BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL

FORUM, VELLORE DISTRICT AT VELLORE.

PRESENT:   THIRU. A. SAMPATH, B.A., B.L.,           PRESIDENT 

                                               TMT. G. MALARVIZHI, B.E.            MEMBER – I

                                           THIRU. K. DHAYALAMURTHI,B.SC.           MEMBER – II

                                                           CC. 9 / 2007

                             MONDAY THE 25^th  DAY OF OCTOBER 2010.

1. Dr. G. Kamaraj,

    S/o. S. Ganesan,

2. S. Ganesan,

    S/o. Subbarayan,

    Both are residing at

    No.2A, Ananda Bhavan,

    VOC, Street, Teachers Colongy,

    Vellore District.                                                                              …  Complainant.

       - Vs –

1. The Chairman and

    Managing Director,

    M/s. United India Insurance Co Ltd.,

    having his office at No.24,

    Whites Road, Royapettai,

    Chennai.

2. The Regional Manager,

    M/s. United India Insurance Co Ltd.,

    having his office at

   134, Greams Road,

   Thousand Lights,

   Chennai.

3. The Divisional Manger,

    United India Insurance Co Ltd.,

    TKM Complex, 1^st Floor,

    Katpadi Road, Vellore.

4. Senior Branch Manager,

    United India Insurance Co Ltd.,

    17 GPM Street,

    Gudiyattam.                                                                        … Opposite parties.

. . . . .

              This petition coming on for final hearing before us on 20.10.2010, in the presence of Thiru. T.M.Sivakumar,  Advocate for the complainant and Thiru. K.M.Boopathi, Advocate for the opposite parties 1 to 4, and having stood over for consideration till this day, the Forum made the following:

O R D E R

            Pronounced by Thiru. A. Sampath, President of the District Consumer Disputes Redressal Forum, Vellore District.

1.         The brief facts of the case of the complainant is as follows:

            The complainants 1 & 2 are son and father.  Since the 2^nd complainant is aged about 73 and as senior citizen he crave the permission of this Forum, that his son the 1^st complainant may be permitted to conduct the case on behalf of the 2^nd complainant as a beneficiary.   The 1^st complainant is a doctor by profession.  He had taken a Mediclaim policy “MEDSAVE HEALTH CARE” from the 4^th opposite party’s branch bearing No.012103/48/06/20/00000020 on 24.6.06 by paying a premium of Rs.8,208.40.  The said policy covers the entire family members viz.1. Dr. G. Kamaraj the 1^st complainant 2. Mrs. Vasuki his wife 3. Minor K. Prasanth  his son 4. Minor Priyadarshini daughter of the 1^st complainant 5. S. Ganesan father of the 1^st complainant and the 2^nd complainant herein 6. Mrs. G. Maragathem mother of the 1^st complainant i.e. policy cover for entire family for the period of 24.6.06 to 23.6.07.  This is policy is renewed 3^rd time.  As per the policy terms and conditions all the members mentioned in the policy coverage are entitled to get reimbursement of the Medical expenses made during the period of Insurance coverage.   The 2^nd complainant herein and father of the 1^st complainant while he was staying at Trichy he had gone for a walk on 2.8.06 at that time he suddenly fell down and he was admitted at Hospital for checkup and at that time it was find out that he is suffering by cataract on his left eye and also suffering from partial renal failure and he was advised to undergo surgery and treatment to clear the same.  The 2^nd complainant got admitted at M/s. AG EYE HOSPITAL TRICHY and cataract removed from his left eye and intraocular lens (IOL) was implanted got treatment for partial renal failure at M/s. Retna Labal Trichy Hospital after that the 2^nd complainant become normal and now he can walk without any problem in his eye sight.  He has spent a sum of Rs.18,317.58 towards the Medical Expenses of the 2^nd complainant as follows

For partial Renal failure treatment               :  Rs. 4,501 . 00

For eye cataract surgery                                          :  Rs.13816 . 58

                                                                                     ---------------------

                                    Total                                        :  Rs.18,317.58.

                                                                                     --------------------

and he paid the money from his pocket and after returned from Trichy with his father the 2^nd complainant on 17.8.06 he submitted the claim form to the 4^th opposite party for medical reimbursement and was under the bonafide impression he will get return the amount spent by him.  But the 4^th opposite party paid a sum of RS.9,666.00/- and rejecting the remaining amount on the basis that cost of spectacles and contact lens, hearing Aids, are excluded in clause 4.6. of the policy coverage and the 2^nd complainant is also suppressed the fact that he was suffering from Diabetes for past several years and rejected the claim on all for treatment expenses. 

2.         The complainant met the 4^th opposite party in person and explained to him that implanting the intra ocular lens (IOL) is not a spectacles nor contact lens and stitched permanently on the place of  original eye lens removed due to cataract, and it could not be removed till life time and with the lens only he can able to see and do his normal work.  2^nd complainant is normal while 1^st incepted into the policy first time and he made claim in the 2^nd year for the medical expenses incurred in that year and got reimbursement from the 4^th opposite party so there is no suppression of material fact apart from that he is a continuously subscriber for the previous two years before this policy.  But the 4^th opposite party blindly refused to accept the explanation given by this complainant.  He sent complaint to the 1^st opposite party who is the head of  the opposite parties 2 7 4 standing entire facts and copies also sent to the 2^nd and 3^rd opposite parties on 20.9.06 all the opposite parties received the same but none of them did not give reply to this complainant.   He again sent letter to the opposite parties on 3.10.06 only the 2^nd opposite party had given reply to this complaint stating that he is enquiring the matter with concerned branch i.e. 4^th opposite party and after got clarification from him he will send reply to this complainant, copies of the letters sent to the opposite parties on 20.9.06 and 3.10.06 and reply given the 2^nd opposite party on 9.10.06.  he was waiting with fond hope that he will get money spent by him as per the assurance given by the 2^nd opposite party.  But against his hope but there is no reply from the opposite parties till date.   So, there is purely deficiency of service on the part of the opposite parties because of the deficiency of service the opposite parties this complainant got mental agony, suffering and monetary loss for that the opposite parties are bound to pay compensation to this complainants.  The complainant therefore prayed for this forum to direct the opposite parties to pay the sum of  Rs.8651.50/- the cost of the intra ocular lens fixed in the eye of the 2^nd complainant and the partial renal failure expenses towards renal failure treatment and to pay a sum of Rs.2,00,000/- as compensation towards the negligence, mental agony and sufferings, and to pay a sum of Rs.25,000/- towards costs of this proceedings.                                                

3.         The averments in the counter filed by the  3^rd  opposite party and adopted by the opposite parties 1, 2 & 4 are as follows:

            The opposite parties denied all the allegations made in the complaint as the name is false.  The allegation made in the complain namely he had taken a Mediclaim policy “MED SAVE HEALTH CARE” from the company by paying premium of Rs.8,208/- and its cover his family members and period of coverage is 24.6.06 to 23.6.07 is hereby admitted.  But the other allegations made in the complaint namely the 2^nd complainant fell down and he was admitted in the hospital and he is suffering by cataract on his left eye and also suffering from partial renal failure and he got admitted at M/s. AGI Eye Hospital, Thiruchy and cataract removed from his left eye and an intra ocular lens (IOL) was implanted and also got treatment for other injuries are all hereby specially and categorically denied by the opposite parties as the same is false.   The conditions of the policy is very clear that the policy will not cover the cost of spectacles and contact lenses.  Now the complainant says that it was only intra ocular lens alone was implanted and it is not the contact lens.  The medical expenses says that the intra ocular lens is also a type of contact lens.  Therefore the complainant is not entitle to get amount spent for implanting IOL.   The 2^nd complainant was a known diabetic for the year 20 years which was preexisting at the time of inception of policy.  The said fact was deliberately and conveniently suppressed by the complainant.  The above said fact is found place in the discharge summary produced by the complainant itself.  The complainant cannot take advantage of reimbursement of the 1^st claim.  Even the complainants who have suppressed the above said ailment as stated in para -5 is not entitled to get the 1^st claim itself.  The opposite parties reserve their right to file separate suit for recover of money which they have received by suppressing the material facts.   The claim of the complainant was repudiated on specific allegations and there is no deficiency of service on the part of the opposite parties.   It is therefore prayed this Forum may be pleased to dismiss the complaint with cost.     

4.         Now the points for consideration are:

(a)  Whether there is any deficiency in service, on 

                 the part of the opposite parties?

            (b)  Whether the complainant is entitled to the

                 reliefs asked for?.

5.         Ex.A1 to Ex.A9 were marked on the side of the complainant and Ex.B1 to Ex.B3 were marked on the side of the opposite parties.  Proof affidavit of the complainant and  Proof affidavit of the  opposite parties have been filed.  No oral evidence let in by either side. 

6.         POINT NO. (a):-

            It is admitted facts of the parties that the 1^st complainant had taken a Mediclaim Policy “MEDSAVE HEALTH CARE” from the 4^th opposite party’s branch bearing No.012103/48/06/20/00000020 on 24.6.06 by paying a premium of Rs.8,208.40.  The said policy covers the entire family members of 1^st complainant and his mother & father i.e. 2^nd complainant for the period from 24.6.06 to 23.6.07.  As per the policy terms and conditions all the members mentioned in the policy coverage are entitled to get reimbursement of the medical expenses made during the period of Insurance coverage. 

7.         The complainant contended that the 2^nd complainant was suffering by cataract on his left eye and checkup and at that time it was find out that he is suffering by cataract on his left eye and also suffering from partial renal failure and he was advised to undergo surgery and treatment to clear the same.  Accordingly the 2^nd complainant got admitted at AG Eye Hospital, Trichy and cataract removed from his left eye and intraocular lens  (IOL) was implanted got treatment for partial renal failure at M/s. Retna Labal Trichy Hospital,  after that the 2^nd complainant become normal.  The 1^st complainant spent a sum of Rs.18,317.58 ( For Partial Renal Failure treatment Rs.4501./- + For eye cataract surgery Rs.13,816.58 = Rs.18.317.58) towards the Medical Expenses of the 2^nd complainant.    The 2^nd complainant had submitted the claim form to the 4^th opposite party on 17.8.06 for medical reimbursement but the 4^th opposite party paid a sum of Rs.9666/- only and rejecting the remaining amount on the basis that cost of spectacles and contact lens, hearing Aides, are excluded in clause 4.6. of the policy coverage.    The 1^st complainant has sent a letter to the 2^nd and 4^th opposite partly explained that implanting the intraocular lens (IOL) is not a spectacles nor contact lens and stitched permanently on the place of original eye lens removed due to cataract, and it could not be removed till life time and with the lens only he can able to see and do his normal work.  But the 4^th opposite party blindly refused to accept the explanation given by the 1^st complainant.  So there is purely deficiency in service on the part of the opposite parties because of the deficiency in service.  The complainant got mental agony, suffering and monetary loss. 

8.         The  opposite parties contended that the conditions of the policy is very clear that the policy will not cover the cost of spectacles and contact lenses.  Now the complainant says that it was only intraocular lens alone was implanted and it is not the contact lens.   But the medical experts says that the intraocular lens is also a type of contact lens and therefore the complainant is not entitle to get amount spent for implanting intraocular lens  (IOL).   Further opposite parties contended that the 2^nd complainant was a known diabetic for 20 years which was preexisting at the time of inception of policy.   The said fact was deliberately and conveniently suppressed by the complainant.   Accordingly the claim of the complainant was repudiated on specific allegations and there is no deficiency of service on the part of the opposite parties. 

9.         According to the opposite parties, as per the terms and conditions of the mediclaim insurance policy mentioned in Ex.B1 the policy will not cover the cost of spectacles and contact lens.  But the contention of the complainant that implanting the intraocular lens (IOL) is not a spectacles nor contact lens and stitched permanently on the place of original eye lens removed due to cataract, and it could not be removed till life time and with the lens only he can able to see and do his normal work.    From the perusal of Ex.B1 Mediclaim Policy No.4.6., it is seen that the policy will not cover the cost of spectacles and contact lens, hearing aids.  But no whisper about the implanted intraocular lens.  The opposite parties have not produced the medical experts, opinion or any documents before this Forum.

10.       Further the opposite parties have contended that the 2^nd complainant was  known diabetic for 20 years which was preexisting at the time of inception of policy.   But the 2^nd complainant was deliberately and conveniently suppressed by the complainant the above facts to the 4^th opposite party.  It is admitted fact of the parties that the as per Ex.B3, the mediclaim policy cover from the entire family of the complainant for the period from 24.6.06 to 23.6.07 and this policy is renewed three times.  From the perusal of Ex.B2, discharge summary of 2^nd complainant issued by the ABC Eye Hospital, Department of Nephrology.  Trichy, it is seen that the 2^nd complainant took treatment from 23.11.05 to 27.11.05 in the said Hospital (for Hyponatremia resting tachycardia – Postural fall BP (?) Autonomic dysfunction) and it is mentioned  that

Origin / Duration / Progression:

            Apparently health, a known hypertensive and diabetic individual on regular drugs

            Presented herewith above said complaints since preceding 3 to 4 days .”

Therefore it is clear that the contention of the opposite parties that the 2^nd complainant was known diabetic for 20 years which was preexisting at the time of inception policy, but the 2^nd complainant was deliberately and conveniently suppressed by the complainant is not acceptable.

11.       Hence taking into account with regard to the contention of the complaint and the counter, as well as proof affidavit of the both the parties and from the documents Ex.A1 to Ex.A9 and Ex.B1 to Ex.B3 we have come to the conclusion that though the 1^st complainant who is a doctor explained about the intraocular lens (IOC)  was implanted and it is not the contact lens through the letters Ex.A4, dt. 20.9.06 and Ex.A5, dt. 3.10.06 to the 2^nd and 4^th opposite parties are simply rejecting the expenses of implanted intraocular lens (IOC) to the complainant.  So there is purely deficiency in service on the part of the opposite parties because of the deficiency in service.  The complainant got mental agony, suffering and monetary loss for that the opposite parties are bound to pay compensation to the complainants.  Hence, we answer this point (a) accordingly.

12.       In view of our findings on point No.(a), as per the policy condition the opposite parties are jointly and severally directed to pay a sum of RS.8651/- the cost of the intraocular lens implanted in the eye of the 2^nd complainant and the  opposite parties are also directed  to pay a sum of Rs.2000/- as compensation for the  mental agony and sufferings.   Hence this point (b) is also accordingly. 

13.         In the result, this complaint is partly allowed.   As per the Policy condition, the opposite parties are jointly and severally directed to pay  a sum of Rs.8651/- the cost of the intraocular lens implanted in the eye of the 2^nd complainant.

           2. The opposite parties are also directed to pay a sum of Rs.2,000/-   as compensation  for the mental agony and sufferings.

3. and also to a pay a sum of Rs.1,000/- towards the cost of this complaint.    

          The opposite parties are also    hereby directed to pay the above said amounts within one month from the date of copy of receipt of this order, failing which, the complainants are also entitled to interest on the above said sum @ 9 % p.a from the date of default till the date of payment.

Dictated to the Steno-typist and transcribed by her, corrected and pronounced by the President, in Open Forum, this the 25^th  day of October  2010.

MEMBER-I                               MEMBER-II                                                     PRESIDENT.

List of Documents:

Complainant’s Exhibits:

Ex.A1 -

MEMBER-I                                    MEMBER-II                                                PRESIDENT.