Chandigarh

DF-II

CC/804/2016

Mr. RK Luther - Complainant(s)

Versus

Star Health & Allied Insurance Co. Ltd., - Opp.Party(s)

In Person

17 Apr 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Consumer Complaint  No	:	804 of 2016
Date  of  Institution	:	22.9.2016
Date   of   Decision	:	17.4.2017

 

 

 

 

 

Mr. R.K. Luther, resident of House No.24, Sector 6, Panchkula.

                …..Complainant

Versus

 

Star Health & Allied Insurance Co. Ltd. 130-131, 4^th floor, Sector 34-A, Chandigarh.

….. Opposite Parties

 

BEFORE:  SH.RAJAN DEWAN                 PRESIDENT

         MRS.PRITI MALHOTRA             MEMBER

         SH. RAVINDER SINGH             MEMBER

 

 

For complainant(s)      :     Complainant in person.  

 

For OP                  :     Sh. Gaurav Bhardwaj, Adv.

 

 

 

RAVINDER SINGH, MEMBER

 

 

     As per the case, the complainant purchased a Senior Citizen Red Carpet Health Insurance Policy No.P/161113/01/2016/003788 dated 18.2.2016 with the OP, in continuation of policy w.e.f. 8.2.2008, and has been paying premium regularly since then. The present policy was valid w.e.f 18.2.2016 to 17.2.2017 for insurance of Rs.7,50,000/-. The complainant has stated that at the time of taking insurance, it was told to the complainant that if he does not claim any amount for 2 years from the date of issue of policy then all medical expenses  after that will be paid by the OP.  The grouse of the complainant that he got treatment of Cataract of his both eyes with the prior understanding with OP that he will get full reimbursement for the expenses incurred on the treatment. The complainant incurred Rs.2,32,800/- on his treatment. However, later on the OP only agreed to pay Rs.23,000/- for one eye only. According to the complaint this act of the OP amounts to unfair trade practice on its part. Alleging the said act of OPs as deficiency in service, this complainant has been filed.

 

2           The Opposite Party in its reply stated that the complainant was well aware that the expenses payable in respect to the cataract surgery is limited to Rs.23,000/- only in one policy year. It is asserted that a chart has been provided on page 2 of the terms and conditions with regard to payable expenses in respect of various ailments. It is further asserted that the complainant got operated his left eye and Rs.23,000/- was paid but the complainant then again filed a claim for right eye and the same was declined  because sub limit for the cataract had already been exhausted. It is pleaded that the complainant is getting the policy since 2008 and every time he was supplied with terms and conditions of the policy. Even with the present policy the terms and conditions were supplied as it is categorically mentioned on the policy that the insurance under this policy is subject to conditions, clauses and exclusion etc. attached.  Pleading no deficiency in service and denying rest of the allegations, it is prayed that the complaint be dismissed.

3           The Complainant also filed rejoinder thereby reiterating the averments as made in complaint and controverting that of the Opposite Party made in the reply.

4           Parties led evidence in support of their contentions.

5           We have heard the complainant in person, ld. Counsel for Opposite Party and have also perused the record.

6           As per policy (Annexure R4), The expenses payable during the entire policy period in respect of the following disease/condition is limited to the amount mentioned there against:-

Disease	Sum insured	Limit of company
Cataract	Rs.7,50,000	Rs.23000/-

 

7       The complainant has operated for cataract in left eye on 1.8.2016 and right eye on 3.8.2016 in Grewal Eye Institute, Chandigarh and paid a total sum of Rs.2,18,717/- as per details below:-

30.7.2016	Rs.917.00	Medicines
29.7.2016	Rs.600.00	Consultation charges
29.7.2016	Rs.2,200.00	cataract evaluation
2.8.2016	Rs.1,15,000.00	Robolazr toric c
3.8.2016	Rs.1,00,000/-	Robolazr toric c

 

8        The complainant has been sanctioned and paid Rs.23000/- by the OPs as permissible under the insurance policy applicable thereto. The complainant is having this insurance policy w.e.f.8.2.2008 and cannot be believed to be ignorant of terms and conditions of the policy and as such are bound by the same.

9           The Hon’ble Supreme Court in Oriental Insurance Co. Ltd. Vs. sony Cheriyan reported as I1999(6) SCC 451 has held;

    

     “The insurance policy between the insurer and the insured represents a contract between the parties

     The terms of the agreement have to be strictly “construed to determine the extent of liability of the insurer.””

 

    The complainant has voluntarily choosen a Private Hospital namely Grewal Eye Institute at Chandigarh which is very expensive than that of other similar hospitals having all such medical facilities  

 

10          The Post Graduate Institute of Medical Education and Research Chandigarh charge only nominal amount of Rs.1000/- for cataract extraction which is explicit from receipt dated 25.4.2017. For a similar treatment the cataract extraction the charges made by Grewal Eye Hospital and PGI are below:-

 

Grewal Eye Hospital Chandigarh	PGI Chandigarh
Rs.1,14,358/- Includes testing, operation medicines etc for one eye	13464/- Includes testing, operation, lense, medicines etc.

 

    Scanned copy of receipt of PGI of such treatment is pasted below:-

 

 

 

 

 

 

 

 

 

 

 

 

11      The facility of Cataract operation is available in PGI, Multi Specialty Hospital, Sector 16, Chandigarh, Govt. Medical College and Hospital, Sector 32, Chandigarh which are admittedly world class institutions for their best treatment of disease and medical facility but the complainant ignored the same and preferred a Private Medical Institute at Chandigarh and paid such a huge amount under some misconception.

 

12         The contention raised by the complainant in the complaint are misconceived, untenable and without merit. Under the garb of insurance policy, he cannot lay claim to the amount which is not permissible under the policy and which has been spent by him just for his more comfort.  Had he been opted for such treatment from abroad, where the amount must have been in multiple than that whatever he has paid in Grewal Eye Hospital, the claim under the insurance policy would have been the same as is permissible under the policy terms and conditions.  The claims under the Insurance Policy liable to be settled as per terms and conditions therein and not on the whimsical preferences of the insured.

 

 

13         Keeping into consideration the above fact and Circumstances, the complaint being without merit is dismissed.

 

14         The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

17.4.2017  

                                                                                       SD/-

 (RAJAN DEWAN)

PRESIDENT

 

Sd/-

(PRITI MALHOTRA)

MEMBER

 

Sd/-

(RAVINDER SINGH)

MEMBER