Delhi

East Delhi

CC/524/2013

SHYAM SUNDER SHARMA - Complainant(s)

Versus

NEW INDIA ASS. - Opp.Party(s)

27 Sep 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

C.C. No. 524/2013

 

1.     2.     3.     4.	SHRI SHYAM SUNDER SHARMA (NOW DECEASED) Through LRs.   SMT. SHARDA SHARMA W/O LATE SHRI SHYAM SUNDER SHARMA   SMT. RAJANI SHARMA D/O LATE SHRI SHYAM SUNDER SHARMA   SMT. RITU SHARMA D/O LATE SHRI SHYAM SUNDER SHARMA   SH. AKASH SHARMA S/O LATE SHRI SHYAM SUNDER SHARMA   ALL RESIDENTS OF;- A-90, RADHEY SHYAM PARK EXTENTION, DELHI - 110051	….Complainant
Versus
	THE BRANCH MANAGER, NEW INDIA ASURANCE COMPANY LTD. A-74, MAIN ROAD, KANTI NAGAR, KRISHNA NAGAR, DELHI - 110051	……OP

 

 

Date of Institution: 21.06.2013

Judgment Reserved on: 14.09.2022

Judgment Passed on: 27.09.2022

                  

CORUM:

Sh. S.S. Malhotra (President)

Ms. Ritu Garodia (Member)

Sh. Ravi Kumar (Member)

 

Order By: Shri S.S. Malhotra (President)

 

JUDGEMENT

1. By this order I shall dispose off the present complaint filed by the Complainant, (since deceased and now through LRs) alleging deficiency in service by the OP in repudiating the claim of the Complainants w.r.t. treatment of his eyes.
2. Before coming to the fact, it is brought on record that the Complaint was originally filed by Sh. Shyam Sunder Sharma who during the pendency of the proceedings expired on 12.09.2013 and an application for substituting the LR was filed which was allowed and therefore now there are four Complainants as mentioned in the amended Memo of Parties, and would be referred as ‘Complainants’. 
3. Brief facts stated by the Complainants in the complaint are that original Complainant was a senior citizen, he had a medical claim policy No. 32030334120100000095. He suffered an eye ailment and was taking treatment from Dr. Rajendra Prasad Centre for Pathalmic Science, AIIMS, New Delhi and he was admitted for treatment on 24.09.2013 and was discharged on the same day.  The bill of the treatment was submitted to the OP with claim form on 12.10.2012 but OP did not give any response and ultimately the legal Notice was sent through the Counsel on 10.02.2013 to the OP but no response was given and as such the present claim was filed thereby claiming an amount of Rs.37,717/- towards medical charges along with compensation towards mental agony, to the extent of Rs. 25,000/- and litigation expenses with interest.
4. OP has filed its written statement taking preliminary objection that the complaint is not maintainable, as he has not complied with the terms and conditions of the policy, and the complaint is without any cause of action. It is explained that the Complainant was admitted as a case of dimmed vision and was treated with injection ‘Macugen’ and the procedure of giving injection is performed by an eye specialist on the day care basis, where no admission is required in the hospital.  Although, the injection is given in the Operation Theatre yet it is only an OPD procedure where the patient  is not required to be admitted in the hospital and as per clause 3.4 which defines hospitalization, it would mean an admission in any hospital/nursing home in India upon the written advise of a medical practitioner for a minimum period of 24 consecutive hours and since in this matter the Complainant was admitted and discharged same day and has not spent a time limit of 24 hours in the hospital, he is not covered within the policy terms and conditions and even otherwise the Complaint falls within the clause No.4.4.23 which defines that the treatment of eyes with injection Macugen is not covered within the policy and therefore the OP was right in repudiating the claims. As far as merits are concerned all these facts of preliminary objection are reiterated.
5. The Complainant has filed the Rejoinder and has stated that the Complainant was admitted in hospital on the advice of doctor, he was given the injection ‘Macugen’ and as per the terms and conditions of the Policy itself the eye treatment is not covered within time limit of 24 hours consecutive admission in the hospital. He has also reproduced the terms and conditions of the policy along with the Complainant has filed his evidence and exhibited the following documents:-

1. Copy of policy and letter dated 12.10.2012 are exhibited as PW1/1 and PW1/2.
2. The claim form, letter dated 24.11.2012 with postal receipt are exhibited as PW1/3 and PW1/4.
3. The copy of the legal notice 10.2.2013 with postal receipts is exhibited as PW1/5.
4. The treatment record and bills are exhibited as PW1/6 (Colly).

6. OP has filed its own evidence and exhibited the following documents and exhibited following documents:-

1. Copy of terms and conditions of Mediclaim Policy (2007) as EX-OPW1/1.
2. Copy of the repudiation letter as EX-OPW1/2.

7. The Commission has heard the arguments and perused the record. A quarry was raised from the Complainant as to how the treatment in Government hospital is chargeable particular with respect to injection charges, and where is the prescription for such treatment. The complainant there after had shown the photocopy of the prescription, which has been placed on record along with demand draft of Rs. 33,000/- in favour of Account Officer Dr. Rajendera Prasad Central for ophthalmic Science by stating that original was deposited with OP along with the claim form. OP has not raised any objection with respect to the fact that Complainant has not spend this amount rather the OP has started abstaining from appearing and hearing, since last two dates.  The contention of the OP otherwise is not maintainable as in the mediclaim policy guidelines particularly Para 3.4 it is mentioned as below: 
   • : Shall mean admission in any Hospital/Nursing Home in India upon the written advice of a Medical Practitioner for a minimum period of 24 consecutive hours.  The time limit of 24 hours will not be applicable for following surgeries/ procedures. 

Anti Rabies Vaccination
	Inguinal / Ventral / Umbillical / Femoral / Hernia repair
Coronary Angiography	Lithotripsy (Kidney Stone Removal)
Coronary Angioplasty	Parentteral Chemotherapy
Dental surgery following an accident	Piles /Fistula
Dilatation & Curettage (D&C) of Cervix
Eye surgery
Fracture/ dislocation excluding hairline fracture
Gastrointestinal tract system	Stone in Gall Bladder, Pancreas, and Bile Duct
	Urinary Tract System

 

8. Therefore, the fact that the father of the Complainant had undergone the treatment, spent an amount of Rs. 33,000/- approximately on the treatment and was discharged same day are the admitted facts, and there is no specific clause in the policy, which is explaining that the treatment of ‘Macugen’ injection would not be covered as an ailment.
9. Further, and above all, from these facts, the Commission is of the opinion that taking a thread of the fact that agreement of Insurance is based on utmost good faith and everything is supposed to be disclosed by both parties to each other, simultaneously the exclusion clause compelling the admission of a patient for continuous 24 hours in hospital with respect to the treatment of eyes, in the considered opinion of this Commission amounts to an ‘unfair trade practice’ on the part of OP as the Commission is of the opinion that such condition would encourage mis-deed on the part of complainant, as well as hospital by colluding to help each other. It otherwise also is not the prerogative of the insurance company to guide as to how a patient would be treated, when he would be admitted and when he would be discharged. Rather it depends upon the treating doctor and treating hospital. Just for the reason that 24 hours have to be spent in a hospital by any patient, it would be encouraging to forge document by the hospital for illegal enrichment to the hospital and the patient. The insurance company must take care of such terms and conditions, which compels the insured to approach the doctor for making their case strong and then to put a pressure on the system that particular patient should remain in the hospital for more than 24 hours. It is not only against the established principles of medical science rather it also amounts to compelling the Complainants or patients to play fraud upon the Insurance Company, fraud upon the hospital administration, and fraud upon the general public at large who would suffer only for the reason that there is no space in the hospital for other patients as one patient has to remain in the hospital for more than 24 hours.  This condition put up by the Insurance Company in the exclusion clause, in the considered opinion of the Commission is against the settled principals of consumer behavior, consumer psychology and is unreasonable apart from being unfair trade practice by the OP.
10. Therefore, the contention of OP is not well found, the claim of the Complainant is allowed, and OP is directed to pay the Complainant:

1. Rs. 33,000/- with 9% interest from the date of deposit the amount. 
2. To pay consolidated amount Rs. 10,000/- towards cost and compensation amount. 

This order be complied within 30 days from the date of receipt of the order.

Copy of the order be supplied / sent to the parties free of cost as per rules.

File be consigned to Record Room.

Announced on 27.09.2022

 

 

 

(Ritu Garodia) Member

(Ravi Kumar) Member

(S.S. Malhotra) President