District Consumer Disputes Redressal Commission, Hooghly
PETITIONER
VS.
OPPOSITE PARTY
Complaint Case No.CC/02/2022
(Date of Filing:-11.01.2022)
- Sri Mani Lal Majumdar
House No. 385, “Udbodhan”
Balagarh Road (west) Opposite of Banamasjid,
Post Office:- Sahaganj, Bandel, Hooghly
West Bengal-712104.…..Complainant
- The Grievance Redressal Officer
HDFC ERGO General Insurance Company Ltd.
9/1, Metro Tower, 10th Floor
1, Ho-Chi-Minh Sarani,
Kolkata- 700071.
- The Grievance Redressal Officer
HDFC ERGO General Insurance Company Ltd.
HDFC House, Backbay Reclamation
H. T. Parekh Marg, Churchgate
-
- The Regional Manager/ Grievance Redressal Officer
Medi-Assist India Pvt. Ltd.
25, Thapar House, 9th Floor
Brabourne Road, Kolkata-700001
- The Grievance Redressal Officer
Medi-Assist India Pvt. Ltd.
Aarpee Chambrs,4th Floor, Shagbaug, Off Andheri-Kurla Road,
Time Square Marol, Andheri East, Mumbai-700059
- The officer-in-charge, Tata Steel Limited ( Ex-Employee Division)
Bungalow No. 4A, Tata Steel Market Office, (Opp:- Jusco Main gate)
Northern Town, Bistupur, Jamshedpur-831001 (Proforma OP)
…………Opposite Parties
Before:-
Mr. Debasish Bandyopadhyay, President
Mrs. Babita Choudhury, Member
Mr. Debasis Bhattacharya, Member
-
Final Order/Judgment
Debasis Bhattacharya:- PRESIDING MEMBER
Being aggrieved by and dissatisfied with partial settlement of a claim after making substantial deduction by the OP Insurance Company, against a Corporate Group Mediclaim Policy held by the Complainant, the instant case has been filed by the complainant, u/s 35 of the Consumer Protection Act 2019.
The fact of the case in a nutshell is as follows.
The complainant, a retired employee of Tata Steel Ltd. was a holder of the Corporate Group Mediclaim Policy which was meant for retired officers and their spouses jointly with subsidized premium, renewable every year either with the same insurer and TPA or with different insurer and TPA as the employer deemed fit.
However during the FY 2019-20 while the policy was within its validity period, the Complainant’s spouse had to undergo a cataract surgery in the right eye in a Kolkata Nursing Home on 25.09.2019.
Reportedly, the policy was a floater one, covering the Complainant and his wife, with available limit of Rs.5,00,000/-.
So far as the cataract surgery was concerned, the policy had no lens cost capping and the only exclusion clause was ‘change of life, or Cosmetic or aesthetic treatment of any description, e.g. correction of eyesight etc.’
Allegedly, the policy features does not clearly clarify the necessary medical conditions needed for usage of both monofocal and multifocal eye lens for cataract surgery.
However, the concerned eye surgeon attending the wife of the Complainant is claimed to have prescribed multifocal lens considering her daily routine and medical necessity.
After the required medical treatment the Complainant submitted a claim for reimbursement of medical expenses to the tune of Rs.85,135/- before the OP 3 on 28.09.2019.
On being asked by OP 3 regarding the requirement of multifocal lens instead of monofocal lens, the Complainant asserted by producing two medical certificates issued by the attending eye surgeon that it was a full fledged cataract surgery with multifocal lens and was not meant for correction of her refractive error.
Eventually the claim was settled for Rs.65, 442/- after deducting an amount of Rs.19,500/- which appeared to be excess of lens charges. However no valid reason for such deduction was categorically stated by the OP Insurance Company.
When repeated persuasions through several representations and e-mails went in vain, a communication was sent to the concerned Insurance Ombudsman on 08.03.21 incorporating all the relevant aspects of the issue. However as on the date of lodging the instant complaint petition the authority was unresponsive.
Considering the treatment extended by the OP Insurance Company by truncating the reimbursement claim to the extent of RS.19,500/-, as deficiency of service and unfair trade practice the Complainant approaches to this Commission with a prayer to impose direction upon the opposite parties, to further reimburse the medical expenses of an amount of Rs.19,500/-, to pay compensation of Rs.2,00,000/-, Rs.1,00,000/- for mental agony and Rs.20,000/- towards litigation cost.
The Complainant along with his petition has annexed certain related documents viz. the policy schedule, evidence of payments of premiums, complaint lodged with the Insurance Ombudsman, mails sent to and received from the concerned TPA and OP insurance Company, letters sent to the TPA and OP Insurance Company, medical documents and bills and copies of medical certificates issued by the concerned eye-surgeon.
Evidence on affidavit and BNA filed by the Complainant are almost replica of the Complaint petition. However the Complainant mentions in his evidence that he received the claimed amount of Rs.77,678/-in full against renewed mediclaim policy issued by ICICI Lombard General Insurance and Tata Steel for the period 2021-22 with exactly the same terms and conditions for identical surgery in the left eye of the wife of the Complainant.
Apparently in the instant case the OP Insurance Company was a service provider.
Thus, in view of the above discussion and on examination of available records it transpires that the complainant is a consumer as far as the provisions laid down under Section 2(7)(ii)of the Consumer Protection Act 2019 are concerned.
The complainant is a resident within the district of Hooghly.
The claim preferred by the complainant does not exceed the limit of Rs.50,00,000/-Thus, this Commission has territorial as well as pecuniary jurisdiction to proceed in the instant case.
The issues related to the questions whether there was any deficiency of service and whether the complainant is entitled to get any relief, being mutually inter-related, will be taken together for convenient disposal.
Defence case
OP 1 and 2 belong to the same organization i.e. the Insurance Company whereas OP 3 and 4 belong to the same organization i.e. the TPA. OP 3 i.e. Tata Steel Ltd., the employer of the Complainant is the proforma OP.
The case ran ex parte against OP 3, 4 and 5. However OP 1 and 2 Insurance Company have contested the case by filing written version. However on prayer the written version filed by the OP 1 and 2 has been treated as evidence on affidavit. NO BNA has been filed by the OP Insurance Company.
Now in the written version OP 1 and 2 have mainly questioned the territorial jurisdiction of this Commission to try this case. Apart from that these OPs have denied all the allegations leveled against them by the Complainant.
It is to be mentioned that though maintainability has been questioned in the written version assigning quite a few reasons, no maintainability petition has been filed by the OP insurance Company in course of the trial.
However while questioning the territorial jurisdiction the OP Insurance Company has referred to section 11 of C.P. Act 1987. But it has not been noticed by the OP Insurance Company that the petition has been filed on 11.01.2022 and thus it is implied that the petition has been filed u/s 35 of the C.P. Act 2019.
In terms of the provision of section 34 (2)(d) of the C.P. Act 2019, ‘A complaint shall be instituted in a District Commission within the local limits of whose jurisdiction the Complainant resides or personally works for gain.’
In the instant case the Complainant resides within the local jurisdiction of this Commission. Hence question raised by the OP Insurance Company in this regard is brushed aside.
However in the written version the OP insurance Company admits that there is no such restriction for monofocal or multifocal lens as per terms and conditions of the policy but there must be medical necessity. It is further pointed out that query was raised for justification for use of multifocal lens but as per treating doctor’s certificate, reason given was ‘strong desire to avoid glass.’ The claim was reimbursed for monofocal lens as multifocal lens was not a medical necessity.
Decision with reasons
Materials on records are perused.
On perusal of all the aspects of the case it transpires that the entire focus lies on the issue whether the Complainant was entitled to the medical reimbursement of the expenses incurred for implanting multifocal intra-ocular lens in course of cataract operation of his wife.
The extant records indicate that the treating doctor actually issued two certificates. In the first one reason assigned for multifocal lens was ‘Strong desire to avoid glass’ and in the second one, it was mentioned that the full-fledged cataract surgery with multifocal intra-ocular lens is not for correction of refractive error.
Multifocal lenses can correct vision at various distances (near, intermediate and far) and are considered premium options. Some insurance companies may partially cover the cost of multifocal lenses, while others might not cover them at all.
Now the treating doctor’s initial certificate indicates that multifocal lens was the patient’s choice as she had a strong desire to avoid glass. This establishes that there was no medical necessity to implant multifocal lens instead of monofocal lens. A patient’s strong desire to avoid glass at post operation stage cannot be termed as medical necessity.
It appears that the employer of the Complainant changed insurance companies from time to time so far as the group insurance policies were concerned. Terms and conditions of one insurance company may differ from the terms and conditions of another. Hence it cannot be expected that identical claims for reimbursement would be treated by all insurance companies in uniform manner.
Here, in the instant case the Commission cannot be expected to compel the OP insurance Company to make full reimbursement of the medical expenses where the absolute medical necessity for implanting multifocal intra-ocular lens in course of the cataract surgery cannot be established.
In view of the above the Commission is of the opinion that any sort of deficiency of service or unfair trade practice on the part of the OP Insurance Company in the instant case cannot be established in unequivocal terms.
Hence it is
ORDERED
that the complainant case no.02/2022 be and the same is dismissed on contest.
However there is no order as to costs.
Let a plain copy of this order be supplied free of cost to the parties/their Ld. Advocates/Agents on record by hand under proper acknowledgement/sent by ordinary post for information and necessary action.
The final order will be available in the website www.confonet.nic.in
