(Passed on 8/2/2023)

Per Mr. Atul D. Alsi, Hon’ble President. 

1. The complainant No. 2 filed a complaint case against repudiation of insurance claim for the cataract operation of her right eye and thereby claiming medical expenses for the treatment amounted to Rs. 31,641/- along with interest and compensation.
2. The story in short are as under.
3. The complainant insured himself along with family with OP/Insurance company by paying premium of Rs. 17,635/- for the period of insurance policy for the period between 18/12/2020 to 17/12/2021 for the sum assured of Rs. 5,00,000/- under the policy bearing No. P/151139/01/2021/000046. Under the policy, the insured is entitled for the benefit of Rs. 40,000/- for cataract operation of one eye and for both eyes the maximum sum assured is payable up to Rs. 60,000/-. On 12/03/2021, the complainant No. 2 has been operated cataract surgery on her left eye by Doctor Sandeep Mungantiwar and the OP/insurance company has paid the insurance claim of Rs. 28,359/-. Thereafter on 23/02/2021, the complainant No. 2 has operated on her right eye cataract operation by Dr. Sandeep Mungantiwar and incurred medical expenses of Rs. 32,000/-. On 31/03/2021, the complainant filed insurance claim for the medical expenses of Rs. 32,417/- along with relevant documents but the OP/insurance company as per letter dated 8/5/2021 repudiated insurance claim that insurance is not payable due to exceed limit for the sum assured. The complainant No. 2 is entitled to get medical expenses for the cataract operation up to Rs. 60,000/- for both eyes as per terms and conditions of  the insurance policy. Therefore the complainant No. 2 is entitled to get the amount of Rs. 31,641/- after disbursement of 1st insurance claim for the left eye amounted to  Rs. 28359/-, dated 13/03/2021. Therefore, rejection of insurance claim thus amounting to deficiency in service. Therefore, petition is filed.
4. The OP filed reply and denied the allegations and admitted the insurance policy. The OP/insurance Company has paid the insurance claim of Rs. 28,359/- for the left eye cataract surgery. The complainant’s medical claim for right eye cataract surgery has been repudiated for the reason of as per terms and conditions of policy, second insurance claim cannot be payable within 24 months for the surgery. Therefore this term and condition is also applicable to second cataract surgery. Therefore rejection of insurance claim for the second cataract surgery of complainant No. 2 does not amount to deficiency in service. Therefore the complaint case is deserves to be dismissed with cost.

REASONING

5. The complainant insured under health insurance policy from 2015 to December 2020 and second policy from 18/12/2020 to 17/12/2021 along with family members. The OP has admitted that the complainant is entitled for medical expenses of Rs. 40,000/- and for one eye cataract operation and for two eyes, the maximum amount of Rs. 60,000/- on 12/3/2021, the complainant operated cataract surgery to her left eye. The Op sanctioned insurance claim of Rs. 28,359/-. Thereafter on 23/3/2021, the complainant No. 2 operated on her right eye cataract surgery and claimed medical expenses of Rs. 31,641/- but the OP denied the insurance claim for the reasons that the complainant No. 2 is not entitled for second medical expenses within a period of 24 months as per terms and conditions of  policy. The complainant No. 2 has purchased the second policy for increased sum assured of Rs. 5,00,000/- and the complainant No. 2 is also entitled to get maximum medical expenses of Rs. 60,000/- for two eyes operation as per admission given by OP in reply. As per terms and condition of policy No. 3,  waiting period for the treatment of illness from the  first policy shall be excluded for the claims covered under subsequent policy. The complainant’s policies have continuous coverage policies and subsequent policy is purchased for increased sum assured. Therefore deniel of complainant’s claim for the reason of waiting period of 24 months is violation of terms and condition of policy of complainant No. 2. Therefore complainant is entitled for the medical expenses for the  second cataract operation of Rs. 31,641/- along with compensation for mental torture amounted to Rs. 10,000/- and cost of litigation amounted to  Rs. 5,000/- as per following order.

ORDER

1. The complaint is partly allowed.
2. The OP shall pay to the complainant for second cataract operation of Rs. 31,641/-.
3. The OP shall pay to the complainant for mental torture of Rs. 10,000/- and cost of litigation of Rs. 5,000/-
4. Copy of order be furnished to both  parties, free of cost.