PER SHRI. S.M. RATNAKAR – HON’BLE  PRESIDENT

1)        Both these complaints can be decided by common order as in both the complaints the parties to the complaints are the same and the claims have been made on the similar facts.

2)        In Complaint No.256/2011 an amount of Rs.19,296/- and in Complaint No.257/2011 an amount of Rs.20,516/- is prayed to be ordered and directed to be paid by the Opposite Parties as balance amount of medical expenditure incurred by the Complainant with interest @ 18% p.a. from the date of deduction of the claim amount till the realization of the aforesaid amounts. In each complaint an amount of Rs.10,000/- is prayed towards mental torture and harassment be directed to be paid by the Opposite Parties to the Complainant. It is also prayed that an amount of Rs.20,000/- in each complaint be ordered to be paid towards advocate’s fees plus cost of the complaint to the Complainant by the Opposite Parties.

3)        According to the Complainant, the Opposite Parties have caused deficiency of service and unfair trade practice while sanctioning the medical expenditure for the treatment she had obtained of each Eye Cataract Operation.  It is submitted that the medical treatment of illness of Left Eye Cataract was obtained by the Complainant on 11/10/2010 at Bombay City Eye Institute and Research Centre and she had incurred an expenditure of Rs.43,296/-.  The Complainant had also obtained medical treatment for Right Eye Cataract Illness on 05/10/2010 in the said institute and incurred expenditure of Rs.44,516/-.  It is submitted that the Complainant was insured herself for Rs.1,00,000/- and at the time of submission of her claim for the treatment of both the eyes and the policy was inforce.  The copy of the said policy is marked as Exh.‘A’ in both complaints.  According to the Complainant, the Opposite Party No.2, however, paid Rs.24,000/- for the treatment of each eye cataract treatment and deducted an amount of Rs.19,296/- towards the Left Eye Cataract treatment and Rs.20516/- towards the Right Eye Cataract treatment.  It is submitted that the Opposite Party No.2 wrongly deducted the valid claim lodged by the Complainant.  The Complainant accepted the amount paid by the Opposite Party No.2 under protest and prayed for the remaining amount to the Opposite Party No.2, but the Opposite Party did not pay the balance amount and informed the Complainant that as per the circular issued by Opposite Party No.1 an amount of Rs.24,000/- only is payable for treatment of cataract.  The Complainant has therefore, filed the complaint for each claim separately against the Opposite Parties and prayed for amounts as mentioned in para 2 of this order.

4)        The Opposite Party No.1 contested the claim by filing written statement.  It is contended that as per the terms and conditions of the mediclaim policy since 2007 the expenses for any cataract surgery will be limited to actual or maximum of Rs.24,000/- whichever is less.  It is contended that as per the terms of the policy the claim to the extent of Rs.24,000/- was paid by the Opposite Parties and balance amount was rightly deducted.  It is admitted that the Complainant had taken a policy from the Opposite Party No.1 in the year 1994 and it was renewed by paying the annual premium and the policy was valid from 18/09/2010 to 17/09/2011.  It is admitted that the said policy was for reimbursement of medical expenses incurred by the Complainant during the validity period of the policy. It is contended that the Complainant was fully aware of the terms and conditions of the policy and therefore, no reliefs should be granted to the Complainant.  The Opposite Party No.1 had denied the parawise allegations made in the complaint and prayed for dismissal of complaint.

5)        The Opposite Party No.2 though served remained absent, the complaint therefore, proceeded ex-parte against the Opposite Party No.2.

6)        The Complainant has filed her affidavit. The Opposite Party No.1 filed affidavit of Mr. S.C. Mohanti, Manager of the Opposite Party No.1.  Both the parties filed their written arguments.  We heard the oral arguments of Ld.Advocate Shri. Sureshchandra Chataule, for the Complainant and Smt. Parveen Contractor, Ld.Advocate for the Opposite Party No.1.  We have perused the documents filed in the complaint.       

7)        From the contentions raised by the Opposite Party No.1 in the written statement, it appears that the Opposite Party No.1 has not disputed that the Complainant is policy holder of mediclaim policy since 1994 and the policy was renewed regularly by paying the premium and it was valid for the disputed transaction and claims lodged by the Complainant.  The submissions made by the Ld.Advocate for the Opposite Party No.1 that as per mediclaim policy (2007) Clause 16 (f), the Opposite Party Nos.1 & 2 had rightly paid Rs.24,000/- to the Complainant for each cataract surgery and therefore, there is no deficiency on the part of Opposite Parties which amounts to unfair trade practice and on that count each complaint is liable to be dismissed, cannot be accepted as legal and proper.  The Complainant has produced the copy of terms and conditions of Mediclaim Insurance Policy (01/09/96).  In the said policy the restrictions imposed in the mediclaim policy, 2007 were not there for reimbursement of medical expenditure incurred by the Policy Holder.  The Opposite Party No.1 has admitted that initially the Complainant has obtained the policy in the year 1994 and the same was renewed by the Complainant from time to time by paying premium and therefore, in our view as per the observations of the Hon’ble Supreme Court in the case of Bimal Krishna Bose V/s. United India Insurance Co. Ltd., reported in III (2001) CPJ 10 (SC) the deduction of the medical expenditure incurred by the Complainant for her each eye cataract treatment is improper and arbitrary.  The Hon’ble Supreme Court in the aforesaid case held as under –

            “A renewal of insurance policy means repetition of the original policy.  When renewed, the policy is extended and the renewed policy in the identical terms from a different date of its expiration comes into force.  In common parlance, by renewal, the old policy is revived and it is sort of a substitution of obligations under the old policy unless such policy provides otherwise.  It may be that on renewal, a new contract comes into being, but the said contract is on the same terms and conditions as of the original policy.”

            The Opposite Party No.1 has also not brought on record that after completion of initial contract of policy agreed by the Complainant, the Complainant thereafter, agreed for alteration of material terms and conditions of the said policy.  We therefore, hold that as the Opposite Parties have not disputed that the Complainant had incurred an expenditure for treatment of each Eye Cataract Surgery as alleged in each complaint and as the Complainant has produced the expenditure bills of the said amount, the deduction made by the Opposite Parties is totally improper and arbitrary. We thus, hold that by deducting an amount of Rs.19,296/- for the Left Eye Cataract Surgery and Rs.20,516/- for the Right Eye Cataract Surgery from the claims lodged by the Complainant, the Opposite Parties have adopted unfair trade practice against the Complainant which amounts to deficiency of service.  In our view the Complainant is entitled for the reimbursement of the said amount with interest @ 6% p.a. from 15/11/2010 till its realization.  The Complainant has claimed compensation for mental torture and harassment in each complaint to the tune of Rs.10,000/-, we hold that an amount of Rs.5,000/- in each complaint on this count would be just and proper.  The Complainant has prayed Rs.20,000/- towards the advocate fees and cost of this complaint.  We hold that an amount of Rs.2,000/-in each complaint on this count would be justifiable. In the result we pass the following order –

O R D E R

i.         Complaint No.256/2011 & 257/2011 are partly allowed against the Opposite Parties.

ii.        Opposite Parties are directed to reimburse an amounts of Rs.19,296/- (Rs.Nineteen Thousand Two Hundred Ninety Six Only) &

           Rs.20,516/-(Rs.Twenty Thousand Five Hundred Sixteen Only) with interest @ 6% p.a. in Complaint No.256/2011 and 257/2011

           respectively from .15/11/2010 till its realization to the Complainant.

iii.       Opposite Parties are directed to pay to the Complainant an amount of Rs.5,000/- (Rs. Five Thousand Only) in each complaint

           towards the mental torture and harassment caused to the Complainant.

iv.       Opposite Parties are also directed to pay to the Complainant Rs.2,000/- (Rs.Two Thousand Only) in each complaint towards the

           advocate fees and cost of the complaint.

v.       Certified copies of this order be furnished to the parties.