ORDER
NIPUR CHANDNA, MEMBER
Complainant was a mediclaim policy holder of the OP company vide its policy no. 350304/48/12/8500003358 for a period from 10.1.2013 to 09.1.2014. it is alleged by the complainant that his son was admitted on 5.7.2013 to Shroff’s eye centre, Kailash colony, Delhi for the treatment/ surgery of Kerataconus in his left eye and he was discharged on the same day after surgery. It is further alleged by the complainant that he filed his claim for reimbursement with the OP. The OP company vide letter dated 6.8.2013 repudiated the claim with the reason that :-
“It is an eye correction surgery and it falls under clause no. 4.6 of the terms and conditions of the policy.”
It is alleged by the complainant that he wrote several letters to the OP company and insisted its office for reimbursement of his claim but all in vain.
The complainant, therefore, approached this forum for the redressal of his grievances.
Complaint has been contested by the OP. Para no. 5 of the preliminary objection of the written statement filed by the OP company is relevant for the disposal of the case and same is reproduced as under:-
5. That the present complaint has been filed on the ground of Individual Mediclaim policy bearing No.350304/48/12/8500003338 valid from 10.01.2013 to 09.01.2014 covering the risk of Shri Vinod Anand, Neelam, Karan 8s Sakshi. The said policy was issued along with terms and condition and the claim, if any, was always subject to terms and condition of the policy. A request for pre-authorization for a sum of Rs. 25000/- was received by the TPA on 05.07.2013 from the Shroff Eye Centre, which was declined by the TPA on the ground that surgery for correction of eye-sight are not payable under Exclusion Clause No. 4.6 of policy terms and conditions. Thereafter the claim was lodged along with documents by the complainant with the Safeway TPA Service Pvt. Ltd. The TPA of the National Insurance Co. Ltd. go through the papers submitted by the complainant and again reiterated the same facts as the son of the complainant was admitted in Sharoff Eye Centre and discharged on the same day after going procedure of correction of eye-sight. Therefore, the claim fall under Exclusion Clause No. 4.6 of policy terms and conditions which is as under:-
The company shall not liable to make any payment under this policy in respect of any expenses whatsoever incurred by any person in
connection with or in respect of : Surgery for correction of eyesight, cost of spectacles, contact lenses, hearing aids etc.
Therefore, as the claim of the complainant was not payable. the claim of the complainant was repudiated and informed the complainant accordingly. Therefore, the claim was not payable. Therefore, present claim is not maintainable and is liable to be dismissed.
Both the parties have filed their evidence by way of affidavit.
We have heard the arguments advanced at the bar and have perused the record.
The counsel for the OP has contended that surgery of the correction of eye-sight are not payable under exclusion clause no. 4.6 of the policy terms and conditions. It has further contended that since the case of the complainant falls under the category of exclusion clause no 4.6 of the policy, the OP company has rightly repudiated the claim of the complainant.
The counsel has further prayed that as there is no deficiency in service on the part of the OP, the present complaint is liable to be dismissed.
During the course of the argument, the counsel for the complainant has placed on record documents relating to the treatment of the correction of right eye of complainant’s son.
The counsel for the complainant has contended that the son of the complainant had undergone a surgery for Keratoconus of right eye in Shroff Eye Centre on 28-7-2014, and for this treatment the OP company had not only provided the cashless facility but has also settled his remaining claim.
The learned counsel for the OP has not rebutted the fact that the claim lodged by the complainant for similar treatment of the right eye of the complainant’s son has been paid. It is, therefore, clear that the repudiation of the claim of treatment of the left eye of the complainant’s son has been unjustifiably repudiated.
We , therefore, hold OP guilty of deficiency in service and direct it as under:-
- To pay to the complainant a sum of Rs. 29,996/- along with interest @ 10% for the date of filing of this complaint i.e. 18-3-2015 till payment.
- To pay to the complainant a sum of Rs. 10,000/- for pain and mental agony suffered by him.
- To pay to the complainant a sum of Rs. 5,000/- as cost of litigation.
The above amount shall be paid by the OP to the complainant within 30 days from the date of this order failing which OP shall be liable to pay interest on the entire awarded amount @ 10% per annum from the date of this order till the date of payment. If OP fails to comply with the order within 30 days, the complainant may approach this Forum u/s 27 of the Consumer Protection Act, 1986.
A copy of this order be made available to both the parties free of cost as per law.
Announced on _________________.
