Passed by Shri Atul D. Alsi, Hon’ble President.

1. The complainant has filed present complaint against repudiation of reimbursement of claim for the Cataract eye surgery of complainant left eye of Rs.34,222/- and thereby claiming compensation with cost.

The story in short is as under

2. The complainant was insured himself under health insurance policy bearing policy no. PROHLRO10440975 for the period between 29.9.2018 to 28.9.2019 for the sum insured of Rs.4,50,000/-as a filmily floater type of insurance.  Due blurring vision in left eye the complainant himself  visited the Doctor in Madhav Natralaya Eye Institute and Research Centre as of SENILE for cataract in left eye  therefore on dated 27.8.2019 the complainant underwent a Cataract Surgery and incurred expenses of Rs.34,222/-.  The complainant submitted his insurance claim alongwith copy of discharge summery and other relevant documents but on 26.9.2019 the O.P. repudiated the insurance claim for the reason of non discloser of history of right eye injury and 6 injections were given to right eye before 30 years. The complainant issued legal notice on dated 9.12.2019 and requested to refund the medical expenses but omission on the part of O.P. the complainant compel to file present complaint.
3. The O.P filed reply and denied allegations and submitted that the complainant has undergone Cataract surgery at Madhav Natralaya Eye Institute and Research Centre on dated 27.8.2019 and submitted insurance claim. On scrutiny it was observed that the complainant has history of right eye injury and 6 injections were given to him before 30 years ago. The complainant has suppressed these fact, the compliant concealed the fact in proposal form hence as per general terms and condition 8-A of the policy the repudiation of insurance claim does not amount to deficiency of service. Therefore the present compliant is deserved to be dismissed with cost.

                                          REASONING

4. The O.P. issued the insurance policy after conducting medical examination of insured by the doctors of O.P.  The complainant was operated Cataract Surgery of left eye at  Madhav Natralaya Eye Institute and Research Centre on dated 27.8.2019.  The insurance claim of complainant came to be rejected for the reason of  non discloser of right eye injury and 6 injections were given to right eye before 30 years. There is no nexus of right eye injury and 6 injections were given to right eye for the blearing vision in left eye.  The O.P. has failed to put its contention with proper opinion of expert Doctors on affidavit for the reason of rejection of claim to prove its contention, therefore rejection of insurance claim with intention to avoid the liability does amount to Unfair Trade Practice on the part of O.P. therefore O.P. is liable to pay the medical expenses of Rs.34,222/- towards operation charges and medical expenses alongwith compensation for mental torture amounted to Rs. 15,000/- alongwith cost of litigation of Rs.10,000/-. Hence the  following order.

                                          ORDER

1. Complaint partly allowed
2. O.P. is directed to pay the amount of Rs.34,222/- as reimbursement of expenses incurred for the Cataract Eye operation of complainant under the  insurance  policy. 
3. O.P. is also directed to pay an amount of Rs.15,000/- for mental torture and agony alongwith cost of litigation of Rs.10,000/- to the complainant.

Copy of the order be supplied to both the parties free of costs.