Delhi

West Delhi

CC/09/162

ABHINAV - Complainant(s)

Versus

The New India Assurance Co. Ltd - Opp.Party(s)

01 Mar 2017

ORDER

CONSUMER DISPUTES REDRESSAL FORUM (WEST)

GOVERNMENT OF NCT OF DELHI

150-151, Community Centre, C-Block, Janakpuri, New Delhi – 110058

 

  Date of institution: 18.02.2009 

Complaint Case No.162/09                                                   Date of order: 01.03.2017

IN  MATTER OF

Shri Abhinav Goel R/o. 257, Ambica Vihar, Paschim Vihar, P.O. Sunder Vihar, New Delhi-110087.                                                                                    Complainant

VERSUS

The New India Assurance Co. Ltd., 260 Anna Salai, Chennai-600601.                                                                                                                               Opposite party No.1

 

TTK Health Care Services Pvt. Ltd., 7 Jeewan Bhim Nagar, Main Road, Hal III Stage, Banalore-560075.                                                                            Opposite party No.2

 

Sri Balaji Action Medical Institute, FC-34, A-04, Paschim Vihar, New Delhi.                                                                                                                    Opposite party No.3

 

ORDER

R.S. BAGRI,PRESIDENT

 

1.           Shri Abhinav Goel named above hereinafter referred as the complainant has filed the present complaint under Section 12 of the Consumer Protection Act 1986 for directions to The New India Assurance Company Ltd. and others hereinafter referred as the opposite parties to pay a sum of Rs.41,081/- spent for his treatment with interest @18% per annum and Rs.20,000/- as compensation on account of deficiency in service on the part of the opposite parties and mental pain and agony suffered by the complainant.

 

2.           The brief necessary facts of the complaint as stated are that the complainant holds a medi claim cashless policy no.71250034073800000003/405705 w.e.f. 01.05.07. The opposite party no.2 is medical agent of the opposite party no.1.

 

3.           That the complainant was suffering from Bilateral Gynaecomastia. He was to be operated upon and surgery for removal of glands caused due to excess of fat in the body was covered under the medi claim policy. The complainant went to Sri Balaji Action Medical Institute  opposite party no.3 for removal of glands caused due to excess of fat in the body of the complainant and deposited all documents including cashless insurance medi claim papers with the opposite party no.1. The opposite party no.3 refused to give cashless medi claim facility to the complainant on the ground that the opposite party no.2 refused  to entertain claim of the complainant on the ground that “Cosmetic  Surgery not payable by Insurance”.

 

4.           That in fact the surgery was done for the disease as stated above and cannot be termed as cosmetic. The complainant tried to convince the opposite party no.3. But the opposite party no.3 refused to entertain the complainant and told him that he will have to bear all cost of surgery himself as the opposite party no.3 has no bearing with the opposite parties no.1 and 2.

 

5.         That the complainant was suffering from Bilateral Gynaecomastia for the last 5 years which could be removed by medical surgery and was to be operated on attaining age of 18 years. The complainant was left with no option except to get himself operated on his own expenses as non-operation could lead to grave physical disfirmity. He was admitted in the opposite party no.3 on 13.07.07  and discharged on 14.07.07 after surgery. He had to pay a sum of Rs.41,081/- to the opposite party no.3 on account of deficiency in service on the part of the opposite parties. The opposite parties have failed to reimburse medical treatment charges of Rs.41,081/-. The complainant on 05.11.07 sent legal notices to the opposite parties to refund the medi claim charges. The opposite parties vide reply dated 24.12.07 refused to reimburse the medical charges. All the opposite parties are jointly and severally liable to pay compensation on account of deificiency in service on the part of the opposite parties. Hence the present complaint for directions to the opposite parties to reimburse sum of Rs.41,081/- spent by him on his treatment with interest @18% per annum and pay Rs.20,000/- as compensation on account of deficiency in service on the part of opposite parties.

 

6.         After notice the opposite party no.1 filed reply while contesting the complainant and raising preliminary objections of cause of action and maintainability. The complaint is false, frivolous, baseless and flagrant abuse of process of law and prayed for dismissal of the complaint.

 

7.         However, on merits it is admitted that the complainant was a cashless medi claim policy holder of the opposite party no.1. But as per terms and conditions no.4 and 5 of the insurance policy cosmetic treatment is not payable by the opposite party no.1. Therefore, claim of the complainant was rejected on the ground that “Cosmetic Surgery not payable by Insurance”.  The notes dated 30.05.06 given by Tandon Clinic shows that the complainant was advised surgery i.e.  Excision and Liposuction. All other allegations of the complaint are vehementally denied and once again prayed for dismissal of the complaint.

 

8.           The opposite party no.3 also filed reply while contesting the complaint and raising preliminary objections of cause of action, maintainability and the complaint is false and frivolous. The complainant has not alleged any deficiency in service on the part of the opposite party no.3 and prayed dismissal of the complaint.

 

9.           However, on merits, the opposite party no.3 admitted that the complainant was admitted in the opposite party no.3 on 13.07.07 vide I.P. no.07/05451 in Plastic Surgery Department for surgical correction of B/L Gynaecomastia. He was operated and discharged on 14.07.07. There is no connection or concern amongst the opposite party no.3 and the opposite parties no.1 and 2. The opposite party no.2 refused to pay surgical charges on the ground that “Cosmetic  Surgery not payable by Insurance”. The opposite party no.3 rightly took charges of Rs.41,081/- from the complainant for the surgery. All other allegations of the complaint are vehementally denied by the opposite party no.3 and once again prayed for dismissal of the complaint.

 

10.         Despite service none appeared on behalf of the opposite party no.2 , therefore, the opposite party no.2 was proceeded against exparte vide order dated 01.05.09.

 

11.         The complainant filed rejoinders to the replies of the opposite parties no.1 and 3 while controverting stand taken by the opposite parties no.1 and 3 and reiterating his stand. He once again prayed for directions to the opposite parties to reimburse  the expenses of the surgery and pay compensation for deficiency in service.

 

12.         When the parties were asked to lead evidence, Shri Abhinav Goel, complainant submitted his affidavit dated 16.11.09 narrating facts of the complaint. The complainant in support of his version relied upon medi claim insurance policy no. 71250034073800000003/405705 w.e.f. 01.05.07 with terms and conditions, note from Tandon Clinic, test reports, admission and discharge record, receipts of payment, legal notice with acknowledgements and reply of the legal notice.

 

13.         The opposite party no.1 tendered in evidence affidavit of Shri Nand Kishore, Manager dated 11.09.09 narrating facts of their reply.

 

14.         The opposite party no.3 filed affidavit of Shri K.N. Gulati, Manager dated 16.11.09 narrating facts of reply of the opposite party no.3. The opposite party no.3 relied upon Annexure-R1 request for admission, Annexure-R2 admission form, Annexure-R-3 discharge summary, Annexure-R4 patient history with physical record, Annexure-R5 post operative instructions, Annexure-R6 nurses sheet and Annexure-R7 test reports.

 

15.       From the complaint,  replies of the opposite parties no.1and 3, affidavits and documents relied upon by both the sides it is proved that the complainant was suffering from Bilateral Gynaecomastia. He was advised surgery i.e.  Excision and Liposuction on 30.05.06. The complainant submitted his papers with the opposite party no.3 for cashless medi claim facility for the operation. The opposite party no.3 submitted the papers of the complainant with the opposite party no.2. He refused to pay the medical expenses on the ground that “Cosmetic  Surgery not payable by Insurance”. Therefore, the complainant had to take treatment on payment of Rs.41,081/-. The complainant submitted the medical claim with the opposite party no.1. They refused to reimburse the medical expenses on the ground that “Cosmetic  Surgery not payable by Insurance”. The complainant  sent legal notices to the opposite parties. But the opposite parties again refused to reimburse the medical claim  of the complainant on the ground that “Cosmetic  Surgery not payable by Insurance”.

 

16.       There is  note from Tandon Nursing Home that “Excision and Liposuction is not cosmetic surgery it comes under the ambit of corrective surgery”. There is also Annexure-R3 discharge summary. Which shows that  complainant was admitted in the opposite party no.3 for surgical correction. There is sufficient evidence in the form of affidavit of complainant, note from Tandon Nursing Home and discharge summary of the opposite party no.3 to prove that surgery/operation i.e.  Excision and Liposuction is not cosmetic surgery and the same is a correctional surgery.

 

17.       The case of the opposite party no.1 is that removal of glands by Excision and Liposuction is “Cosmetic  Surgery not payable by Insurance” and is cosmetic surgery. But there is nothing on the record to prove that removal of glands by Excision and Liposuction is “Cosmetic  Surgery”.

 

18.       Therefore the complainant succeeded to prove that he was suffering from Bilateral Gynaecomastia. He required surgery/operation i.e.  Excision and Liposuction. The same is correctional surgery and not cosmetic surgery. There is no term and condition in the medi claim insurance policy that medical expenses born by the complainant for correctional surgery cannot be reimbursed under the medical claim policy of the complainant with the opposite partyno.1. But the opposite party no.1 without any reason refused to honour cashless medi claim facility provided to the complainant and refused to reimburse Rs.41,081/- born by the complainant on his treatment. Hence there is unfair trade practice and deficiency in service on the part of the opposite party no.1.

 

19.         The complainant has spent Rs.41,081/- on his treatment. He has also suffered mental and physical agony on account of unfair trade practice and deficiency in service on the part of the opposite party no.1.

 

20.     Therefore, we direct the opposite party no.1 to reimburse Rs.41,081/- expenses born by the complainant on his correctional surgery with interest @9% per annum from the date of filing the complaint till actual realization of the amount and pay a sum of Rs.20,000/- as compensation on account of mental and physical agony suffered by him on account of unfair trade practice and deficiency in service on the part of the opposite party no.1.

          Order pronounced on : 01.03.2017

  • Compliance of the order be made within 30 days after receipt of the order.
  • Copy of order be sent to the concerned parties free of cost.
  • Thereafter, file be consigned to record.

 

 

 

 

 

                       (URMILA GUPTA)                                          (R.S.  BAGRI)

                                        MEMBER                                                           PRESIDENT

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