DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Amarjit Singh s/o Sh. Kartar Singh, R/o #1649, Phase-10, Mohali.

                   --- Complainant

V E R S U S

The New India Assurance Co. Limited, SCO No. 36-37, Ground Floor, Sector 17-A, Chandigarh, through its Divisional Manager.

---- Opposite Party

BEFORE:      SH. LAKSHMAN SHARMA                    PRESIDENT

MADHU MUTNEJA                               MEMBER

                   SH.JASWINDER SINGH SIDHU             MEMBER

Argued By:             Sh. Gaurav Bhardwaj, Counsel for Complainant.

Sh. Pavinder Singh Bedi, Counsel for Opposite Party

PER JASWINDER SINGH SIDHU, MEMBER

1.                Briefly stated, the Complainant had taken a medi-claim insurance policy from the Opposite Party in 1994 for himself and his spouse so as to cater for unforeseen medical exigencies. The Complainant got the said medi-claim policy renewed every year and as such, Policy No. 35010034110100000028, valid from 27.4.2011 to 26.5.2012 was issued by the Opposite Party (Annexure C-1). During the currency of the policy, in question, the Complainant was diagnosed with Senile Cataract of the right eye by the doctors at the Grewal Eye Institute, Sector 9, Chandigarh, sometime in the first week of Oct., 2011 and was advised a procedure described as Phaco Premium Aspheric Single Piece IOL. The Complainant got his right eye operated on 08.11.2011 and paid an amount of Rs.15,800/- as advance on 07.10.2011 vide receipt no. CH253694. A bill for Rs.39,000/- was raised by the Eye Institute and the Opposite Party paid only Rs.24,000/- directly to the Eye Institute and rest of the amount of Rs.15,800/- paid by the Complainant was not refunded by the Opposite Party (copy of bill & receipt at Annexure C-2 and C-3). Accordingly, the Complainant approached the Opposite Party to know the reasons for denial of Rs.15,800/-, but when nothing fructify, the Complainant preferred the instant complaint seeking payment of Rs.15,800/- along with interest, compensation and costs of litigation. 

2.                Notice of the complaint was sent to Opposite Party seeking its version of the case.  

3.                Opposite Party its reply admitted the issuance of the policy in question, which was valid from 27.4.2011 to 26.4.2012. It is also admitted that the Complainant was diagnosed as a case Senile Cataract in right eye by the Grewal Eye Institute, and was advised surgery Phaco Premium Aspheric Single Piece IOL. It is pleaded that as per the record of the Grewal Eye Institute, the date of surgery was 08.10.2011 instead of 08.11.2011 as averred by the Complainant. It is asserted that the Raksha TPA Pvt. Ltd. approved the cashless facility of Rs.24,000/- to the Grewal Eye Institute Pvt. Ltd. for the treatment of Cataract RT as per rates agreed and policy limit (Annexure C). While denying that a sum of Rs.15,800/- had been illegally denied, it is pleaded that as per the insurance policy and as per circular in this regard, the maximum liability of the answering Opposite Party was to the extent of Rs.24,000/- in the case of Cataract (Circular Annexure D), which was sanctioned.  Denying all other allegations and pleading that the Complainant is not entitled to any amount from the answering Opposite Party, a prayer has been made for dismissal of the complaint. 

4.                Parties were permitted to place their respective evidence on record in support of their contentions.

5.                We have heard the learned counsel for the parties and have perused the record.

6.                The present complaint is borne out of the medi-claim of the Complainant for the reason that he had undergone Senile Cataract Surgery for the right eye at Grewal Eye Institute, Sector 9-C, Chandigarh. As per the Complainant it was the treating doctor’s advice that a single piece Aspheric IOL was implanted after the cataract surgery through Phaco procedure. The Complainant having incurred an expenditure of Rs.39,800/- on the surgery lodged his claim with the Opposite Party. The details of the expenses are annexed as Annexure C-2 which is on the pad and under the signatures of the treating doctor. While settling the claim of the Complainant, Opposite Party paid only Rs.24,000/- and the remaining amount of Rs.15,800/- was denied. The Opposite Party while denying the remaining part cited the clause of the terms & conditions of the policy and also a circular which is annexed as Annex.D with its reply.  

7.                Though the Complainant had claimed that when the Opposite Party supplied him with the policy document no terms and conditions were made available to him; whereas on the other hand, the Opposite Party while defending itself has claimed that the same were supplied along with the policy document. As the Complainant and the Opposite Party have tendered their respective affidavits, we feel in order to falsify the claim of the Complainant, the Opposite Party should have brought on record some cogent evidence to substantiate that the document Annexure-B which are the terms and conditions and run into as many as 15 pages was sent to the Complainant. In the absence of any such evidence from the side of the Opposite Party, it is difficult to believe their version. However, the very basis of the rejection of the claim of the Complainant is the circular which is dated 10.5.2012 (Annexure-D) through which the main office of the Opposite Party had directed all its Branches to limit the claim of cataract surgery to Rs.24,000/- per eye; and citing this ground, the Opposite Party paid Rs.24,000/- and denied the remaining Rs.15,800/- to the Complainant. 

8.                Interestingly, the claim of the Complainant is borne out of the policy which was valid for the period beginning 27.4.2011 to 26.4.2012 and the surgery for which the claim was lodged was performed on 8.10.2011 and was well within the currency of the policy under which the claim was preferred. Surprisingly, the circular on the basis of which the genuine claim of the Complainant was denied is actually dated 10.5.2012 and the same is well beyond the currency of the insurance policy. In the given situation, the Opposite Party has actually delayed the claim of the Complainant for nearly seven months, which was mandated to be settled within one month after it as lodged with them; whereas, the Opposite Party have not cited any reason for such a delay and adding insult to the injury of the Complainant repudiated the claim on the basis of circular which was an intra-office communication of the Opposite Party, which was not made available to the Complainant at the time of beginning of the policy. The Opposite Party has wronged the Complainant on the basis of a document which in no manner has any bearing on neither the policy subscribed by the Complainant nor its terms and conditions and that too the ground which came into existence after happening of the event for which the claim was lodged. Hence, the Opposite Party is found deficient in not giving proper service to the Complainant by denying him his genuine claim.

9.                In the light of above observations, we are of the concerted view that the Opposite Party is found deficient in giving proper service to the complainant. Hence, the present complaint of the Complainant deserves to succeed against the Opposite Party, and the same is allowed, qua it. The Opposite Party is directed to:-

[a]     To pay Rs.15,800/ remaining part of the claim;

[b]     To pay Rs.7,000/-on account of deficiency in service and causing mental and physical harassment to the Complainant; 

[C]    To pay Rs.5,000/- as cost of litigation;

10.              The above said order shall be complied within 45 days of its receipt by the Opposite Party; thereafter, it shall be liable for an interest @18% per annum on the amount mentioned in per sub-para [a] & [b] of para 9 above, apart from cost of litigation of Rs.5,000/-, from the date of institution of this complaint, till it is paid.  

11.              Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced

26^th April, 2013.                                           

                                          Sd/-

(LAKSHMAN SHARMA)

PRESIDENT

Sd/-

 (MADHU MUTNEJA)

MEMBER

Sd/-

(JASWINDER SINGH SIDHU)

MEMBER