BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (CENTRAL)
MAHARANA PARTAP BUS TERMINAL, 5TH FLOOR,
ISBT, KASHMERE GATE: DELHI-110006
No. DF(Central)/2015/ Dated:
Complaint Case N0. 5 of 2013
Sh. Sunil Kumar Saini
S/o Sh.Jaswant Singh Saini
R/o WZ-520, Palam Village
NEW DELHI Complainant
Versus
The Branch Manager
The New India Assurance Co. Ltd.
C.D.U. 323200, Gulab Bhawan-6,
B.S. Zafar Marg,
New Delhi – 110 002
HEAD OFFICE
The New India Assurance Co. Ltd.,
New India Assurance Bldg. 57,
M G Road, Fort,
MUMBAI – 400 001 Opposite Parties
ORDER
Complaint under Sec.12 of the CPA 1986 as amended upto date
Per Sh. Rakesh Kapoor, President
The complainant is holder of a Family Floater Medi-claim policy issued by the OP. He had first purchased this policy on 13.5.2010 and has been renewing it year after year. The policy was operative till 12.4.2013. It is alleged by the complainant that he was detected with a disease called Choriditis Patch at Macula – Retina in Right Eye on 25.8.2011. He was advised by Dr. Neeraj Sanduja to get himself admitted in the hospital for the treatment of the said disease and an injection namely Lucentis was injected into his eye five times at a cost of Rs.3,35,695/-. The complainant had lodged a claim with the OP which was repudiated on the ground “repudiation is non-hospitalization for 24 hours”.
The complainant has alleged that the repudiation of the claim was illegal and unwarranted as he had undergone the treatment under medical advice. Hence, the complaint.
After service of the complaint had been effected on the OP, its counsel had appeared on different dates and had supplied an advance copy of its reply to the complainant. However, the original reply was never filed on the record. No evidence of the OP has also been placed on record even though written arguments have been filed on behalf of the OP.
We have heard arguments advanced at the bar and have perused the record.
The facts are not in dispute the complainant is holding a family floater mediclaim policy from the OP. During the subsistence of the said policy he had undergone a procedure in his right eye. The procedure had cost him Rs.3,35,695/-. The claim lodged by the complainant has been repudiated by the OP insurance company on the ground that it is an OPD treatment and falls outside the scope of the health policy. The question for consideration is as to whether the OP shall justify in repudiating the claim lodged by the complainant. The complainant has placed on record a copy of the e-mail which he had received from Dr. Girdhar to whom he had requested for guidance/opinion of lucentis injection. Dr. Girdhar had made the following observations:
1.Lucentis is a day care procedure performed in the operation theatre.
2. This is a procedure where the lucentis is injected into the vitreous cavity of the eye. Therefore this is an intraocular procedure which cannot be done in OP department. This procedure has to be done in a sterile condition therefore it is always done in the operation theatre.
The complainant has placed on record the copy of the certificate issued by Dr. Neeraj Sanduja in this regard. The certificate reads as under:-
This is to certify that Mr. Sunil Saini was diagnosed to have Right eye CNVN and received Intra Vitreous injection Lucentis for that. This is to affirm that this procedure is an operation theatre procedure and needs day care admission. This procedure is not done in OPD in view of __________.
In this face of the aforesaid opinion/certificate, it appears to us that the OP was not justified in repudiating the claim lodged by the complainant on the plea that the treatment taken was an OPD procedure.
We hold the OP is deficient in rendering service to the complainant and directed as under:-
- Pay to the complainant a sum of Rs.3,00,000/- (Three Lacs Only) alongwith interest @ 10% p.a. from the date of institution of this complaint i.e. 18.1.2013 till payment.
- Pay to the complainant a sum of Rs.5000/-(Rupees Five Thousand only) for pain and mental agony suffered by the complainant.
- Pay to the complainant a sum of Rs.5000/- (Rupees Five Thousand only) as cost of litigation.
The OP shall pay this amount within a period of 30 days from the date of this order failing which they shall be liable to pay interest on the entire awarded amount @ 10% per annum. IF the OP fails to comply with this order, the complainant may approach this Forum for execution of the order under Section 25/27 of the Consumer Protection Act.
Copy of the order be made available to the parties as per rule. File be consigned to record room.
Announced in open sitting of the Forum on.....................
(NIPUR CHANDNA) (DR. VIKRAM DABAS) (RAKESH KAPOOR) MEMBER MEMBER PRESIDENT
