, they will reimburse the amount spent for treatment after consultations with other officials. The complainant submitted that the eye sight is left eye is only 15 % and the right eye is almost seen effected. Falco plus PPB plus ILMO plus AADI in Vitreous cavity was done by the doctor. The surgery done in Vitreous cavity was a complicated surgery and it is not simple cataract surgery. All these surgeries were done to control glaucoma.
3. The complainant submitted that, they put in to irreparable loss and hardship due to the deficiency in service committed by the opposite party. The opposite party under the guise of granting services committed gross deficiency in service. If the opposite party had not enticed the complainant stating false facts, no policy will have been taken by the complainant. The complainant submitted that, they are entitled to get Rs. 45,505/ towards the claim. The amount was spent for the treatment of the second complainant. The opposite party accepted the claim form stating that the entire amount spent will be sanctioned and same will be credited in the bank account of the first complainant. But only part of claim was sanctioned and credited in the account. The opposite party was not even supplied policy conditions and they committed gross deficiency in service. Hence the prayer of the complainant is that to allow Rs. 45,505/- to the first complainant and also to order compensation of Rs. 50,000/- along with cost of the proceedings.
4. On admission of the complaint notice was issued to the opposite party and the opposite party filed version. The opposite party denied the entire allegations and averments in the complaint and contented that, the complaint is legally unsustainable on question of law as well as facts and liable to be dismissed.
5. The opposite party admitted that they had issued a Family Medicare PolicyNo.1019002817P111556347 in favor of the complainants for the period 06/12/2017 to 05/12/2018. The liability of the opposite party is subject to the terms and conditions and limitations of the policy. The complainant renewed the policy from time-to-time 2010 and there was a claim before this Forum as CC/496/2016 which was allowed and an appeal is pending before the State Commission. The opposite party preferred an appeal and execution of the order passed by this Forum is stayed by the State Commission. The opposite party denied the averments in the complaint that while issuing the Medicare policy the opposite party had promised to cover the medical expenses by cash less facility. As per the terms of the policy, it is specified that cash less facility will be extended to the insured for the medial expenses incurred, provided that the hospital/nursing home/health care provider is enlisted as a net work provider (definition 3.24 in terms and conditions) which list is maintained by the insurer or its third-party Administrator. The opposite party denied the averment that the second complainant had underwent surgery to her eye and spent Rs. 55,505/-and the opposite party allowed only Rs. 10,000/- and she is entitled the balance amount. The opposite party contented that as per clause ‘F’ in the policy, since the complainant undergone cataract surgery, they are entitled only 10% of the insured sum subject to the maximum of Rs. 25,000/-. The opposite party also denied the allegation of the complainant that they were not aware of role of third-party assistance. The opposite party denied the allegations of deficiency in service, or out of order or irregular promises and also denied the allegations of unfair trade practice. The opposite party prayed for the dismissal of complaint with cost.
6. The complainant and opposite party filed affidavit and documents. Complainantdid not file any documents. But the opposite party filed documents and it is marked as Ext.B1. Ext. B1 is true copy of policy terms and conditions issued by opposite party to complainant.
7. Perused affidavit and documents. Heard complainant and opposite party. The opposite party filed argument note also. The following points arise for consideration:-
- Whether the complainant is entitled the benefit as claimed under the policy?
- Relief and cost.
8. Points No.1& 2
The case of the complaint is that, the second complainant was undergone treatment while the insurance policy was in force and the opposite party denied the insurance claim despite submitting all the documents. The contention of the opposite party is that, as per the policy condition the complainant is entitled only Rs.10,000/- and that has been duly paid. According to the opposite party the treatment undergone by the complainant comes under the limited liability clause as per the insurance policy, Ext.B1. The contention is that, as per the coverage clause ‘F’ in the terms that the expenses in respect of cataract surgery is restricted. The complainant submitted that, they approached Aravind eye hospital, Coimbatore for the treatment since the experts in retina treatment are only available in Aravind eye hospital. The doctors diagnosed the Pseudophakia in right eye, Ice syndrome and immature cataract. She was under gone surgery namely Phaco with Aurofoldable lenses, surgery with PPV, ILMP, AADI in vitreous cavity. The submission is that she was undergone three surgeries from the hospital. At present the eye sight in left eye of the complainant is restricted to 15% and right eye is also seen affected. The surgery done in Vitreous cavity was a complicated surgery and not a simple cataract surgery. The surgeries undergone by the complainant to control glaucoma. Now the question is whether the surgery undergone by the complainant can be included as stated by the opposite party in the coverage ‘clause F’ in respect of cataract surgery which is restricted to 10 % of the sum insured subject to maximum of Rs. 25,000/-. The opposite party produced Ext. B1 document regarding the policy conditions. Ext. B1 policy conditions reveal that clause ‘H’ 1.2I that there are 34 items are mentioned and the same is explained as expenses, on hospitalization for minimum period of 24 hours are admissible. However, it can be seen that eye surgery also included in the 34 items of treatments. So it is to be distinguished whether the treatment undergone by the complainant was a simple cataract surgery as stated by the opposite party or is it covered by clause (i) 1 vide 2. It can be seen from the treatment records which is produced as per the order of the Commission that the surgery under gone was not simple cataract surgery. So, it will be proper to hold from the records that the surgery under gone by the complainant was not a simple cataract surgery and restriction clause is not applicable in the case of complaint. That being the fact the complaint is entitled for the treatment expenses. The complaint submitted claim form before the opposite party and according to complainant she submitted bill worth Rs. 55,505/-, which is to be allowed to the complaint. The total expenses met by the complainant was nearly Rs. 55,505/- . So the claim of the complaint is that she is entitled the balance amount as per the documents. The Commission finds the claim of the complainant as genuine, the surgery undergone by the complainant was not a simple cataract surgery and restriction clause as stated by the opposite party is not applicable in the matter. So, we allow the complaint and the opposite party is directed to pay the balance amount of the treatment expenses Rs. 45,505/-to the complainant. The complainant also claimed compensation of Rs. 15,000/-and also cost of proceedings. It will be proper to direct the opposite party to pay interest at the rate of 9% from the date of this complaint till the payment. Hence considering the entire documents and averments available before this Commission, we are of the view that there is deficiency in service on the part of the opposite party and the complainant is entitled for treatment expenses as prayed. It will be proper to allow reasonable amount as compensation also. We allow this complaint and direct the opposite party as follows: -
- The opposite party is directed to pay an amount Rs. 45,505/-(Rupees Forty five thousand five hundred and five only) towards the treatment expenses.
- The opposite party is directed to pay Rs. 20,000/-(Rupees Twenty thousand only) as compensation to the complainant on account of deficiency in service and thereby caused inconvenience and hardships to the complainant.
- The opposite party is also directed to pay Rs. 5000/- (Rupees Five thousand only)as cost of the proceedings.
The opposite party shall comply this order within one month from the dateof receipt of copy of this order, failing which the complainant is entitled to interest @ 9% per annum from the date of filing this complaint till realization.
Dated this 7th day of November, 2022.
MOHANDASAN K., PRESIDENT
PREETHI SIVARAMAN C., MEMBER
MOHAMED ISMAYIL C.V., MEMBER
APPENDIX
Witness examined on the side of the complainant : Nil
Documents marked on the side of the complainant : Nil
Witness examined on the side of the opposite party : Nil
Documents marked on the side of the opposite party : Ext.B1
Ext. B1 : True copy of policy terms and conditions issued by opposite party to
complainant.
MOHANDASAN K., PRESIDENT
PREETHI SIVARAMAN C., MEMBER
MOHAMED ISMAYIL C.V., MEMBER
