Date of Filing:27.11.2009<br /> Date of Order: 11.08.2010<br /> <br /> 2<br /> <br /> BEFORE THE II ADDITIONAL DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SESHADRIPURAM BANGALORE-20<br /> <br /> Dated: 11TH DAY OF AUGUST 2010<br /> <br /> PRESENT<br /> <br /> <br /> <br /> Sri S.S. NAGARALE, B.A, LL.B. (SPL.), President.<br /> Smt. D. LEELAVATHI, M.A.LL.B, Member.<br /> Sri BALAKRISHNA. V. MASALI, B.A, LL.B. (SPL.), Member.<br /> COMPLAINT NO: 2796 OF 2009<br /> <br /> Ravikanth Angadi<br /> R/at No. 52, 4th Main<br /> Postal Colony, Sanjaynagar<br /> Bangalore 560 094 Complainant<br /> V/S<br /> 1. The Director<br /> United India Insurance Co. Ltd.<br /> No. 25 & 25/1, II Floor<br /> Vinod Complex, J.C. Road<br /> Bangalore 560 002<br /> <br /> 2. The Director<br /> E Meditek Solutions Ltd.<br /> Bangalore RO No. 36/1<br /> Dickenson Road<br /> Bangalore 560 042 Opposite Parties<br /> <br /> ORDER<br /> By the Member Smt. D. Leelavathi<br /> <br /> This is a complaint filed under Section 12 of the Consumer Protection Act.<br /> The complainant submits that he holds an individual mediclaim with opposite party No. 1 through a group insurance taken by M/s Swathi Mahila Sangha from 21st October onwards and the same was renewed for the year 2008 to 2009 July 12th policy No. 071800148108105100001395. The opposite party No. 1 is the insurance company and opposite party No. 2 is the third party administrator for opposite party No. 1. The complainant further submits he was suffering from decreasing vision and on consultation with the doctors in Nethradhama Hospitals Pvt. Ltd, Bangalore and he was diagnosed that he had high Myopic Astigmatism in his left eye. The doctors advised that if he should go in for a surgery. So the complainant under fear of loosing his vision got himself admitted in Nethradhama Hospital. The complainant was inferred that the cost of his surgery will be assured 1,00,000/-. On 11th Feb 2009, he underwent the surgery successfully and was discharged on 12th Feb 2009. Medical expenses towards hospitalization and surgery costs came up to 97,000. The opposite party had repudiated the claim of the complainant as per the terms and conditions of policy EXCLUSION. Under clause 4.6, the second opposite party has stated the reasons for repudiation of the claim of the complainant, as the complainant got treated for high myopic astigmatism/cosmetic or aesthetic treatment of any description such as surgery for correction of eye sight. On 4th March 2009 the complainant had sent his hospitalization claim form with relevant documents and was given the reference No. UI/SWAT/32009/00807478. On 9th March the complainant has shocked to receive a letter from opposite party No. 2 repudiation letter No. EMSL/REJ/32009/00042464 on the ground that the claim was not payable as per exclusion clause 4.6. When the complainant contacted the opposite parties for an explanation they offered no explanation for repudiating the claim. The complainant with no option sent a legal notice through his counsel on 17th July 2009.<br /> 2. After hearing the complaint was admitted and notices were issued to opposite party No. 1 and opposite party No. 2. Opposite party No. 1 appeared and opposite party No. 2 remained ex-parte.<br /> 3. In the version and affidavit of the opposite party No. 1 it has denied all the averments made in the complaint. The opposite party accepts that complainant was holding a mediclaim policy No. 0718001 48108105100001395.<br /> 4. Heard the arguments of complainant. Opposite party No. 1 has filed written arguments.<br /> 5. The points for consideration are:<br /> 1. Whether repudiation of claim is justified?<br /> 2. Whether there was deficiency of service on the part of the ops?<br /> 3. Whether the complainant is entitled for any reliefs?<br /> 6. The complainant has taken the right decision as advised by the doctors that he should go in for a surgery. There is a wide difference from contact lens to eye correction surgery. Contact lens is mainly used by youngsters it helps only for short sight and not for long sight deficiency. It is true that contact lens can be put on and taken off everyday. It is not a permanent fixture. In this present complaint the complainant has undergone RE-Toric Implantable contact lens Implantation[T-ICL] Guarded visual Prognosis TA and LE-Intralase with Custon Vue Lasik [I-Lasik] TA surgery on his eyes. So the opposite parties were deficient in their service by relying on the clause 4.6. In the same policy given by opposite parties under health insurance policy-group in clause 2.1 expenses on hospitalization for minimum period of 24 hrs are admissible. However this time limit is not applied to specific treatments which include eye surgery. The opposite parties are deficient in their service by over looking the above said policy condition. Hence we deem it fit to allow the complaint. The complainant is entitled to full policy coverage amount of Rs. 50,000/- though he spent Rs. 97,000/- for his treatment. The repudiation of lawful mediclaim put up by the complainant by the opposite parties is unjustified and wholly unwarranted in this case. The opposite parties should have accepted the claim and paid the insured amount of Rs. 50,000/- immediately. It is admitted decision of law that if more than one interpretation is possible, the interpretation which is beneficial to the consumer should be adopted and given effect to. Since, in this case the complainant has under gone eye surgery definitely he is entitled for the expenses spent for his treatment. The complainant has claimed Rs. 1,00,000/- as compensation from the opposite parties for deficiency of service and mental agony. The complainant has not proved as to how he has suffered mental agony so as to claim Rs. 1,00,000/- as compensation. Therefore, the claim of the complainant for grant of compensation is not allowed. Hence, for the above reasons we pass the following:<br /> ORDER<br /> 7. The complaint is allowed. The opposite party No. 1 is directed to pay Rs. 50,000/- to the complainant within 30 days from the date of this order. In the event of non-compliance of the order within 30 days the above amount carries interest at 6% p.a. from the date of this order till payment / realisation.<br /> 8. The complainant is also entitled for Rs. 1,000/- as costs of the present proceedings from the opposite party No. 1.<br /> 9. Send the copy of this Order to both the parties free of costs immediately. <br /> 10. Pronounced in the Open Forum on this 11TH DAY OF AUGUST 2010. <br /> Order accordingly,<br /> <br /> MEMBER<br /> We concur the above findings.<br /> <br /> MEMBER PRESIDENT<br />