C O M M O N O R D E R
PER SHRI. S.M. RATNAKAR – HON’BLE PRESIDENT
1) Both these complaints can be decided by common order as in both the complaints the parties to the complaints are the same and the claims have been made on the similar facts.
2) In Complaint No.86/2012 an amount of Rs.49,210/- and in Complaint No.87/2012 an amount of Rs.52,600/- of the principal claim amount with interest @ 18% p.a. from the date of filing of the complaint till it’s realization has been claimed against the Opposite Parties by the Complainant. The Complainant has also prayed compensation for mental agony, harassment, etc. to the tune of Rs.1,00,000/- in each complaint and cost of Rs.50,000/- in each complaint against the Opposite Parties.
3) According to the Complainant, the Complainant had obtained insurance policy from the Opposite Parties as per Exh.‘A’ for the period 19/04/2010 to 18/04/2011. It is submitted that as the Complainant was suffering eye problem she was required to undergo Eye Cataract Operation of her both eyes and the left eye treatment was obtained between 25/10/2010 to 26/10/2010 and right eye treatment was obtained between 22/11/2010 to 23/11/2010. An amount of Rs.97,814/- was spent for the treatment of left eye and an amount of Rs.98,014.75 for the treatment of right eye. The treatment was taken at Banaji Eye Care at the time of both Cataract operations. The hospital bills and medical bills are filed with the complaint at Exh.‘B’ colly. (in both complaints). The Complainant thereafter, lodged her claims with the Opposite Parties for the above referred amount as per Exh.‘C’(in both complaints). It is submitted that the Opposite Party No.2 on behalf of Opposite Party No.1 by letter dtd.09/09/2011 issued to the Complainant forwarded cheque for Rs.45,214/- for the treatment of left eye and by letter dtd.10/08/2011 sent cheque of Rs.48,804/- to the Complainant. It is alleged that the Coplainant by letters dtd.29/08/2011 and 19/09/2011 had informed to the Opposite Party No.2 that she had accepted the cheques for both the claims under protest. The copies of the said letter are filed at Exh.‘D’ colly.(in both complaints). It is submitted that the deduction made by the Opposite Parties in respect of both the claims is illegal, arbitrary and without any basis as the policy was taken by the Complainant to cover ailments to the extent of Rs.5,00,000/-. According to the Complainant deductions made in both the claims are not as per the terms of the policy. The Complainant has therefore, prayed the reliefs claimed in para 2 of this order against the Opposite Parties.
4) The Opposite Parties though served remained absent hence, both the complaints were proceeded ex-parte against the Opposite Parties. Thereafter, Shri.Gorvankol, Ld.Advocate appeared on behalf of Opposite Party No.1 and filed written arguments on behalf of Opposite Party No.1. The Complainant has filed affidavit of evidence and written argument. We heard the oral arguments of Shri. Ankush Navghare, Ld.Advocate for the Complainant and Shri. Gorvankol, Ld.Advocate for the Opposite Party No.1. We have perused the documents filed in the complaint.
5) While considering the claim made by the Complainant in both the complaints it is necessary to be taken into consideration that while forwarding the cheque of Rs.48,804/-(C.No.86/2012) and of Rs.45,214/- (C.No.87/2012). The Opposite Party No.2 have as per the documents at Exh.‘D’ at page 19 (C.No.86/2012) and at page 22 (C.No.87/12) has specifically shown non admissible amount and the reasons thereof. Shri.Gorvankol, Ld.Advocate for the Opposite Party No.1 in his argument pointed out the policy Clause No.3.12. He made submission that the copy of the policy document (terms and conditions) is placed on record with written argument at Exh.‘D’. He pointed out that as per the terms and conditions in the policy, the Opposite Party No.2 had made reasonable and proper deduction in the exorbitant claim lodged by the Complainant. The advocate for the Complainant - Shri. Navghare made submission that the bills have been produced by the Complainant showing that he had incurred the expenditure for the Cataract Eye Treatment. He thus, submitted that the Opposite Party is liable to pay all the expenditure which the Complainant has incurred. Considering the controversy between the parties in our view the terms of policy issued by the Opposite Party No.1 are required to be taken into consideration. Clause No.3.12 of the policy is as under –
“Reasonably and customary expenses: means reasonably and customary surgical/medical treatment expenses within the scope of cover of this policy to treat the condition for which the insured person was hospitalized.
In the bill produced by the Complainant Surgeon charges are shown Rs.25,000/-. The said charges are of one day i.e. 25/10/2010 and 22/11/2010 each O.T. charges are also shown to the tune of Rs.14,000/-. Intraocular Lens charges have been shown for each eye to the tune of Rs.35,000/-. The said charges and other charges claimed in the claims lodged by the Complainant to the Opposite Parties in our view appears exorbitant for the reasons stated in the deduction sheet issued by the Opposite Party No.2 and in view of the aforesaid Clause No.3.12 and Clause No.1 in the terms and conditions of the policy being non admissible have been properly deducted by the Opposite Parties. We therefore, hold that the claim made by the Complainant in each complaint is not justifiable as the Opposite Parties have acted fairly and within the ambit of the terms and conditions of policy. The deducted amount of each claim lodged by the Complainant as shown in the deduction sheet therefore cannot be held as arbitrary. The Complainant has failed to prove any unfair trade practice on the part of Opposite Parties. In the result we hold that the both the complaints are liable to be dismissed. The following order is therefore, passed –
O R D E R
i. Complaint No.86/2012 & 87/2012 are dismissed with no order as to cost.
ii. Certified copies of this order be furnished to the parties.
