BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I, U.T. CHANDIGARH ======== Complaint Case No : 515 of 2010 Date of Institution : 23.08.2010 Date of Decision : 17.06.2011 Dr. Tarvinder Pal Singh, R/o Flat No.3, Near Civil Hospital, Ph-6, Mohali – 160058. .…Complainant V E R S U S [1] Reliance General Insurance Company Ltd., SCO No. 145-146, Top Floor, Above VLCC, Sector 9-C, Chandigarh. [2] The Manager, Medi Assit Pvt. Ltd., SCO No.61, 2nd Floor, Phase-7, S.A.S. Nagar, Mohali. [3] Reliance General Insurance Company Ltd., 909, 9th Floor, Regent Chambers, Nariman Point, Mumbai – 400021. .…..Opposite Parties CORAM: Sh.P.D. GOEL PRESIDENT SH.RAJINDER SINGH GILL MEMBER Argued by:Sh.Vaibhav Narang, Advocate for complainant Sh.Tajender Joshi, Advocate for OPs No.1 & 3. OP-2 exparte. --- PER P.D.GOEL, PRESIDENT Succinctly put, the Complainant took a medi-claim policy from OP No.2 for himself and his family for providing cashless medical facilities. His contention was that his wife was operated for varicose veins with incompetent saphenofemoral volve at Sama Nursing Home, Delhi on 21.10.09. The procedure was endovascular ablation of saphenofemoral junction done under general anesthesia and hospital stay was for one day. This procedure was previously done by open surgery, but with advancement in medical field, this was done by radio frequency ablation or laser fiber. But to his utter surprise and dismay, OP No.2 denied cashless facility by taking plea that in the treatment provided was through laser and, therefore, it was not within the scope of terms and condition of the insurance policy. A legal notice was also served upon the OP, but it failed to fructify. Hence this complaint, alleging that the aforesaid acts of the OP amount to deficiency in service and unfair trade practice. 2] Notice of the complaint was sent to OPs seeking their version of the case. 3] OP-2 did not appear despite service, therefore, it was proceeded against exparte vide order dated 17.01.2011. 4] OPs No.1 and 3 in their joint reply, while admitting the fundamental facts of the case, pleaded that OP No.2 denied cashless facility to the Complainant on the ground that as per documents submitted by the Complainant it was evidenced that the treatment was through laser only and, therefore, it was not in the scope of terms and conditions of the insurance policy. As such, in view of Condition No. 7 of the medi-claim policy, the claim of the Complainant was rightly repudiated. All other material contentions of the complaint were controverted. Pleading that there was no deficiency in service on their part, a prayer has been made for dismissal of the complaint. 5] Parties led evidence in support of their contentions. 6] We have heard the learned counsel for the parties and have also perused the record. 7] Admittedly, the complainant got cashless policy for himself and his family from OP Nos.1 and 3. It is the case of the complainant that he was operated for varicose veins with incompetent saphenofemoral volve at Sama Nursing Home, Delhi on 21.10.09. The surgery was done by laser fiber. The grouse of the complainant is that OP-2 has denied the cashless medical facility by raising the plea that the treatment was done through laser. So, it does not fall within the scope of the terms and conditions of the insurance policy. Admittedly, the OPs have denied the cashless facility to the complainant on the ground that as per the documents submitted by him, the treatment was done through laser, therefore, it was beyond the scope of the terms and conditions of the insurance policy and in view of exclusion clause No.7 of the mediclaim insurance policy, the claim was not payable. So the same was rightly repudiated. The exclusion clause No.7 of the mediclaim insurance policy is reproduced for the purpose of ready reference:- “7. Routine medical, eye and ear examinations, cost of spectacles, laser surgery, contact lenses or hearing aids, vaccinations, issue of medical certificates and examinations as to suitability for employment or travel.”. 8] The sole point for consideration is that whether the treatment of the complainant through laser was covered under the terms and conditions of the insurance policy. The answer to this is in negative. 9] Learned counsel for the complainant admitted at the bar during the course of arguments that the operation of the complainant was done by laser surgery. If the exclusion clause No.7 referred to above is read in between lines, it gives a clear indication that it applies to all the laser surgery and not only to eye surgery. 10]. The repudiation letter is dated 13.01.2010. The perusal of the same makes it clear that the claim of the complainant has been repudiated on the ground that laser surgery falls under the exclusion clause of the insurance policy. It has been averred by the complainant in his complaint that the treatment was done by laser fiber. As per exclusion clause No.7, if the treatment is done by laser surgery, the claim is not payable as it falls within the said exclusion clause. In view of this, it is held that the repudiation of the claim vide letter dated 13.01.2010 was valid and legal. 11] In view of the above findings, we are of the considered opinion that the OPs had rightly repudiated the claim as it falls in the exclusion clause No.7 of the terms and conditions of the insurance policy. Hence, the complaint is hereby dismissed leaving the parties to bear their own costs. 12] Certified copies of this order be sent to the parties free of charge. The file be consigned. | | Sd/- | Sd/- | 17.6.2011 | | [Rajinder Singh Gill] | [P.D. Goel] | | | Member | President | ‘cm’ | | | |
| | MR. RAJINDER SINGH GILL, MEMBER | HONABLE MR. P. D. Goel, PRESIDENT | , | | 
