Date of Filing: 01/10/2015
Date of Order: 03/11/2017
ORDER
BY SRI.SYED ANSER KHALEEM, PRESIDENT
1. This is the complaint filed under Section 12 of the Consumer Protection Act, 1986 against the Opposite Parties (herein referred in short as O.Ps) alleging the deficiency in service and prays for orders to direct the O.Ps to reimburse the medical expenses of Rs.1,20,000/- towards the cataract surgery and to pay compensation of Rs.50,000/- along with legal notice charges and cost of proceedings to an extent of Rs.10,000/-.
2. The brief facts of the complaint are that the complainant after the retirement is practicing as an advocate and also commercial tax consultant. The complainant states that, O.Ps are a company incorporated under the Companies Act and engaged in the business of Health and Allied Insurance, undertake to cover the risk of hospitalization and medical expenses incurred by the its policy holder. The grievance of the complaint is that, he had taken Senior Citizen Red Carpet insurance policy from the O.Ps vide its policy No. P/141115/01/2013/009274 for the period from 12.2.2014 to 11.2.2015 to cover his medical expenses in a sum of Rs.4,00,000/- and for which complainant paid premium amount of Rs. 17,416/-. Further states that there was no claim made by the complainant for the first year of the insurance policy and the complainant renewed the insurance policy for the second year also from 12.2.2015 to 11.12.2016 and the O.Ps issued the renewed insurance policy vide policy No.P/141115/01/2014/009202.
3. It is stated that, the complainant underwent cataract surgery with IOL (Implantation under Tropical Anesthesia) to both his right and left eyes at Mirle Eye Care, St. Johns Road Bangalore on 13.3.2015. The cost of surgery was Rs.60,000/- per eye and he incurred medical expenditure of Rs.1,20,000/- . Further complainant made two separate claim for reimbursement of expenses vide claim No.0293492 for his right eye and claim No. 0293489 for left eye on 13.4.2015. The complainant states that, he has also underwent bypass heart surgery in Fortis Hospital Bangalore on 29.7.2013 and he had disclosed the said fact to the O.Ps in the insurance claim. Hence, he states that, O.Ps were required to reimburse the sum of Rs.1,22,000/- to the complainant towards the expenses incurred by him for the aforesaid cataract surgery. But the O.Ps failed to reimburse the said expenses to the complainant and instead called upon him vide letter dated 18.4.2015 to furnish the copies of discharge summary, ECG, ECO report relating to bypass surgery and the complainant complied with all the requirements of the O.Ps. It is stated that, whereas the O.Ps failed to reimburse the expenses to the complainant. Hence the complainant got issued the legal notice dated 7.2.2016 and called upon O.Ps to reimburse a sum of Rs.1,22,000/- and a sum of Rs.50,000/- towards mental agony and harassment and for other reliefs. Further The O.Ps settled the claim for Rs.15,000/- and sent the Demand Draft but that D.D amount was misused by the some miscreants as the D.D not received by the complainant. Hence this complaint.
4. Upon issuance of notice O.Ps entered their appearance through their counsel and filed the version. In the version it is contended that, though the insurance policy obtained by the complainant from the O.Ps but the complainant failed to state the policy terms and conditions. It is contended that for cataract surgery the limit incurred under one policy period and the complaint is filed by suppression of material facts. As per the terms of the policy payable against the cataract surgery and it is maximum limit of Rs.15,000/- and hence contended that there is no deficiency in service on the part of the O.Ps. Further contended that, there is no cause of action accrued to the complainant to file this complaint. Further O.Ps contended that, as per the terms and conditions of the policy they have issued D.D for Rs.15,000/- through professional courier to the complainant and hence contended that they paid the amount of Rs.15,000/- entirely. On the basis of other grounds by denying the allegations of the complainant ultimately O.Ps prays for dismissal of the complaint.
5. In order to substantiate the case of the parties and both parties filed their affidavit evidence and we also heard the arguments.
6. On the basis of the pleading of the parties, the following points will arise for our consideration is:-
(A) Whether the complainant has proved
deficiency in service on the part of the O.Ps?
(B) Whether the complainant is entitled to
the relief prayed for in the complaint?
(C) What order?
7. Our answers to the above points are:-
POINT (A) & (B) : In the Negative.
POINT (C): As per the final order
for the following:
REASONS
POINT No. (A) & (B):-
8. On perusal of the pleadings of the parties it is not in dispute that the complainant by availing the service of the O.Ps has taken the insurance policy under Senior Citizens Red Carpet Insurance Policy bearing Policy No. P/141115/01/2013/009274 for the period from 12.2.2014 to 11.2.2015.
9. Further it is also not in dispute that the complainant underwent Cataract Eye surgery i.e. I.O.L (Implantation under Tropical Anesthesia) for his both eyes and incurred medical expenditure of the Rs.1,20,000/-. Thereafter the complainant filed claim papers with the O.Ps and the O.Ps refused to reimburse the medical expenditure of Rs. 1,20,000/- which leads to filing of this Complaint.
10. Per-contra, O.Ps contended that, the policy issued to the O.Ps with certain terms and conditions. Hence, O.Ps contended that, the complainant only eligible for Rs.15,000/- to his cataract surgery.
11. In order to prove the case of the complainant and the complainant filed his affidavit evidence by reiterating all the facts narrated in the complaint. The O.Ps also filed its affidavit evidence and deposed that, almost similar facts stated in the version.
12. The crux of the matter is to consider whether complainant is entitled for the medical expenditure incurred for his cataract surgery to an extent of Rs.1,20,000/- as per the terms of the insurance policy in question.
13. It is worth to note that, insurance is a contract based on public policy and hence, both parties will binds to the contract. In a catena of decisions of the Hon’ble National Commission as well as the Apex Court of India held that: ‘the terms and conditions of the contract construed strictly and there is no scope to interpret beyond its agreed terms and conditions.’
14. The O.Ps also filed terms and conditions of the Senior Citizen Red Carpet policy in support of their evidence to substantiate the case. On perusal of the terms and conditions under the head note of Clause-1: COVERAGE: it reads thus:
- “Room, Boarding expenses as provided by the Hospital/Nursing Home at 1% of the sum insured subject to a maximum of Rs.4,000/- per day.
- ICU charges up to 2% of the sum insured per day.
- Nursing expenses.
- Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialist fees subject to a maximum of 25% of he sum insured per hospitalization
- Anaesthesia, Blood, Oxygen, Operation Theatre charges, Surgical Appliances, Medicines and Drugs, Diagnostic Materials and X-ray, Dialysis, Chemotherapy, Radiotherapy, cost of pacemaker and similar expenses subject o a maximum of 50% of the sum insured per hospitalization.
- Emergency ambulance charges up-to a sum of Rs.600/- per hospitalization and overall limit of Rs.1200/- per policy period for transportation of the insured person by private ambulance service when this is needed for medical reasons to go to hospital for treatment provided such hospitalization claim is admissible as per the policy.
- A sum equivalent to 7% of the hospitalization expenses incurred comprising of Nursing charges, surgeon/consultant fees, Diagnostic charges medicines and drugs only subject to a maximum of Rs.5,000/- per occurrence towards post hospitalization medical expensive wherever recommended by the attending Medical Practitioner.
Where package rates are charged by the hospitals the post Hospitalisation benefit will be calculated after taking the room and boarding charges at Rs.4,000/- pr day.
Expenses on Hospitalization for minimu period of 24 hours are admissible. However this time limit will not apply for Dialysis, Chemotherapy, Radiotherapy, Cataract surgery, Dental Surgery, Lithotripsy (Kidney stone removal) Tonsillectomy, Cutting and Draining of Abscess, Liver Aspiration,
Pleural Effusion Aspiration, Colonoscopy, Sclerotheraphy, taken in the hospital/Nursing Home and the Insured in discharged on the same day.
The amount payable respect of the following treatment is up to the limit mentioned there against.
Cataract Surgery Rs.15,000/- in respect of the one or both eyes in the entire policy period.
Lithotripsy (Kidney stone removal)– Rs.20,000/-
Tonsillectomy Rs. 7,500/-
Cutting and Draining of Abscess Rs.1,500/- Liver Aspiration RS.2,000/
Pleural Effusion Aspiration Rs.2,000/-
Colonoscopy Rs.2,000/-
Sclerotheraphy Rs.5,000/-
15. On perusal of the above terms and conditions in Clause-1 of COVERAGE, wherein which it is clearly mentioned that “Cataract Surgery Rs.15,000/- in respect of the one or both eyes in the entire policy period.” Hence as per the policy terms and conditions complainant is entitled for Rs.15,000/- only. However the O.Ps contended that they have already sent the DD for an amount of Rs.15,000/- through professional courier to the complainant, but the complainant stating that he has not received the said amount. It is worth to note that any DD/Cheque sent to the beneficiary that will payable through account payee cheque or it may be encashed in their bank, if such being case complainant if not received the amount at least he has to file statement of account in order to show that the said DD amount is not received. However on perusing the copy of the professional courier endorsement it clearly discloses on 6.7.2016 the article consisting of the DD delivered to the complainant, but the complainant did not place any rebuttable evidence in order to falsify the case of the complainant. Furthermore one who alleges the deficiency in service the burden of proving always lies on the complainant himself. View from any angle complainant failed to prove deficiency of service on the part of the O.Ps and hence he is not entitled for the relief as sought in the complaint. Accordingly we answered these Points in the Negative.
POINT No. (C):
16. On the basis of answering the Points, we proceed to pass the following:-
ORDER
- The complaint is hereby dismissed no order as to cost.
- Copy of this order to both parties free of cost.
(Dictated to the Stenographer, transcribed and computerized by him, corrected and then pronounced by us in the Open Forum on this the 3rd Day of November 2017)
MEMBER MEMBER PRESIDENT
*Rak
