Date of Filing : 14.09.2011
Date of Order : 27.03.2012
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, KOLAR
Dated 27th MARCH 2012
PRESENT
Sri. H.V. RAMACHANDRA RAO, B.Sc., BL, ……. PRESIDENT
Sri. T.NAGARAJA, B.Sc., LLB. …….. MEMBER
Smt. K.G.SHANTALA …….. MEMBER
CC No. 195 / 2011
Sri. D. Shanth Murthy,
S/o. Doddappaiah,
Aged about 58 years,
R/at: Byre Gowda Compound,
Kolar.
(By Sri. A. Srinivasa, Adv.) ……. Complainant
V/s.
1. The Managing Director,
Kolar Milk Union,
NH-4, Huthur Post,
Kolar.
2. M/s. Medi Assist Ind. TPA Pvt. Ltd.,
“Shilpa Vidya”, 3rd Floor,
No. 49, 1st Main Road,
Sarakki Indl. Layout, III Phase, J.P.Nagar,
Bangalore.
3. The Oriental Insurance Co. Ltd.,
Regional Office, No. 44/45,
Leo Shopping Complex, Residency Road,
Bangalore – 560 025.
(By Smt. Radha Kumar, Adv. for OP1)
(By Sri. B. Kumar, Adv. for OP3) …… Opposite Parties
ORDER
By Sri. H.V. RAMACHANDRA RAO, PRESIDENT
The brief antecedents that lead to the filing of the Complainant made u/s. 12 of the C.P. Act, 1986 seeking direction to Ops to pay Rs.48,619/- with interest @ 18% P.A. to the Complainant are necessary:
Complainant is working as a Asst. Manager – Marketing, under the OP1 who had obtained Group Mediclaim Policy through other Ops which covers all their employees, their family members and dependents of the employees of the OP1. Daughter of the Complainant Nayana S. Murthy was admitted to Narayana Nethralaya on 22.10.2010 and she has undergone eye surgery of Bilateral Lasik on 23.10.2010 and discharged on 24.10.2010. Complainant has paid Rs.38,618.74. Complainant sought reimbursement of the said amount as per the terms & conditions of the Policy. Ops have declined to grant the relief. Hence the Complaint.
2. In this case OP2 though served remained absent throughout the proceedings. In brief version of other OPs are:-
Work of the complainant under the OP1, OP1 taking the insurance by paying premium with the OP2 and the OP2 issuing Policy are admitted. The surgery of the Complainant’s daughter is admitted, his claim is admitted, but rejection is proper. The surgery of correction of eye sight, cost of spectacles, contact lenses, hearing aids etc., are not covered under the schedule. As such, Ops have repudiated the claim which is just & proper.
3. To substantiate their respective cases, parties have filed respective affidavit. Arguments were heard.
4. Point that arise for our consideration are as under:
POINTS
(A) Whether there is deficiency in service on the part of Ops ?
(B) What Order ?
5. Our answers for the above points are as under:
(A) Positive
(B) As per detailed order for the following reasons
REASONS
6. Point Nos. A & B - Reading of the pleadings in conjunction with the affidavits and documents on record, it is an admitted fact that the Complainant is an employee of OP1. It is also an admitted fact that OP1 had taken Group Insurance from OP3 with respect to all its employees and their family members and the same was valid during the period in question. It is also an admitted fact that Complainant’s daughter by name Nayana S. Murthy was admitted to Narayana Nethrayala on 22.10.2010 and she has undergone eye surgery “Bilateral Lasik” on 23.10.2010 and discharged on 24.10.2010. Expenses of Rs.38,618.74 was incurred by the Complainant in this regard. It is also an undisputed fact that Ops have repudiated the claim. Now, we have to see whether the repudiation is justified or not.
7. The daughter of the Complainant had undergone Bilateral Lasik Topical Anesthesia and her eye sight was rectified. The schedule in the Policy does not exclude Lasik operation. The only contention is that this surgery is for correction of eye sight and hence the insurance is not liable. Here cost of spectacles, contact lenses, hearing aids are excluded. The Lasik operation is not excluded. The Lasik is not only correction of eye sight, but it has different conception also. The very thin Lasik in the eye boll has to be opened, surgical operation is to be made in the pupil, again the black portion in the eye has to be replaced, all these things is to be done with machines with utmost care and caution. Eye drops has to be given which has to be tapered for about 2 months and if there is any problem, then the surgeon is responsible. Here all these things are not excluded under the Policy. OP would have specifically stated in the Policy that this Lasik is not covered under the Policy, but that has not done so. Merely stating that correction surgery of eye sight is not permissible, does not state anything with respect to Lasik surgery and hence under these circumstances repudiation is unjustified. It amounts to deficiency in service. Hence, we hold the points accordingly and we pass the following order:
ORDER
1. Complaint is allowed in part.
2. OP3 is directed to pay to the Complainant a sum of Rs.38,618.74 together with interest thereon @ 12% P.A. from 24.10.2010 until payment within 30 days from the date of this order.
3. OP3 is also directed to pay costs of Rs.2,000/- to the Complainant.
4. OP3 is directed to send the above said amounts as ordered at serial Nos. 2 & 3 above to the complainant by way of DD through RPAD and submit the compliance report along with necessary documents to this Forum within 45 days from the date of this order.
5. Send copy of this Order to the parties free of costs.
6. Return extra sets to the parties concerned under the Regulation 20(3) of the Consumer Protection Regulations 2005.
7. Dictated to the Stenographer, got it transcribed and corrected and pronounced in the open Forum on this the 27th day of March 2012.
T. NAGARAJA K.G.SHANTALA H.V.RAMACHANDRA RAO
Member Member President
SSS
