DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II U.T. CHANDIGARH [Consumer Complaint Case No: 456 of 2010] -------------------------------- Date of Institution : 22.07.2010 Date of Decision : 06.09.2012 -------------------------------- Narinder Kumar Singla son of Sh. Kapur Chand Singla, resident of House No. 780, Sector 12, Panchkula, Haryana. ---Complainant V E R S U S [1] New India Assurance Company Limited, SCO No. 36-37, Sector 17-A, Chandigarh, (through its chief Regional Manager, Grievance Cell, Regional Office). [2] M/s Raksha TPA Private Limited, SCO No. 188-189, Sector 7-C, Chandigarh, through its Manager. [3] The Branch Manager, The New India Assurance Company Limited, Railway Road, Shahabad, District Ambala. ---Opposite Parties BEFORE: SH. LAKSHMAN SHARMA PRESIDENT MRS.MADHU MUTNEJA MEMBER SH. JASWINDER SINGH SIDHU MEMBER Argued By: Sh. Hitender Kansal, Counsel for Complainant. Sh. Sukaam Gupta, Counsel for Opposite Parties. PER JASWINDER SINGH SIDHU, MEMBER 1. Complainant has filed the present complaint, against the Opposite Parties on the ground that he had purchased a medi-claim policy bearing No. 353603/34/07/11/00000052 in the year 2007, valid form 7.9.07 to 10.9.2008. An identity card bearing ID No. 89491 was issued by the Opposite Parties. This policy was renewed twice; firstly, from 11.9.2008 to 12.9.2009 and thereafter, from 11.9.2009 to 10.9.2010. Copies of these Policies along with renewals at annexed as Annexure C-1 (colly) and copy of ID card issued by Opposite Party No.2 is at Annexure C-1A. The said policy was cashless and Opposite Parties were liable to make payment to the hospital directly. The Complainant suffered some eye ailment and was admitted with Shroff Eye Center, A-9, Kailash Colony, New Delhi on 20.4.2009 and was diagnosed for a disease namely “Cystoid Macular Edema in left eye”. The Complainant was advised an injection intra-vitreal Avastin and Tricort injection in the left eye, by Dr. Cyrus M. Shroff, as treatment. Copy of medical treatment record is annexed as Annexure C-2. That on the same very day, the left eye of the Complainant was operated upon, and Complainant spent a sum of Rs.11750/- on his treatment, the payment was made vide Bill NO. 2009/340, dated 20.4.2009. This bill was submitted to Opposite Party No.2 on 23.4.2009 and the same was duly acknowledged by Opposite Party No.2. The copy of the bill & receipt are annexed as Annexure C-3 and C-4, while copy of accompanying letter dated 23.4.2009 is annexed as Annexure C-5. The alleges that inspite of processing the genuine and bonafide claim the Opposite Party No.2 rejected the claim on the ground that the “Patient diagnosed as a case of Cystoid MACULAR Edema Lt. Eye treated with Intra Vitreal Injection. Since the scope of using intra vitreal injection is not covered in the policy conditions. Hence the claim is non-payable”. A copy of the repudiation letter is attached as Annexure C-6. The Complainant claims that in the repudiation letter dated 23.4.2010, issued by Opposite Party No.2, has mentioned that since the scope of using intra vitreal injection is not covered in the policy conditions, hence the claim is not payable; whereas in their earlier letter dated 21.3.2010, issued by Opposite Party No.2, they have mentioned that intra vitreal injection in Lt. (can be treated in OPD basis), thus, claiming that two different reasons have been mentioned for not paying the claim. The Complainant further claims that an earlier claim lodged with the Opposite Parties for the same treatment was duly approved by Opposite Party No.2. A copy of the claim settlement voucher of the earlier claim is annexed as Annexure C-7. Thus claiming that the repudiation of the just claim of the Complainant as deficiency in service on the part of the Opposite Parties, the Complainant served the Opposite Parties with a legal notice (Annexure C-8), and on not hearing anything from the side of the Opposite Parties, has preferred the present complaint, claiming relief of:- [a] refund of Rs.11,750/- spent on treatment; [b] Rs.50,000/- as compensation for mental agony and harassment; [c] Litigation expenses & counsel fee of Rs.10,000/-, along interest @ Rs.18% per annum. The complaint of the complainant is duly verified and supported by his detailed affidavit. 2. The Opposite Parties No.1 & 3 have contested the claim of the complainant by filing their joint reply, taking preliminary objections to the effect that the present complaint is barred on account of territorial jurisdiction, as the policy of insurance was obtained from Shahabad Branch of the answering Opposite Parties. Furthermore, the Opposite Parties have also objected to the allegations of defect, delay, deficiency or negligence on their part, as the claim of the Complainant was rightly repudiated as the same falls outside the scope of terms and conditions of the insurance policy and that further, as per circular dated 9.2.2009, issued by the Head Office of the answering Opposite Parties “AGE RELATED MACULAR DEGENERATION (ARMD)” THE DRUGS LIKE AVASTIN OR LUCENTIS OR MACUGEN AND OTHER RELATED DRUG IS GIVEN AS “INTRA VITREAL INJECTION”. Being an OPD based treatment not requiring hospitalization for 24 hours, falls outside the scope of terms and conditions of the policy. Thus, the claim was rightly repudiated and the complaint deserves to be dismissed on this score alone. On merits, the Opposite Parties No.1 & 3 have repeated their preliminary objections, while replying to the averments of the present complaint, in their para-wise reply. Thus, claiming no deficiency in service or unfair trade practice on their part, the answering Opposite Parties have prayed for the dismissal of the complaint with heavy costs. The reply of the Opposite Parties No.1 & 3 is duly supported by detailed affidavit of Sh. A.L. Madan, Manager. 3. The Opposite Party No. 2 has adopted the reply/ version filed by the answering Opposite Parties No.1 and 3, vide its statement dated 27.3.2012. 4. Having gone through the entire complaint, version of the Opposite Parties, the evidence of the parties and with the able assistance of the learned counsel for the opposite parties, we have come to the following conclusions. 5. While addressing the preliminary objections, taken by the Opposite Parties, with regard to the territorial jurisdiction of this Forum, as the Complainant having subscribed for the Policies at Shahabad office of the Opposite Parties. We have gone through the documents tendered by the Complainant, as well as the Opposite Parties. No doubt, Annexure C-1 (Pg. 11-12) of the complaint and Annexure R-1 (Pg.7-8) of the reply of the Opposite Parties clearly show that the policies through which the claim of the Complainant arose were issued from Shahabad (M) office of the Opposite Parties, but as the claim was filed by the Complainant with the Chandigarh Office of Opposite Party No. 2 and the same was repudiated by the Opposite Party No.2 at the very first instance. Annexure C-5 dated 23.4.2009 is shown to have been received by Chandigarh Office of Opposite Party No. 2. Hence, the present complaint is not barred by jurisdiction and this Forum has the territorial jurisdiction to try and decide the present complaint. 6. While going through the repudiation letter the observation and opinion quoted in this letter is reproduced as below: - “Patient diagnosed as a case of Cystoid MACULAR Edema Lt. Eye treated with Intra Vitreal Injections. Since the scope of using intra vitreal injection is not covered in the policy conditions. Hence the claim is non-payable.” However, while citing this opinion, the Opposite Party No.2 failed to quote the Policy conditions which have been breached or controverted. The medi-claim insurance policy of the year 2007 (Annexure R-2) at pg. 11 clause 3.4 shows that The hospitalization means admission in any hospital, nursing home in India upon the written advise 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. Under this the eye-surgery is clearly mentioned. There is also a foot note, clearly mentioning that any other surgeries/ procedures, agreed by the TPA/ Company which requires less than 24 hours hospitalization due to subsequent advancement in medical technology. The Opposite Parties in their version/ reply have also mentioned about a copy of circular and repudiation letter Exhibited as Ex.R-3 and R-4, in order to support their claim about the claim of the Complainant falling outside the scope of terms and conditions of the insurance policy. On perusal of Annexure R-3 dated 9.2.2009, it comes to light that the Mumbai office of the Opposite Party No.1 & and 3 has communicated to one Mr. R.K. Attri about the exclusion of Age Related Macula Degeneration (ARMD) under medi-claim policy 2007, wherein drugs like Avastin or Lucentis, or Macugen is given as intra-vitreal injections and the same being an OPD treatment is excluded from the scope of cover. 7. On perusal of Annexure R-3, which is an intra-office communication of the Opposite Parties No.1 and 3, and the same has not been made available or conveyed to the Complainant, and as no office memo can take away or amend the original terms and condition of the insurance policy, we feel that Annexure R-3 can not be imposed in any manner, on the Complainant, as he is totally ignorant about this fact. Thus, in these circumstances, as the original terms and conditions reproduced above (Para 6), the claim of the Complainant was just, and deserved to be honoured. And as the original terms and conditions of the policy subscribed for by the Complainant have not been amended, or changed with the common consent of the parties to this contract, hence, Annexure R-3 has not force and is out rightly ignored. 8. In the light of above observations, we find a definite deficiency in service on the part of the Opposite Parties as they have acted contrary to their own terms and conditions made available to the Complainant at the time of subscription of the policy. Hence, the present complaint of the Complainant succeeds against the Opposite Parties, and the same is allowed. The Opposite Parties are directed, jointly & severally, to:- [a] To reimburse Rs.11,750/- spent by the Complainant; [b] To pay Rs.10,000/- on account of deficiency in service and causing mental harassment to the Complainant; [c] To pay Rs.7,000/- as cost of litigation; 9. The above said order shall be complied within 45 days of its receipt by Opposite Parties; thereafter, they shall be liable for an interest @18% per annum on the amount mentioned in sub-para [a] & [b] of para 9 above, apart from cost of litigation of Rs.7,000/-, from the date of institution of the present complaint i.e. 22.07.2010, till it is paid. 10. Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room. Announced 06th September, 2012 Sd/- (LAKSHMAN SHARMA) PRESIDENT Sd/- (MADHU MUTNEJA) MEMBER Sd/- (JASWINDER SINGH SIDHU) MEMBER
| | MRS. MADHU MUTNEJA, MEMBER | HONABLE MR. LAKSHMAN SHARMA, PRESIDENT | MR. JASWINDER SINGH SIDHU, MEMBER | | 
