IN THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,
MURSHIDABAD, AT BERHAMPORE.
CASE No. CC No. 129/2016.
Date of Filing Date of Admission Date of Disposal
26.08.2016 03.10.2016 21.09.2017
Siddhartha Ghosh,
S/O JitendraNath Ghosh,
Vill.& P.O Palsonda,
P.S. Nabagram,
Dist. Murshidabad,
Pin 742238. ……………… Complainant.
-Vs –
- Branch Manager,
United Insurance Company Ltd.,
3/20, A. K. Banerjee Road,
Berhampore,
Dist. Murshidabad, Pin 742101.
- The Branch Manager,
The Heritage Health Pvt. Ltd.,
Nicco House, 5th Floor,
2, Hare Street, Kolkata 700001. …………….. Opposite Parties.
Cont. ……….…. 2
= 2 =
Sri Saugata Biswas, Advocate ……. for the Complainant
Sri Siddhartha S. Dhar, Advocate ……. for the Opposite Party No.1
Present Sri Anupam Bhattacharyya ………… President.
Smt. Chandrima Chakraborty …. .….. Member.
Sri Manas Kumar Mukherjee …….…. Member
J U D G M E N T
Chandrima Chakraborty, Member.
Claiming himself as a consumer, under the C. P. Act, 1986, the Complainant has sought for interference of this Forum in respect of fact complained of.
The case stated in the complaint, in nutshell, is that, the Complainant had a Health Insurance Policy, being the Policy No. 0314052815 P 110492689 to the Opposite Party Insurance Co. for the period from 08.12.2015 to 07.12.2016.
The Complainant in the mean time to the LV Prasad Eye Institute at Hyderabad on 18.06.2016 for eye treatment and was diagnosed to have vasculitis in his left eye and ultimately the Complainant underwent for eye surgery in his left eye on the same day on 18.06.2016.
Cont. ……….…. 3
= 3 =
The Complainant had submitted the claim of Rs. 25,400/- from the Opposite Party Insurance Co. for the said amount payable under the said Policy but Opposite Party Insurance Co. had repudiated the said claim by a letter dated 01.08.2016 informing that the claim is not admissible under the Clause of the Opposite Party Insurance Co. what amounts to negligence and deficiency in rendering service by the Opposite Party towards the Complainant for which being victimized and harassed the Complainant has to file the instant case seeking adequate redressal against the Opposite Party.
Resisting the complaint, the Opposite Party no. 1 filed the Written Version denying the contention made by the Complainant in his complaint and stating inter alia that the case is not maintainable, the complainant has no cause of action and lastly the complaint is not the consumer under the definition of the C.P. Act, 1986.
The specific case of the Opposite Party Insurance Co., in terse, is that there is no deficiency in service on the part of the Opposite Party Insurance Co. and they have correctly repudiated the claim of the Complainant. The Complainant was diagnosed to have vasculitis in his left eye and was admitted to the LV Prasad Eye Institute for treatment on 18.06.2016 and an accentrix injection was given to the Complainant.s left eye and thereafter the Complainant was discharged from the Hospital on the same day. But the treatment was not a surgery, but only an injection was applied to the left Eye of the Complainant. So, the Complainant is not entitled to get any amount from this Insurance Company as per the Clause 1.2.1 of the Policy and the Complainant was admitted to the Hospital for less than 24 hours. Moreover the procedure has not been listed in the day care list and not required for the hospitalization.
Cont. ……….…. 4
= 4 =
Thus the Opposite Party No. 1 rightly rejected the claim of the Complainant and denies any deficiency and negligence towards the Complainant for which the complaint is liable to be dismissed.
Despite service of the notice, the Opposite Party No. 2 never appeared before the Forum in person and/or through their authorized representative/Ld. Advocate to contest the case by filing Written Version and so the instant case has been heard ex-parte against the Opposite Party No. 2.
Point for Determination
- Whether the instant case is maintainable ?
- Whether the complainant is a consumer ?
- Whether there is negligence or deficiency in service on the part of the O.Ps ?
- Whether the complainant is entitled to get the relief as prayed for ?
Decision with Reasons
All the points are taken up together for consideration for convenience and brevity.
The main dispute between the Complainant and the Opposite Parties is that, whether the Opposite Parties are justified to repudiate the claim submitted by the Complainant or not and whether the Complainant is entitled to get the claim as prayed for from the Opposite Parties or not.
Cont. ……….…. 5
= 5 =
On overall evaluation of the argument made before us by the Ld. Advocate for the Complainant and the ld. Advocate of the Opposite Party No. 1 and critically perused the material evidences on record, it is clearly evident that admittedly the Complainant had a Health Insurance Policy, being the Policy No. 0314052815 P 110492689 to the Opposite Party Insurance Co. for the period from 08.12.2015 to 07.12.2016.
The record reveals that the Complainant had admitted to the LV Prasad Eye Institute at Hyderabad on 18.06.2016 for his eye treatment and was diagnosed to have the vasculitis in his left eye which was never denied rather specifically admitted by the Opposite Parties by filing the written Version.
It is also revealed from the photocopies of the documents (.Discharge Summery. and .To Whom So Ever It may concern.) filed by the Complainant that admittedly the Complainant was admitted in the said hospital named LV Prasad Eye Institute at Hyderabad on 18.06.2016 and was discharged on the same day which specifically indicates that the Complainant was admitted in the said hospital for the period of less than 24 hours.
The photocopies of the documents (Policy Certificate) filed by the Complainant undoubtedly evident that, as per the Clause 1.2.1 of the said Policy noticeably denotes that, .Expenses on hospitalization for minimum period of 24 hours are admissible. However, this time limit is not applied to specific treatments, such as No. 11. Eye Surgery.
Cont. ……….…. 6
= 6 =
Moreover, the fact remains that admittedly the Complainant was pushed an injection named OS ACCENTRIX on 18.06.2016 the day when the Complainant got admitted on the said hospital.
Now the only question is whether the said .OS ACCENTRIX Injection. is considered as an eye surgery or not.
At the time of hearing argument, neither the Complainant nor the contesting Opposite Party No. 1 submitted any medical journal to show the view of the Medical Experts regarding the said OS ACCENTRIX Injection.
Now from the Internet download, it is visible that the said OS ACCENTRIX Injection means,
This is an injection into the vitreous, which is the jelly-like substance inside your eye. It is performed to place medicines inside the eye near the retina.
Intravitreal injections are used to deliver drugs to the retina and other structures in the back of the eye, thus avoiding effects on the rest of the body. Common conditions treated with intravitreal injections include diabetic retinopathy, macular degeneration, retinal vascular diseases and ocular inflammation.
It is further found from the Journal published by the .American Academy of Ophthalmology. about the said OS ACCENTRIX Injection that the said Injection is an Intravitreal drug delivery has become a popular method of treatment of many retinal diseases, commonly including AMD, Diabetic Retinopathy, and Retinal Vein Occlusions. The frequency of intravitreal injections has significantly increased since the introduction of Anti-VEGF medications. This is an important procedure that Retina Specialists use on a daily basis, and it is important to master the techniques of effective injections for patient safety and reduction of complications.
Cont. ……….…. 7
= 7 =
So, from the above literature available from the Internet regarding the said OS ACCENTRIX Injection, it is clearly evident that the said OS ACCENTRIX Injection is a mere injection inserted into the eye of the patient for proper treatment but not any eye surgery as claimed by the Complainant.
Moreover, Ld. Advocate for the Complainant referred a case being C.C. No. 129/2013 as reference, similar to the instant case, passed an Order by this Forum in favour of the Complainant, in which the Forum decided that
.anterior Retinal Cryopexy with intravitral Avestin Injection in the left eye having diagnosis of O.S. V.H. and the Anterior Retinal Cryopexy Injection concluded as the said 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 AvastinInJfrom 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. ,
which clearly indicates that the previous case referred by the Complainant is also for the treatment of his left eye wherein another Injection (anterior Retinal Cryopexy with intravitral Avestin Injection) was injected into the same left eye of the Complainant and the same is considered as the eye surgery as per the medical document submitted by the Complainant, though this case (C.C. No. 129/2013) referred by the Complainant is not at all binding upon this Forum by any means.
Cont. ……….…. 8
= 8 =
But in the instant case, the Complainant failed to submit any such Medical Journal and/or Report to prove that the said alleged Injection named the OS ACCENTRIX Injection. which was further injected and/or inserted into the left eye of the Complainant can be considered as an eye surgery and it is also pertinent to mention here that the Ld. Advocate on behalf of the Opposite Party No. 1 vehemently objected and challenged the fact that the said .OS ACCENTRIX Injection. is liable to be considered as an eye surgery and strictly argued that the said Injection is mere a simple Injection which is used in the eye in specific eye problem for which the Complainant was suffered from.
Furthermore, it is the liability and/or responsibility of the Complainant to prove his own case wherein in this case the Complainant miserably failed to prove his case that the said alleged .OS ACCENTRIX Injection. can be considered as an eye surgery.
So, considering the all circumstances it is concluded that the Opposite Party Insurance Co. is justified to repudiate the claim submitted by the Complainant as the said claim is barred by the Clause 1.2.1 of the Policy Certificate issued by the Insurance Co.
Thus the unanimous decision of the Forum is that the Complainant miserably failed to prove his case by submitting the documents in the support of his case including the Medical Journal/Report in this regard.
Cont. ……….…. 9
= 9 =
Therefore in light of the above analysis, we are of the opinion that the Complainant has not proved his case and is not entitled to get the relief as prayed for and consequentially the points for determination are decided in negative.
In short, the Complainant deserves failure.
In the result, we proceed to pass
O R D E R
That the case be and the same is dismissed on contest against the Opposite Party no. 1 and also dismissed ex-parte against the Opposite Party No. 2 but without any cost.
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.
MEMBER MEMBER PRESIDENT
