By : SMT. BANDANA ROY, PRESIDENT

            The short fact of the present case is that the complainant took a Medi Claim Policy from the OP, effective from 26.03.2013 to the midnight of 25.03.2014 for himself for a sum of Rs. 1,00,000/- being No.  150305/48/12/8500001338 which is still continuing. The complainant also paid the premium of Rs 7,576 for the said policy for the period from 26.03.2017 to the mid night of 25.03.2018 to the OP.  Unfortunately the complainant suffered from eye problem since October, 2017 and on 11.10.2017 his eye was checked by the eye specialist Dr. J. C. Kuila who advised for cataract surgery of right eye. Accordingly the complainant got admitted in Sunayan Advanced Eye Institute at Tamluk on 28.10.2017 and on the same night and doctor made surgical operation of his eye and discharged from the Nursing home on 29.10.2017. The total expenditure was to the tune of Rs 24,530/-.  The complainant placed the claim before the OP on 03.11.2017 for payment but by a letter dated 02.01.2018   the OP denied to pay the amount.

Hence, the instant case with the prayers as made in the complaint petition on the allegation of deficiency of service and unfair trade practice against the OP.

Being summoned by this Forum the OP Insurance Company appeared and contested the case by filing written version and claimed dismissal of the complaint case with explanatory costs on the grounds as stated below.

The defense of this OP is that the complainant availed an Insurance policy for the first time  from 26.03.2017 to 25.03.2018 under the scheme of Varistha Medi claim for Senior Citizen as per and subject to the strict  terms and condition of the certificate of insurance policy. The certificate was issued  with a TPA facility  under observation of Grand Healthcare TPA service (P) Ltd. After receipt of all the document from the complainant along with his application for claim, the OP sent the same to the TPA Grand Insurance TPA Private Ltd for their verification, comment and opinion as to the said claim.  After getting such advice the OP learnt that the complainant is eligible for a sum of Rs. 10,000/- only for cataract operation as per terms and conditions of the said Medi Claim insurance. The OP accordingly  requested the complainant to submit voucher for a sum of Rs. 10,000/- but the complainant insisted for Rs. 24,530/- . It is the further case of this OP that the disease of the complainant in respect of eye is pre-existing one. The OP never repudiated the claim of the complainant.  Under such circumstances, the OP prays for dismissal of the complaint  case.

The points require discussion are whether the case is maintainable and whether the complainant is entitled to get the reliefs  as prayed for.

Decision with reasons

            Both the issues are taken up together for discussion for the sake of convenience and brevity.

            Perused the complaint, the WV, WNA of the OP , the questionnaires   and reply thereto filed by the complaint and the documents filed in the record from the respective sides in order to substantiate their plea.  Heard argument advanced by the ld. Advocate for both the parties and considered.

            It is not disputed that the OP is the insurer and the complainant is the insured in this case. Admittedly the complainant availed of the insurance policy commencing from 26.03.2017 to 25.03.2018 under the scheme of Varistha Medi claim for Senior Citizen, subject to the strict  terms and condition of the certificate of insurance policy .  The complainant accepted the terms and conditions in the policy issued to him being No.  150305/48/12/8500001338 for an insured sum of Rs. 1,00,000/- with a TPA facility  under observation of Grand Healthcare TPA service (P) Ltd. under observation  of Grand Heath care TPA Serices (P)Ltd.,  The premium was Rs. 6,588/- + central and State GST  of Rs. 1186/-, totaling Rs. 7,576/-. According to the OP liability of the Insurance Co  in the  medi claim policy  for senior citizens was Rs. 10,000/- for the cataract surgery  and the complainant was requested to submit voucher for that amount  but the complainant insisted for payment of Rs. 24,530/-  which according to the Op beyond the norms of the conditions of the said policy.

           The complainant filed examination in –  chief against the written version of the OP  but he was silent regarding the terms and conditions of the insurance policy and stated that his expenditure for surgery was Rs. 24,530/- and he has prayed for compensation of Rs., 50,000/- and litigation cost of Rs 10,000/-.

We have carefully perused the cross-examination in questionnaires filed by the OP Insurance Co.  where the OP in question no 2 asked the complainant  whether  the liability of the OP was up to Rs. 10,000/-for cataract  operation, in reply the complainant stated  in the negative.  The complainant also stated in the answer to question no 3 that the policy has been filed by the complainant.

We find from the records that the OP has filed the Annexure A and B in this case which are the terms and conditions of the policy.  From the Annexure B Clause (i) we find the company has the liability in respect of claims arising due to cataract is up to  Rs. 10,000/- and that of Benign prostatic  hyperplasia is up to Rs 20,000/-. The case of the complainant is that he made cataract surgery of his right eye.

It appears that the complainant has not filed  any copy of this prospectus disclosing the terms and conditions of the policy along with the complaint which seems to this Bench  suppression of material fact by the complainant for getting more payment from the OP Insurance Co.  It can not be ruled out that the complainant has initiated this complaint without waiting for repudiation of his claim.  OP has alleged that  the OP offered a sum of Rs. 10,000/-  to the  insured complainant  but the complainant instead of submitting voucher for that amount has filed this case.

In view of the above we find there is no deficiency on the part of the OP regarding payment of the medi claim policy.

We have perused the entire materials on record and in our considered view the complainant is entitled for only Rs. 10,000/- as per the terms and conditions of the medi claim policy and the OP  is to  pay that amount on production of voucher, as per case of the OP.   

            Both the issues are decided accordingly.

            Hence, it is

O R D E R E D

That the CC/87 of 2018 be and the same is dismissed on contest against the OP.

 Parties do bear their respective cost in this case.

Let copy of the judgment be supplied to all the parties free of cost.