Case of the complainant is that he being a retired Govt. employee belonging to the category of senior citizen who purchased Mediclaim policy being                                                       

its number 030702/48/12/97/00002419 having its validity from 15.9.2012 to 14.9.2013with a coverage of sum insured Rs.1,75,000/- with cumulative bonus for himself and for his wife, complainant no.2 continued from previous policy  no.33070248119700002636.It is alleged that the complainant made a claim for Rs.45,293/-  but the same has been repudiated by the OP, United India Insurance Company Ltd. inspite of relevant documents including bills and money receipts on account of medical treatment of his wife complainant no.2 . Ultimately, both  the complainants have come before us  for reliefs as mentioned in their petition of complaint.

            In this connection, the documentary evidence,  namely Insurance policy, Claim form , Medical discharge certificate , Bills and several letters as per firisti is produced on behalf of the complainants.

            The case of the complainants is challenged by the Ops by filing written version stating therein that the case is not maintainable for want of cause of action . In fact, the claim is not permissible on the ground that the patient was not admitted administration of LUCENTIS Injection . The terms and conditions of the policy as per circular no. TPA054/09 dated 9.9.2009 do not cover any claim on

such treatment cost and accordingly, the decision repudiating the claim has already been intimated to the complainant . Thus, the case should be dismissed.

            Upon the case of both the parties the following issues are framed.

ISSUES

1. Whether the case is maintainable in fact or law.?

2. Whether the complainants have any cause of action for presentation of the Mediclaim before the OP/Insurance company?

3. If the Mediclaim policy covers the benefit as claimed by the complainants ?

4. Whether the complainants are entitled to get relief as prayed

   for ?

DECISION WITH REASONS :

All the points are taken up together for the sake of convenience and brevity of discussion.

Ld. Advocate for the complainants made his argument that there raised   no question of challenge regarding  validity of the Mediclaim policy for the benefit of the complainants. Now, during the validity of the said policy complainant no.2 Smt. Purnima Mitra was medically  treated under Dr.T.K.Sinha attached to the Disha Eye Hospital, Barrackpore where she was administered with LUCENTIS Injection in its operation theatre on 12.12.2012 and thereafter   discharged therefrom on 13.12.2012 at a cost of Rs.45,293/- . It is very much surprising that the claim of the  complainants has been unreasonably  denied and refused by the oP/Insurance company defying the valid terms and conditions laid down in the policy . Thus, the decision of repudiation to the claim raised by the complainants should be considered unjustified , baseless and whimsical and thereby the claims of the complainant should be allowed.

            Strong challenge has been made by the learned Advocate appearing  for the oP /Insurance company through point to point argument that the alleged administration of Lucentis injection does not qualify the present claim of the complainants. There is no  case of hospital admission and as such the claim preferred by the complainants has no merit. The discharge summary is referred to

and categorically discussed by the ld. Advocate that mere pushing such injection , the patient does not required for taking admission in the hospital. So, this is  nothing but a case of false claim before the oP/Insurance company who deals with public money and the same in no case is a subject for misuse. In this way, ld. Advocate claims for dismissal of this case urging to hold that the complainants have no cause of action for presentation of the petition of complaint.

            We have carefully considered the entire case upon careful scrutiny of the documentary evidence, very particularly to the discharge certificate , Insurance policy , medical advice. We find that OP no.2 Smt. Purnima Mitra received medical treatment in Disha Eye hospital and accordingly was admitted under Dr.Tushar Kanti Sinha on 12.12.2012 and discharged on 13.12.2012 . In this connection, the claim relating to  hospital treatment as in the medical documents is appeared to have been recognized by the available  terms and conditions stipulated in the Health Insurance Policy and thereby we do not find any sound and valid ground for passing the order of repudiation against the mediclaim of the complainant.

Under the facts and circumstances , It is held and decided that the complainants have  good cause of action for presentation of their claim  against the

OP/Insurance company and at the same time order of repudiation passed by OP Insurance company stands unjustified.

            Accordingly,  all the issues are disposed of in favour of the complainants.

As a result, the complaint case succeeds in their favour.

                                                            Hence ordered

            That the case be and the same is allowed on contest with cost .

            The complainants do get Insurance claim of Rs. 45,293/- and compensation @ Rs.15,000/-  and litigation cost Rs.5,000/- payable by the Insurance company .

            The Insurance company is hereby directed to pay the entire amounts within 30 days .

            Let a copy of this order be made over to the parties free of cost.