BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no.25 of 2016
Date of Institution : 21.1.2016
Date of Decision : 20.07.2017.
Bharat Bhushan, HGA-SR-177312 Life Insurance Corporation of India, Sirsa, R/o H. No.356, Sector 20, HUDA Colony, Sirsa.
….Complainant.
Versus
The New India Assurance company Ltd., Sirsa through its Divisional Manager with which the Group Medical Insurance for Employees of LIC.
..…Opposite pary.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SMT. RAJNI GOYAT ……….…… PRESIDING MEMBER.
SH. MOHINDER PAUL RATHEE……… MEMBER
Present: Sh. A.K. Gupta, Advocate for the complainant.
Sh. Rakesh Bajaj, Advocate for opposite party.
ORDER
Case of complainant, in brief, is that he is an employee in Life Insurance Corporation of India, Sirsa. The New India Assurance Company Ltd. has issued a group medical insurance policy to all the employees of Life Insurance Corporation of India including the complainant for the reimbursement of the hospitalization expenses to all classes of employees of the corporation and the coverage is available to the family of the employees i.e. spouse (wife of husband) of the employees and any two dependent children. It is further averred that a female baby was born to the wife of complainant on 12.12.2003 who was named as Sanya. The baby was born in Jyani Maternity and Children Hospital, Hisar road, Sirsa. That at the time of birth of the child, she was quite healthy and had no deformity in the eyes or any other part of the body. In August, 2004, Sanya developed a squint problem in eyes and she was taken to Kanwar Mohan’s Squint Center at Chandigarh on 9.8.2004 and the doctor advised some treatment. The baby was regularly being checked up at the said hospital and was given the treatment accordingly. It was diagnosed as a case of infantile esotropia with inferior oblique over action in the left eye and ultimately the baby was advised surgery for the left eye. On 4.12.2007 she was admitted in the said hospital and Dr. Kanwar Mohan conducted the operation of the squint left eye and an amount of Rs.28,800/- was paid for surgery charges, OT charges and anesthesia charges and accordingly the claim was lodged with the op. It is further averred that the requisite documents as demanded by the op from time to time including the certificate of the doctor at the time of birth of the child and the bills and treatment record etc. were duly handed over to the op but the claim was repudiated on 25.5.2008 on the ground that the baby child was having squint disease by birth. That there was no such squint disease at the time of birth and as such the complainant filed a complaint under Section 12 of the Act before this Forum vide complaint No.92 of 2009, which was decided on 10.12.2013 by this Forum and it was held that the squint problem was not from the birth and had developed later on and such repudiation was held to be illegal. This Forum awarded the medical expenses alongwith interest from the date of surgery alongwith damages as well. That on account of the squint of right eye as advised by the doctors the surgery was conducted on the second eye i.e. right eye on 26.3.2014 at Dr. Kanwar Mohan’s Squint Centre Chandigarh and an amount of Rs.42,349/- was incurred for the treatment of the child baby Sanya. It is further averred that all the requisite bills of treatment, discharge certificate and other documents were handed over to the op. That on 18.11.2014, the op has repudiated the claim lodged by the complainant in respect of the reimbursement of the medical expenses incurred on the treatment of Sanya by holding that she has been operated for cosmetic reasons which is under the exclusion clause of the policy. That the op has been right from day one ought to reject the claim of complainant by taking false pretext and after keeping same pending for so long has ultimately repudiated the claim on wrong grounds. The operation conducted upon the Sanya was not a cosmetic surgery rather it was long back advised by the doctors, the operation was interventional and not Lasik laser. The surgery was required otherwise the vision of the child could have been hampered. That the repudiation order as passed by the op is totally a non speaking one, vague and arbitrary. The very purpose of taking the medical claim policy stands shattered. The opposite party has caused deficiency in service and unfair trade practice towards the complainant. Hence, this complaint.
2. On notice, opposite party appeared and filed written statement taking certain preliminary objections regarding maintainability, locus standi, suppression of material facts, estoppal and that no consumer dispute is made out between the parties and that there is no deficiency in service on the part of answering op towards complainant. On merits, it has been asserted that repudiation of the claim of the complainant by the op on 25.5.2008 are a matter of record but rest of the contents are wrong and incorrect, hence denied. The contents of para no.6 regarding decision of complaint no.92 of 2009 vide order dated 10.12.2013 are a matter of record and need no reply. It has been further asserted that complainant failed to supply all the relevant and necessary documents as required by the op. It has been further asserted that on receipt of the claim from the complainant, the op got inquired the same and also referred the case to Dr. Satish Midha of Karnal for second opinion on the matter. The said doctor opined that the said treatment was/is a Lasik Laser and falls in the exclusion of the policy agreement para (ii) of Sub head of Exclusion. Accordingly, the claim of the complainant has been repudiated by the op vide letter dated 18.11.2014 in a legal and lawful manner. Remaining contents of the complaint have been denied.
3. The complainant produced his affidavit Ex.C1 and copies of documents Ex.C2 to Ex.C12. On the other hand, op produced affidavit Ex.R1 and copy of repudiation letter dated 18.11.2014 Ex.R2.
4. We have heard learned counsel for the parties and have perused the case file carefully.
5. There is no dispute that complainant was duly insured with the opposite party under Group Medical Insurance Policy, covering his wife and minor children including female child Sanya born to him on 12.12.2003. The claim submitted by the complainant for the surgery of right eye of his daughter Sanya has been repudiated by the opposite party on the ground that patient Sanya had squint in the right eye and she was operated for cosmetic reasons which comes under exclusion in the policy. However, the opposite party has not placed on file any medical opinion of eye specialist in this regard to show that Sanya was operated for cosmetic reasons. Whereas the complainant has proved on record that the surgery of her right eye for squint problem was required. In this regard, the complainant has placed on file copy of certificate of Dr.Kanwar Mohan, MS Squint Centre, Chandigarh Ex.C3 wherein he has certified that Ms. Saniya daughter of Sh. Bharat Bhushan, r/o # 356, Sector 20, HUDA, Sirsa vide SQN. No.8860 was diagnosed to have right convergent squint. She was advised squint surgery for the right eye which was carried out on 26th March, 2014. The report of Dr. Satish Midha, M.B.B.S placed on file by the op on the basis of which the claim of complainant has been repudiated by op is not proved as per law. Moreover, it is also not proved on file by the opposite party that Dr. Satish Midha is also an eye specialist. It may also be mentioned here that the complaint No.92 of 2009 filed by the complainant against the opposite party regarding claim of surgery of left eye of Ms. Sanya was accepted by this Forum vide order dated 10.12.2013 and it was held that squint problem in the left eye was developed after the birth of Sanya. She developed the same disease i.e. squint problem in her right eye and same was diagnosed by Dr. Kanwar Mohan, an eye specialist and therefore, the above said surgery was required otherwise the vision of the child could have been disappeared. The complainant has also proved on record that he spent an amount of Rs.42,349/- on the above said surgery of right eye of his daughter Sanya and in this regard he has placed on file copies of bill and receipts Ex.C4 to Ex C9. In these circumstances, opposite party has failed to prove its version and the repudiation of the claim of the complainant is not justified.
6. Thus, as a sequel to our above discussion, we allow the present complaint and direct the opposite party to pay the amount of Rs.42,349/- i.e. medical expenses to the complainant alongwith simple interest @4% per annum with effect from 29.3.2014 (date of submission of claim by the complainant to the opposite party) till the date of actual realization. We also direct the opposite party to pay a sum of Rs.5500/- to the complainant as litigation expenses. The op is directed to comply with this order within a period of 30 days from the date of receipt of copy of this order. A copy of this order be supplied to the parties free of costs. File be consigned to record room after due compliance
Announced in open Forum. Presiding Member,
Dated: 20.7.2017. District Consumer Disputes
Redressal Forum, Sirsa.
Member.
