PRESIDENT
1) By this complaint the Complainant has prayed to reimburse two medical claims i.e. dtd.07/10/2010 of Rs.68,535.50 and dtd.29/10/2010 of Rs.62,155.25 with due interest till its actual payment and Rs.10,000/- towards mental agony and cost of Rs.10,000/- of this complaint.
2) According to the Complainant, the Policy No.112500/34/09/11/00019217 for the period 20/03/2010 to 19/03/2011 was obtained by the Complainant’s wife Mrs. Yamini for herself and the Complainant from the Opposite Party No.1 as Hospitalization Benefits/Mediclaim Policy 2007. The copy of the medical policy as well as the premium receipt of the same are marked as Annexure ‘I’ colly. It is alleged that the Opposite Party No.1 did not enclosed any other document with the said policy document and therefore, the terms and conditions mentioned in the said policy document are the only the terms of the insurance contract. It is submitted that the Complainant had obtained such medical policies from the year 2006-07. Copies of which are marked as Annexure ‘II’. The policy for the earlier year i.e. 2009-2010 is also placed on record as Annexure ‘III’. It is submitted that the Complainant had taken treatment of his eyes at a hospital as permissible clause 3.2 and 3.3. of the policy. The Complainant was subjected to surgery under clause 3.4 of the insurance terms by the treating surgeon in order to get his eyes treated for age related problems as being a Senior Citizen. According to the Complainant, he is entitled for day care treatment as per clause 3.12 of the policy. The Complainant had taken the treatment for CNVM for age related eye disease AMD from an Eye Surgeon Dr. Ajay Dudnani. The Complainant had intimated the Opposite Party No.1 on 29/09/2010 when the treatment had just begun as per the procedure which was duly acknowledge with remarks “Please submit the paper to TPA after each and every dose immediately”. It is submitted that the Complainant had filed claim in time and in the form given by the Opposite Party No.2, but the Opposite Party No.1 did not entertain the said claim. The Complainant had also enclosed the Eye Specialists Report and the recommendation as to how the said surgical corrective eye treatment for the age related disease will be done. The said documents are filed as Annexure ‘IV’ colly. According to the Complainant, the Opposite Party No.1 was fully aware of the eye treatment being taken by the Complainant which was in III Phase (3 Injections each) at an interval of 1 month. It is submitted that the Complainant took the Phase I treatment on 24/9/2010 and he had taken the Phase II treatment on 24/10/2010. It is submitted that the eye treatment was surgical procedure performed by the surgeon in Operation Theater and continued with only 2 injections in the right eye of the Complainant. According to the Complainant, the 3rd injection was not required and the therefore, the treatment was discontinued after admission of II Phases.
3) It is alleged that bill for the first phase was of Rs.68535.50. It is submitted by the Complainant on 07/10/2010 as per Annexure ‘V’ and bill for the II Phase of Rs.62,155.25 was submitted on 29/10/2010 as per Annexure ‘VI’. According to the Complainant, as per the advise of the Opposite Party No.1 he checked the status of his claim as regards the above bills and he discovered on 18/11/2010 that the said both claims had been rejected on different grounds. For rejection of claim of Rs.62,155.25 reason quoted was the “Treated with injection Lucentis which is not covered”. As regards Bill No.68535.50 it was informed that because an OPD treatment though the injection is given in the operation theater the same is rejected. The Complainant also received reply dtd.13/12/2010 from the Opposite Party No.2 in which it was informed that the claim is rejected due to some internal circular issued by the Opposite Party No.1. The copies of rejection letters are marked Annexure ‘VII’ colly. It is submitted that the said internal circular was not attached to the policy document and was not forming part of agreed terms of insurance contract. It is alleged that the said practice adopted by the Opposite Parties is bad practice (cheating) and also amounts to deficiency in service. The Complainant protested the rejection by issuing letter to Opposite Party No.1 dtd.19/11/2010. The copies of the said correspondence are marked as Annexure VIII colly. The Opposite Parties did not reply to the said letter of the Complainant. The Complainant sent legal notice. Copy of the said notice dtd.09/02/2011 is filed as Annexure IX. It is alleged that the Opposite Parties did not reply to the said notice also. It also amounts to deficiency in service. The Complainant therefore, submitted that the claim made in the complaint as mentioned in para 1of this complaint may be allowed
4) The Opposite Party No.2 though served but not appeared and filed written statement complaint therefore, proceeded ex-parte against Opposite Party No.2. The Opposite Party No.1 contested the claim on the ground that the Complainant had undergone treatment Lucentis which is not covered under the policy the same was based on circular issued by the insurance policy and hence, the claim is not tenable. The Complainant was conveyed the same vide 2 letters dtd.18/11/2010 by the Opposite Party No.2 wherein it is categorically informed to the Complainant that he was treated for Neo Vascular Membrane and the drugs like Avantis or Lucentis or Macugen and other related drugs are given as intravetral injection which is OPD treatment though such injection is given in the Operation Theater under antiseptic condition. It is contended that in view of the nature of the treatment as it falls outside the scope of the Health Policy the Opposite Party No.2 had forwarded another letter dtd.13/12/2010 wherein it was mentioned that the claim made by the Complainant was/is not tenable. The Complainant was also informed that the said claims were not payable. The Opposite Party No.1 had repudiated the claim after a conscientious application of mind. It is contended that the insurance policy clearly states that when there is no admission in the hospital for the period of more than 24 hrs. the claim is not payable. The Complainant is unnecessarily pursuing his claim and trying to bring his claim within the purview of the policy and therefore, it deserves to be dismissed with cost. It is contended that the interpretation of insurance policy cannot be held in the summary jurisdiction of Consumer Courts and the same is subject matter of Civil Suit. The proper remedy in such cases is a Civil Suit in a Civil Court. It is contended that the claim of the Complainant repudiated on just and fair grounds. It is contended that the terms of the insurance policy have to be strictly constitute to determine the extent of liability of the insured. The insured cannot claim more than what is covered by the insurance policy. The policy clearly excludes the treatment undergone by the Complainant and therefore, the Complainant cannot seek relief under the same. The Complainant had informed after the treatment had begun. The Opposite Party No.1 denied that the Complainant is entitled to reimburse two medical claims dtd.07/10/2010 and 28/10/2010 as mentioned in the complaint as well as compensation for mental agony and cost of the complaint. The other allegations made in the complaint are specifically denied and submitted that the complaint be dismissed with cost.
5) The Complainant has filed his affidavit of evidence as well as additional evidence of affidavit under which he has produced the opinion of SAARC Academy of Ophthalmology, New Delhi, dtd.15/06/2011. The Opposite Party has filed affidavit of evidence of Deepak Bhatt, Divisional Manager. Both the parties filed their written arguments. We heard the Ld.Advocates V.K. Govil, for the Complainant and Smt. Sapna Bhuptani, for the Opposite Party No.1.
6) While considering the rival contentions, it is undisputed that the date of issuance of first policy in favour of the Complainant as per the document at Annexure- ‘I’ is 20/03/1998. The Complainant had obtained the mediclaim policy known as ‘Hospitalization and Domiciliary Hospitalization Benefit Policy’ for the period 20/03/07 to midnight 19/03/08 is also supported by the document placed on record on 01/06/2012 before this Forum. The copy of the terms and conditions of mediclaim policy 2007 is placed on record alongwith the complaint in Annexure - I . In the said terms and conditions policy documents in clause no.3.4 the time limit of 24 hours will not be applicable for following surgeries/procedures is noted under the heading Hospitalization and the eye surgery is shown included under the said heading. Upon going through the Annexure ‘VII’ filed with the complaint under which the Opposite Party No.2 has repudiated the claim made by the Complainant appears to be against the terms of the policy. The Complainant has produced on record the certificate issued by Dr. Dudnani as well as the certificate SAARC Academy of Ophthalmology issued by Prof. Rajwardhan Azad of the said institute dtd.15/06/2011 wherein he has certified that the Administration of Anty VEGF Injection treatment is a surgical procedure and not an OPD Procedure though it has reduced Hospitalization and additional cost of Post Operative Care for the patience that were associated with earlier forms of treatment. Considering those certificates and the terms of the policy it appears that the treatment which the Complainant has taken from Dr. Dudnani to his age related eye problem is covered under the mediclaim policy (2007). The contention raised by the Opposite Party No.1 that it is beyond the terms of the policy cannot be accepted. The contention raised by the Opposite Party that the interpretation of policy clause cannot be made by the Consumer Forum also cannot be accepted as the terms of the policy relied by the Complainant are very clear and the Opposite Parties ought to have granted the claim made by the Complainant on the basis of the said terms and conditions of the policy 2007. The authorities relied by both sides in our view are not required to be gone into as the claim made by the Complainant is covered under clause 3.4 of the mediclaim policy (2007). The Opposite Party No.2 while rejecting claim had stated two different grounds which in our view are also not consistent with the terms of the policy. We therefore, hold that the claim made by the Complainant for grant of his two claims submitted to the Opposite Parties dtd.07/10/2010 of Rs.68,535.50 and dtd.29/10/2010 of Rs.62,155.25 are required to be granted against both the parties with interest @ 6% p.a. from the date of notice to the Opposite Parties dtd.09/02/2011 till its realization. The Opposite Parties are also liable to pay Rs.5,000/- towards compensation to the Complainant for adopting unfair trade practices and for guilty of deficiency in service by which the Complainant had suffered hardship and mental agony. The Opposite Parties are also liable to pay cost of Rs.3,000/- to the Complainant towards this complaint. In the result the following order is passed –
O R D E R
i. Complaint No.109/2011 is partly allowed against the Opposite Parties.
ii. The Opposite Parties are directed to pay an amount of Rs.1,30,691/- (Rs.One Lac Thirty Thousand Six Hundred Ninety One Only) to the Complainant towards the claim dtd.07/10/2010 &29/03/2010 alongwith interest @ 6% p.a. from the date of notice to the Opposite Parties dtd.09/02/2011 till its realization.
iii. The Opposite Parties are directed to pay an amount of Rs.5,000/- (Rs.Five Thousand Only) to the Complainant towards compensation for the mental agony and hardship suffered by the Complainant
iv. The Opposite Parties are also directed to pay cost of Rs.3,000/- (Rs. Three Thousand Only) to the Complainant for this complaint.
v. The Opposite Parties are directed to comply the aforesaid order within one month from the date of receipt of this order.
vi. Certified copies of this order be furnished to the parties.
