ORDER

(Passed on  04/10 /2019)

PER SHRI.ATUL D.ALSI, PRESIDENT.

     The complainant has filed this complaint U/s 12 of the Consumer Protection Act,1986 repudiation of his health insurance claim and thereby praying for reimbursement of Medical Expenses under the policy of Rs.90,000/- along with compensation and cost of litigation.

2.      The facts in short giving rise to this petition are that the complainant and his wife were insured under the Joint Health Policy bearing No.281107501710000006 for the period between 2/4/2017 to 1/4/2018 and have paid yearly premium of Rs.9056/-. The complainant had obtained the policy in the year 2010 and it was continued each year by renuing it. There was an eye nsurgery on the complainants right eye at Prasad Eye Care Hospial, Hyderabad on 11/4/2017 and the complainant had to pay Rs.90,000/- towards operation charges and further Rs.20,159/- towards other miscelleneous charges. On 24/4/2017, the complainant filed insurance claim for the reimbursement of medical expenses under the policy alongwith requisite documents, but the OPs repudiated the insurance claim on 16/9/2017. Thereafter, the complainant a letter on 13/10/2017 to the OP for reconsideration of claim and further issued a notice through his advocate Mr.Sonule, but the claim was not reconsidered. Therefore, the complainant has filed this complaint.

3.      The complaint is admitted and notices were served on the OPs. The OP No.1 and 2, despite due service of notice, did not appear before the Forum and hence the case proceeded exparte against OP Nos.1 & 2.

4.      Counsel for the complainant argued that the complainant has filed insurance claim with requisite documents and has submitted further documents as demanded by the OP insurance company and inspite of that his claim is repudiated with an intention to avoide the liability which amounts to deficiency in service. Therefore the petition may be allowed.

5.    We have gone through the complaint, affidavit, documents and WNA filed by the complainant. We have also heard the oral arguments advanced by counsel for complainant.

                    Points                                                                           Finding

1. Whether the complainant is a Consumer ?                                     Yes

2.  Whether  there is deficiency in service on the part

   of OPs?                                                                                    Yes

3.  What order ?                                                                  As per final order..

                                                          REASONING

As to issue No.1

6.     The complainant has filed insurance policy document wherein the complainant and his wife were insured under the Joint Health Policy bearing No.281107501710000006 for the period between 2/4/2017 to 1/4/2018 and have paid yearly premium of Rs.9056/-. As such, the complainant is a consumer within the meaning of Section 2(1) D and the services as promised are the services within the meaning of section 2(1)(d)(ii) of CP act. and hence the issue is decided accordingly.

As to issue No.2

7.       It is admitted fact that a DTP surgery was performed on the right eye of the complainant at Prasad Eye Care Hospial, Hyderabad on 11/4/2017 and the complainant had to pay Rs.90,000/- towards operation charges. The medical treatment papers and payment receipt are filed by the complainant at Exh.A-1 to A-5.  The complainant has filed insurance claim for the reimbursement of medical expenses under the policy on 24/4/2017, alongwith requisite documents. Acknowledgement of receipt of claim is filed on record at Exh.10 by the complainant. The complainant has also submitted ncessary papers as and when demanded by the OPs., but the OPs repudiated the insurance claim on 16/9/2017.

8.      The claim of the complainant is otherwise genuine as per documents filed on record. Now a days eye surgeries are performed by adopting modern techniques wherein latest modern equipments are used. The technology has advanced to such an extent that in many eye surgeries, the patient is not rquired to be admitted for a long period in the hospital as is required for other surgeries. The patient is discharged and is advised bedrest and to follow administration of course of drugs which would have been administered in case he would have been admitted for that period in the hospital. Hence, though the patient is discharged after the operation in the case in hand, he was under continuous treatment of treationg doctors and as such he should be presumed to be under treatment as an indoor patient. Hence the policy conditions can not be said to be breached for the reason of non hospitalization of the patient for more than 48 hours. Hence, the complainant is entitled for reimbursement of his medical expenses under the policy besides compensation for physical and mental agony and cost of litigation.

As to issue No.3

9.      In view of our observations as above, we pass the following order..

Final order

1.  The Complaint is partly allowed.

2.  The OP Nos.1 & 2 jointly and severally shall reimburse medical

   expenses of Rs.90,000/- to the complainant under the Joint   

   Health Policy.      

3. The OP Nos.1 & 2 jointly and severally shall pay to the

   complainant a compensation of Rs.10,000/- for physical and

   mental agony and further Rs.5,000/- towards cost of litigation.

4. Copy of the order be furnished to both the parties free of cost.

(Smt.Kalpana Jangade (Kute)  (Smt.Kirti Vaidya (Gadgil)     (Shri.Atul D.Alsi)

               Member                                 Member                                    President