Punjab

Faridkot

CC/18/146

Dr. Romesh Chander - Complainant(s)

Versus

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

Anil Kumar Chawla

09 Apr 2019

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

C. C. No. :             146 of 2018

Date of Institution:   11.09.2018

Date of Decision :       9.04.2019

 

Dr Romesh Chander Garg, aged about 72 yers, son of Amar Nath c/o Amar Hospital, Fauji Road, Kotkapura Tehsil Kotkapura, District Faridkot.

                                                                                   .........Complainant

Versus

National Insurance Co. Ltd. 2^nd Floor, Tota Bargadi Plaza Opposite Petrol Pump, Muktsar Road, Kotkapura Tehsil Kotkapura, District Faridkot through its Branch Manager..                                                                         

.............OP

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum: Sh. Ajit Aggarwal, President,

               Smt  Param Pal Kaur, Member.

 

Present: Sh Anil Chawla, Ld Counsel for Complainant,

              Sh Yash Pal Bansal, Ld Counsel for OP.

 

ORDER

(Ajit Aggarwal, President)

                                        Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against  OPs seeking directions to OPs to make remaining payment of Rs.1,76,000/- on account of insurance claim with interest and for further directing OPs to

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pay Rs.2,00,000/- as compensation for deficiency in service and harassment alongwith litigation expenses of Rs.20,000/-.

2                                                Briefly stated, the case of the complainant is that complainant purchased a Family Medicare Policy from OP for sum assured of Rs.4 lacs valid for the period from 3.02.2018 to 2.02.2019 and during the subsistence of said policy, complainant suffered from cataract in both the eyes and on recommendations of doctor, cataract surgery was conducted on his eyes. First surgery for cataract to his right eye was conducted on 13.02.2018 on which he spent Rs.1,35,000/- and second surgery on his left eye for cataract was conducted on 18.05.2018 and he again spent Rs.1,35,000/-for his second operation. Thereafter, complainant lodged his claim for Rs.2,70,000/- for surgeries conducted upon his eyes i.e Rs.1,35,000/-for each eye with OP and completed all the formalities and furnished requisite documents to them, but Opposite Party cleared his claim only for Rs.47,000/-for each operation and withheld the remaining amount of Rs.88,000/-of each operation with them and thus, total amount of Rs.1,76,000/-is due towards  them which they withheld without disclosing any cogent reason. Ld counsel for complainant submitted before the Forum that since long complainant was using minus spherical and cylindrical lenses and on extensive search, he found that for best distant and near vision without spectacles, multifocal and toric lenses are best and checking his eyes doctor recommended that if he uses monofocal lens then, he would have to use glasses but if multifocal and

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toric lens are used then, there would be no need of glasses for distant and near vision. It is submitted that complainant made several requests to OP to make payment of remaining amount but all in vain, which amounts to deficiency in service and trade mal practice on the part of OP. Complainant has prayed for directing the OP to pay compensation alongwith litigation expenses besides the main relief of making payment of remaining claim amount. Hence, the complaint.

3                                                         The counsel for complainant was heard with regard to admission of the complaint and vide order dated 12.09.2018, complaint was admitted and notice was ordered to be issued to the OPs.

4                                                         On receipt of the notice, the OP filed reply wherein admitted that complainant was insured under mediclaim policy in question and it is also admitted that complainant suffered from cataract and he underwent cataract surgery, but denied all the allegations of complainant being wrong and incorrect and asserted that complainant was eligible to get cashless treatment or reimbursement benefits in case of any hospitalization due to illness or accident covered under the policy. Policy provides that hospitalization expenses incurred has to customary and reasonable for the purpose of payment. Company/TPA has a package rate agreement with hospitals in the city for some specified procedures including cataract, but in present case, complainant opted for expensive procedure which is well over the

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approved rate, despite the availability of standard and effective cataract surgery giving the same outcome. The additional expenses incurred for this expensive procedure are over and above the approved rate for cataract surgery and is therefore not reasonable and equitable for payment from the Insurance Policy. As per policy terms and conditions, toric/multifocal IOL is not admissible and in this case, toric lens is used which is not admissible. It is further averred that only mono-focal lens are sufficient and complainant is entitled for the reimbursement of monofocal lens only and not for reimbursement of toric multifocal lens. Expensive procedure incurred by complainant is beyond the approved rates and complainant is not entitled for reimbursement of same. It is further averred that for non preferred private network cases, the claim is to be settled up to expenses on mono-focal lens only. It is further averred that complainant is stopped for his own act and conduct to file the complaint as claim for both the eye operations of complainant has already been settled as per terms and conditions of the policy. This Forum has no jurisdiction to hear and try the present complaint as complainant is not the consumer of OP and there is no deficiency in service on the part of opposite party. All the other allegations and allegation with regard to relief sought too were refuted with a prayer that complaint deserves to be dismissed with costs.

5                                              Parties were given proper opportunities to prove their respective case. Counsel for complainant tendered in

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evidence her affidavit Ex.C-1 and documents Ex C-2 to C-14 and then, closed their evidence.

6                                                      In order to rebut the evidence of the complainant, Counsel for OP tendered in evidence affidavit of Manjeet Singh Ex OP-1 and documents Ex OP-2 to OP-6 and then, closed the evidence on behalf of OP.

7                                               We have heard the ld counsel for complainant as well as OP-1 and have carefully gone through evidence and documents placed on record by respective parties.

8                                              From the careful perusal of the record and after going through the evidence and documents, it is observed that               

9                                               The case of the complainant is that complainant was insured under the policy in question and he got conducted cataract operation for his both eyes at Brar Hospital, Kotkapura and complainant spent about Rs.2,70,00/-on his treatment. Complainant lodged claim with Ops, but Ops made payment of Rs.94,000/-only and withheld the reimbursement of remaining amount. Grievance of complainant is that despite repeated requests, OP have refused to make payment of remaining claim amount to complainant which amounts to deficiency in service. He has prayed for accepting the complaint. In reply, OP have stressed mainly on the point that they have already paid the reasonable amount admissible as per rules and as per

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terms and conditions of policy and nothing is due towards them. Complainant is not entitled for further relief of claim amount as sought by him. Moreover, they have stressed on the point that complainant opted for expensive procedure which is beyond the approved rates. The additional expenses incurred by complainant which are beyond the approved rate for cataract surgery are not reasonable  because as per policy terms and conditions of Policy, toric/multifocal IOL is not admissible and in this case, toric lens is used which is not admissible. Only mono-focal lens are sufficient and complainant is entitled for the reimbursement of monofocal lens only and not for reimbursement of toric multifocal lens. Reasonable reimbursement as per terms and conditions of policy has already been made to complainant. It is reiterated that there is no deficiency in service on the part of OPs and prayed for dismissal of complaint with costs.

10                                                          From the careful perusal of evidence and documents placed on record and pleading made by parties in above discussion, it is observed that there is no dispute regarding insurance of complainant with OPs. OP have themselves admitted that he was insured with them as per Family Medicare Policy. The case of the complainant is that he was suffering from cataract in both the eyes which needs to be removed with surgery. He was using spectacles since long time of minus spherical and cylindrical lenses. The doctor informed complainant that if

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he got mono focal lens then he would need glasses for reading purpose and if uses multifocal lens then, he would be able to get best distant and near vision without glasses. As such, complainant opted for Toric Multifocal Lens and spent Rs.1,35,000/-for surgery of his each eye i.e total Rs.2,70,000/-, but out of this amount, the OP paid only Rs.47,000/-for each eye and retained the balance amount of Rs.88,000/-for each operation. The version of the OP is that as per policy, the complainant is eligible to get benefit of hospitalization on customary and reasonable rates. The basic purpose of cataract surgery is to restore vision of insured and opposite party is liable to pay claim for standard and effective treatment which is needed and not for special and expensive treatment. In the case of cataract, the standard procedure is that monofocal lens are used in conventional surgeries as per terms and conditions and Insurance Company is liable to only pay the expenses for monofocal lens, but in the present case, complainant opted for expensive and special multifocal lens which are not used in standard procedure and he is not entitled to claim expenses for the same. He is entitled only for expenses as per mono focal lens which are already paid to the complainant as per customary and reasonable rates and now, nothing is due towards the OP. It is correct that under the Insurance Policy, complainant can claim only for standard and effective treatment and not for any special or expensive treatment. In standard treatment of cataract, only mono focal lens are used but the complainant opted for special multi focal lens which are not admissible and he is entitled only for expenses as per mono focal lens.

 

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Now, the version of the OP is that they have paid Rs.47,000/-for each eye as per multi focal lens as per customary and reasonable rates. They  produced Claim Approval Letter Ex Op-5 where they assessed the rates of lens only Rs.10,000/- as per reasonable and customary rates. Further they approved consultation charges as Rs.25,000/-instead of Rs.48,000/- as claimed by the complainant but they have nowhere explained that how they assessed these rates as reasonable and customary. They have not produced any document to prove that they have assessed these rates as per prevalent market rate.

11                                                 From the above discussion, we come to the conclusion that complainant cannot claim the expenses for his surgery for multi focal lens and he is entitled only for expenses of mono focal lens. However, the amount paid by the OP alleging to be as per customary and reasonable rates also does not seem to be genuine and is lesser. Hence, present complaint is hereby partly allowed. Opposite party are directed to pay Rs.60,000/- more to complainant for his treatment of cataract in both the eyes alongwith interest at the rate of 9 % per anum from the date of filing the present complaint till final realization. They are further directed to pay Rs.3,000/-to complainant as consolidated compensation for harassment and mental agony suffered by him as well as for litigation expenses incurred by him. Compliance of this order be made within prescribed period of 30 days of receipt of the copy of this

 

 

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order, failing which complainant shall be entitled to proceed under section 25 and 27 of the Consumer Protection Act. Copy of the order be supplied to parties free of cost. File be consigned to record room.

Announced in Open Forum

Dated : 9.04.2019

 

(Param Pal Kaur)              (Ajit Aggarwal)

                                        Member                          President