BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BHIWANI.
Complaint No.: 212 of 2016
Date of Institution: 29.09.2016.
Date of Decision: 8.4.2021
Subhash Singh s/o Balbir Singh resident of village and post office JattuLohari District Bhiwani presently employed with LIC of India, Branch Office Bhiwani.
….Complainant.
Versus
- L. I. C. of India through its Chairman, Central Office, Jeevan Bima Marg, Mumbai.
- Branch Manager, LIC of India, Branch Office Bhiwani.
- The new India Assurance Company Limited through its managing Director, Corporate Office, 87, MG Road, Fort, Mumbai.
- Branch Manager, New India Assurance Company Limited, Opp Civil Hospital, GhantaGharChowk, Bhiwani.
…...Opposite Parties.
COMPLAINT UNDER SECTIONS 12 OF
THE CONSUMER PROTECTION ACT, 1986.
Before: - Mr. Nagender Singh, President.
Mr. ShriniwasKhundia, Member.
Present: Sh. Anand Singh Dabas, Advocate for the complainant.
Sh. N.S. Vijayrania, Advocate for opposite party No.1 & 2.
Sh. Avinash Sardana, Advocate for opposite party No. 3 & 4.
ORDER
NAGENDER SINGH, PRESIDENT:
Brief facts of the case are that the complainant being employee of the LIC of India (hereinafter called Corporation), alongwith his family members have been covered under Group Mediclaim Scheme. This scheme provides reimbursement of hospitalization/domiciliary hospitalization expenses of the family members including employee by the Corporation. Complainant stated that the scheme is being served by the New India Assurance Company Limited as per agreement with the Corporation and as such his son was issued Card No. MD15-0029255585 under Policy No. 120700/34/15/04/00000003 and monthly premium towards the scheme are deducted from the salary of complainant by the Corporation. It is submitted that Sandeep son of complainant consulted Eye-Q Super Specialty Eye Hospital at Hisar about his eye problem and after checking his eyes it was discovered that refraction of both eyes is above -2.75 and recommended Lasik laser. Thereafter, on advice of the Doctor, Sandeep was operated for Lasik laser at Eye-Q Super Specialty Eye Hospital, Barwala Road, Hisar on 02.06.2016 and Rs. 66,737/- were charged by the hospital. It is further submitted that on 04.06.2016, his father Subhash Singh completed the entire requirement for payment of above said amount and it was assured that mediclaim amount will be paid with 15 days. Complainant requested several times for his payment of bill amount of Rs. 66,737/- being facing financial hardship but the genuine claim was not paid. Now, the claim has been repudiated on false grounds without any justification which is unjust and unwarranted and deficiency in service. It is further alleged that on 16.08.2016, a legal notice was also served upon the opposite parties but payment has not been released till date. It is further alleged that complainant Subhash Singh is entitled to receive mediclaim of his son namely Sandeep. Accordingly, the complainant prays for mediclaim payment amounting to Rs. 66,737/- alongwith interest @ 18 % per annum from 04.06.2016 till final payment with compensation and other cost which the Forum deem fit.
2. After registration of the case, opposite parties no. 1 &2 appeared and filed their joint reply after taking several preliminary objections such as not maintainability, no locus standi, no cause of action etc. It is alleged that complainant, who is the employee of the OP Corporation, is holder of card No. MD15-0029255585 and Northern Central Zone Policy No. 120700/34/15/04/00000003. It is further alleged that the Complainant’s complaint was sent to the OP No.3 New India Assurance Company Limited through TPA MD India for their consideration. The claim was repudiated by the New India Assurance Company Limited as intimated to the OP Corporation vide letter dated 04.08.2016, which was conveyed to the complainant vide letter dated 05.08.2016, The reasons given for repudiating the claim is as follows:-
“ Current illness Dm with Htn is since-Days as per discharge summary6. The claim is repudiated, as there is no hospitalization.4 Current illness plain in calf Muscle is since acute days as per discharge summary6. As per claim documents it is observed that the patient was treated on OPD basis and as per policy terms OPD based treatment is not payable. Hence, the claim was repudiated, 4 Current illness diabetes mellitus, hypertension, hypothyroidism is since-Days as per OPD case paper6. As per claim terms OPD based treatment is not payable. Hence the claim has been repudiated., 4 Current illness depression is since acute days as per discharge summary6. The claim is repudiated as Convalescence, generaldebility, ‘Run-down’ condition or rest cure, obesity treatment and its complications, congenital external disease/defects or anomalies, treatment relating to all psychiatric and psychosomatic disorders, infertility, sterility, use of intoxicating drugs/alcohol, use of tobacco leading to cancer4 Current illness. Both eye myopia is since ACUTE days as per OPD case paper6. As per claim documents it has been observed that the procedure was done for correction of refractive error for myopia. Policy terms, highmyopia more than-4 is payable in current claim refractive error for OD is-2.75 and OS is-3 hence current claim is not payable”.
Therefore, there is no deficiency in service on the part of the OP-Corporation and this complaint is not maintainable. It is further stated that the complainant is estopped by his own act and conduct from filing the present complaint. Therefore, this complaint is false, frivolous and vexations to the knowledge of the complainant and it has been filed with ulterior motive to drag the OPs in unnecessary litigations and to harass and humiliate the OPS unnecessarily. It is submitted that OPs are not liable to pay the sum of Rs. 66,737/- on account of mediclaimalongwith interest at the rate of 18% per annum from 04.06.2016 till payment thereof and the complainant is also not entitled to receive Rs. 10,000/- towards cost of harassment, correspondence and deficiency in service. It is submitted that the OPs are not liable to pay any claim. It is also submitted that the OP No.3 & 4 have decided the claim as per terms and conditions of the insurance policy and prayed for dismissal of complaint with compensatory costs.
On notice, the opposite parties no.3 & 4 appeared and filed their joint reply wherein several preliminary objections such as not maintainability, complainant is stopped from filing this complaint by his own act and conduct and neither any locus standi, nor any cause of action has accrued to him for filing and maintaining this complaint, has been taken. It has been submitted that the intricate questions of law and facts are involved in the present litigation which can only be decided by the Civil Court after taking extensive evidence of the parties. There is no privity of contract between the petitioner and the answering OPs and there is no deficiency in service on their part. It is submitted that the complainant has not come to this Hon’ble Commission with clean hands and has concealed material and true facts and as such is not entitled to any relief. As per claim documents it has been observed that the procedure was done for correction of refractive error for myopia. Policy terms, highmyopia more than-4 is payable in current claim refractive error for right eye i.e. 2.75 and left eye is 2.75., hence the current claim is not payable. It is also submitted that this complaint is false, frivolous and vexations to the knowledge of the complainant and as such it is liable to be dismissed with special costs. It is alleged that when the complainant did not lodge any claim with the answering OPs, the question of any assurance as alleged in this para of the complaint does not arise. It is further alleged that it is a matter of record and the intimation regarding repudiation of claim was sent to the LIC of India and stated that complainant is not entitled to any claim. Therefore, OPs have prayed for dismissal of complaint with special costs.
3. The parties led evidence in support of their case. Complainant counsel in his evidence has tendered Ex.CW1/A and documents Annexure-A1 to Annexure A8 and closed the evidence on dated 05.11.2018. Ld. Counsel for the opposite party No.1 & 2 has tendered Anneuxre-R1 to Annexure R3 and closed the evidence on dated 02.08.2019. Thereafter, Ld. Counsel for OP No.3 & 4 has tendered Ex.RW1/A and documents Annexure R4 to Annexure R11 and closed the evidence on dated 16.01.2020.
4. We have heard the arguments of learned counsel of the parties and gone through the entire evidence so placed on record by the respective parties very carefully and minutely.
During the course of arguments, the counsel for the parties reiterated the contents of complaint as well as the written statements filed on behalf of the parties and also drawn the attention of this Forum/Commission towards the documents so placed on record by them.
5. We have perused the documents placed on file very carefully and minutely. After hearing arguments and going through the entire case file and perusing the documents so placed on record very carefully and minutely, we have observed that in the present complaint, the claim of complainant is that his son Sandeep was suffering from some eye problem and he consulted in Eye-Q super Specialty Eye Hospital at Hisar. On checking, refraction of both eyes found more than -2.75 and Lasik laser surgery was advised by the treating doctor. Sandeep was operated for Lasik laser surgery on 2.6.2016 and the hospital charged an amount of Rs. 66,737/-towards the Lasik laser surgery. The claim of complainant was lodged with the respondents and after some time, the claim of complainant was repudiated by the insurance company on the ground that the procedure was done for correction of refractive error for myopia. It is further submitted that as per terms and conditions of the policy, high myopia more than -4 is payable and in current claim refractive error of right eye was found -2.75 for the left eye as -3, hence, the current claim is not payable as per terms and conditions of the policy.
In the present complaint, the main contention of the complainant is that the complainant has suffered from refractive error of right eye (OD) i.e. -2.75 and left eye (OS) i.e. -3 and operated from Eye-Q Super Specialty Hospital, Hisar. The Group Mediclaim Policy is Annexure A-6, for the year 2014-15 issued by The New India Assurance Company Limited as a Group Mediclaim policy for LIC employees. The limitation for the payment for cataract surgery was Rs. 60,000/-. Regarding the Lasik laser surgery, the clause of policy (for the year 2014-15 is section 7)….
Sub Limit Clause, which is as under:-
7) “Lasik laser treatment performed to get rid of spectacles and/or contact lenses unless the treatment is for keratotomy of insured having more than (-2) refractive error.”
As per Group Mediclaim Insurance Master policy for the period 2016 to 2017, the relevant clause is 7) Lasik Laser treatment performed to get rid of spectacles and/or contract lenses unless (which is read as under:-)
“the treatment is for keratotomy of insured having more than (-4) refractive error, and for therapeutic reason like recurrent corneal erosions, nebular opacities and non healing ulcer. The maximum amount payable under this section is Rs. 35,000/-per eye”.
Meaning thereby the range regarding refractive error has been changed from -2 to -4 by the New India Assurance Company Limited. The accidental limit was also changed from Rs. 60,000/-to Rs. 35,000/-per eye in the insurance policy for the year 2016-17. We have perused the required and relevant documents placed on record by both the parties. We have also minutely perused the terms and conditions of the policy placed on record by both the parties. In fact, a Group Insurance Mediclaim Master Policy has been purchased by the LIC for their employees. Some terms and conditions have been changed during issuance of the policy for the period 2016 to 2017. A MOU has been signed between LIC of India and respondent Nos. 3 & 4. The changed terms and conditions have not been supplied to the policy holder i.e. the employee of the LIC of India by the respondents regarding the fact that some changes have been made in the terms and conditions of the Mediclaim Insurance Master Policy. No doubt, a MOU has been signed between the LIC and between the New India Assurance Company Limited regarding the Group Mediclaim Policy. But it was prime duty of the respondent Nos. 1 to 4 to inform each member of the Group mediclaim policy holder that certain changes have been made in the terms and conditions of the policy issued by the respondent Nos. 3 & 4 year to year for the benefits of the employees of the corporation, meaning thereby there is deficiency in service on the part of respondent Nos. 1 & 2 that they have not informed their employees regarding the major changes in the group mediclaim policy well within time prior to issuance of the new policy. In fact, when a group mediclaim policy was issued by the insurance company, prior to that MOU has been signed between LIC and the New India Assurance Company Limited. Major changes should be informed by the LIC of India prior to issuance of the new policy. So there is deficiency in service on the part of respondent Nos. 1 & 2. Hence, it is found that there is grave deficiency in service on the part of respondent Nos. 1 & 2 that they have not informed to the employees well within time regarding the changes which took place before issuance of new policy by the New India Assurance Company Limited. Therefore, we are of the considered view that the claim of complainant is genuine one and the complainant is entitled for the relief from the respondent Nos. 1 & 2. Perusal of prayer clause of complaint shows that the complainant is asking to release the mediclaim amount i.e. Rs. 66,737/-, which stands hereby allowed. Accordingly, we hereby direct the respondent Nos. 1 & 2 to make the payment of aforesaid amount of Rs. 66,737/-to the complainant on account of mediclaim bill paid by the complainant to Eye-Q Super Specialty Hospital, Hisar, alongwith an interest @ 9% p.a. from the date of filing of the present complaint i.e. 22.9.2016 till its realization to the complainant. Opposite party Nos. 1 & 2 are further directed to pay Rs.5000/-(Rupees five thousand only) as compensation on account of deficiency in service and Rs.5000/- (Rupees five thousand only) as litigation expenses to the complainant. The above order shall be complied within one month from the date of decision. Certified copies of the order be supplied to the parties free of costs.
File be consigned to the record room after due compliance
Announced in open Commission
Dated: - 8.4.2021
(ShriniwasKhundia) (Nagender Singh)
Member President,
District Consumer Disputes
Redressal Commission, Bhiwani.
