Punjab

Ludhiana

CC/14/458

Malika Singh - Complainant(s)

Versus

National Ins.Co.Ltd - Opp.Party(s)

28 Jan 2015

ORDER

THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

CC No: 458 of 26.06.2014

                                                                     Date of Decision: 28.01.2015

 

Malika Singh aged about 25 years, d/o Sh.Jaspal Singh, resident of 1877/1, Street No.5, Maharaj Nagar, Ludhiana.

                                                                                      … Complainant

                                      Versus

1. M/s National Insurance Company Limited, Registered and Head Office at 3, Middleton Street, Kolkata, through its Chairman/Managing Director.

2. M/s National Insurance Company Limited, Branch Office7, G.T.Road, Dhandari Kalan, Ludhiana.

                                                                             … Opposite parties

 

COMPLAINT UNDER SECTION 12 OF THE

CONSUMER PROTECTION ACT, 1986.

 

Quorum:     Sh.R.L.Ahuja, President

                   Sh.Sat Paul Garg, Member

 

Present:       Sh.A.K.Kalsi, Advocate for complainant.

                   Sh.Gurjeet Singh Kalyan, Advocate for OPs.

 

                   

                        ORDER

 

(S.P.GARG, MEMBER)

 

1.                The present complaint under section 12 of The Consumer Protection Act (hereinafter in short to be referred as ‘Act’) has been filed by Sh.Malika Singh d/o Sh.Jaspal Singh, resident of 1877/1, Street No.5, Maharaj Nagar, Ludhiana (hereinafter to be referred as ‘complainant’) against M/s National Insurance Company Limited, Registered and Head Office at 3, Middleton Street, Kolkata, through its Chairman/Managing Director and others (hereinafter to be referred as ‘OPs’)-directing them to pay Rs.2,50,000/- alongwith interest @ 24% p.a. and to pay Rs.25,000/- as litigation cost to the complainant alongwith any other additional or alternative relief in addition to the relief already prayed for.

2.                Brief facts of the complaint are that Smt.Inder Pal Kaur mother of the complainant purchased an insurance policy bearing no.401314/48/13/8500000114 issued on 21.5.13 and it was valid upto 20.05.14. The policy was for three persons i.e. Smt.Inder Pal Kaur mother of the complainant, Jaspal Singh father of the complainant and complainant herself. The Ops have been insuring the above said three persons continuously since 21.5.03 and every year a new policy was being issued without any break after completion of all the formalities and legal requirements. The complainant’s eye sight became defective and the doctor advised her to get the eyes sight corrected through Lasik Surgery for the treatment of refractive error. The complainant got herself treated as per the medical advise at Centre for Sight, 1^st Floor, Sandhu Tower, B-XX-336, Ferozepur Road, Near Ansari Plaza, Ludhiana on 22.02.14 and the complainant spent Rs.25,000/- on her treatment. The complainant applied for claim with the OPs, but her claim was rejected on account of that the treatment of correction of eye sight falls in exclusion clause 4.6 and rejected the claim of the complainant, vide letter dated 31.3.14. The rejection of the claim of the complainant is illegal on the fact of it. Claiming the above act as deficiency in service on the part of the Ops, the complainant has filed this complaint.

3.                On notice of the complaint, Ops appeared through their counsel and filed written statement taking preliminary objections that the present complaint is not maintainable in the present form for want of cause of action; complainant has not come to the Forum with clean hands and suppressed the material facts from the Forum; as per the documents submitted by the complainant, the complainant has obtained mediclaim policy from the Ops and during policy period, she was admitted in Centre for Sight, Ludhiana for surgery/treatment of Refractive Error on 22.2.14. The Ops appointed/deputed its service provider Park Mediclaim TPA Pvt. Ltd. to entertain, register, process and decided the claim in terms of policy. The Ops processed the claim and found that as per policy terms and conditions as under:-

            “Individual Medicalim policy does not cover the expenses incurred for correction of Eye Surgery, vide exclusion clause 4.6. Hence the claim is not admissible.”

 

                   The service provider also recommended with the above said observations, vide letter dated 28.3.14. On receipt of the claim file, the officials of the OPs repudiated the claim of the complainant in terms of the policy, vide letter dated 31.3.14, 20.06.14 under exclusion clause 4.6.

4.                Ld. counsel for complainant has adduced the evidence by way of duly sworn affidavit of complainant Sh.Malika Singh Ex.CA, wherein, the same facts have been reiterated as narrated in the complaint alongwith documents Ex.C1 to Ex.C3. On the other hand, Ld. counsel for Ops has adduced the evidence by way of duly sworn affidavit of Sh.Parmod Jain, Branch Manager, BO-III, National Insurance Co. Ltd. D.O.I, Ludhiana Ex.RA, wherein, the same facts have been reiterated as narrated in the written statement and further deposed that the complainant had obtained mediclaim policy from the complainant and during the policy coverage mother of the complainant was admitted in Centre For Sight, Ludhiana for the surgery/treatment of Refractive Error on 22.2.14 and as per the terms of the policy OPs rendered his service provider Park Mediclaim to entertain, process the claim in terms of the policy and the service provider rejected the claim under clause 4.6 of the policy and conveyed the same, vide their letter dated 28.3.14 to the OPs, who applied their mind and repudiated the claim, vide letter dated 31.3.14. There is no deficiency in service on the part of the OPs and also attached documents Ex.R1 to Ex.R6.

5.                Case was fixed for arguments. Ld. counsel for the complainant argued orally that Lasik surgery was necessary for the insured and it was not for the correction of eye sight, but was for the treatment of eyes of the complainant. As such, exclusion clause 4.6 of the policy is not attracted in this case and the repudiation of the claim if unjustified and further relied upon the judgements passed in cases titled as M.Sitarama Reddy Vs United India Insurance Company Ltd. and others-III (2005) CPJ 112 (NC), whereby it was held that Company liable to reimburse loss damage etc. except causes specifically excluded and there should be no ambiguity and also relied upon the judgement passed in case titled as National Insurance Co. Ltd. Vs Mukesh Kumar Arora-II (2005) CPJ 723 (Punjab State Commission, Chandigarh).

6.                Refuting the allegations leveled by the complainant, Ld. Counsel for the OPs argued that there is no deficiency in service on the part of the OPs. OPs specifically mentioned the clause 4.6, wherein exclusion of treatment has been detailed is not covered, which is reproduced as under for the sake of convenience:-

            “Exclusion 4.6- Surgery for correction of eye sight, cost of spectacles, contact lenses, hearing aids etc.”

                   Ld. counsel for OPs also relied upon the judgement passed in case titled as Deokar Exports Pvt. Ltd. Vs New India Assurance Company Ltd.- 2009 (2) CLT 15 passed by Supreme Court of India.

7.                We have gone through the pleadings of the complainant as well as defence taken by the OPs and have also perused the entire record placed on file.

8.                It is evident that the complainant availed the Insurance policies from the OPs since the year 2003 and complainant was also availed the insurance policy bearing no.401314/48/13/8500000114 valid from 21.05.13 to 20.05.14 in continuation of the previous policies. The eye sight of the complainant became defective and the Lasik surgery for the treatment of the refractive error was performed on the complainant and she spent Rs.25,000/- on her treatment.  But her claim was rejected on the ground that the treatment of correction of eye sight falls under the exclusion clause 4.6 of the policy. The rejection of the claim of the complainant is not tenable, since it was Lasik surgery for the correction of refraction error for the correction of eye sight. In the policy for the exclusion clause 4.6 there is no mention about the exclusion of this type of surgery for the correction of refraction error which the OPs failed to prove by any medical expert that this type of Lasik surgery falls within the exclusion clause and all this issue is not free from ambiguity as the disease is not specifically excluded as held in the case M.Sitaram Reddy Vs United India Insurance Company Ltd.

9.                Sequel to the above discussion, the present complaint is allowed and OPs are directed to settle the claim of the complainant. Further OPs are directed to pay Rs.2000/-(Two thousand only) as compensation and litigation expenses, compositely assessed to the complainant. Order be complied within 30 days of receipt of the copy of the order, which be made available to the parties, free of costs. File be consigned to record room.

 

                   (S.P.Garg)                                         (R.L.Ahuja)

                     Member                                             President

Announced in Open Forum.

Dated:28.01.2015 

Hardeep Singh