BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I, U.T. CHANDIGARH

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Shri Harish Chander Soni, aged about 72 years, s/o Late Sh. K.L. Soni, r/o Flat No. E-319, Group Housing No.2, Shikhar Apartments, Sector 5, Mansadevi Complex, Panchkula, Haryana.

…..Complainant

                 V E R S U S

1]  The New India Assurance Company Ltd., through its Branch Manager, SCO No. 54-55, Sector 34-A, U.T. Chandigarh – 160 034.

2]  Raksha TPA Pvt. Ltd., through its Managing Director, 15/5, Mathura Road, Faridabad 121 003 Haryana.

                      ……Opposite Parties

CORAM:   SH.P.D.GOEL                   PRESIDENT

         SH.RAJINDER SINGH GILL       MEMBER

         DR.(MRS) MADANJIT KAUR SAHOTA, MEMBER

Argued by: Sh.Neeraj Pal Sharma, Counsel for Complainant.

          Sh.Sukhdarshan Singh, Counsel for OPs.         

PER DR.(MRS) MADANJIT KAUR SAHOTA, MEMBER

        The complainant has filed the present complaint under Sec.12 of the Consumer Protection Act (as amended upto date) “hereinafter referred to as the Act”. The Complainant took a Mediclaim/ Hospitalization Policy for himself as well as his spouse namely Smt. Veena Soni, from OP No.1 on 3.3.2005, which was renewed from time to time and lastly renewed on 15.2.2010 for the period 3.3.2010 to 2.3.2011. During the currency of the policy in question i.e. 1^st week of Feb.2011, the Complainant was diagnosed with Cataract of the Left Eye by the doctors at the Grewal Eye Institute, Sector 9-C, Chandigarh and was advised a Procedure described as PHACO of the left eye. Accordingly, the Complainant informed the OP No.2 vide request note Annexure C-3 that he would be undergoing a PHACO of the left eye which would require a timeline of about 3-4 hours with a private room and a package cost of Rs.67,00/- plus taxes as applicable and requested for approval of cashless settlement. In response thereto, OP No.2 vide its return fax dated 8.2.2011 accorded a cashless settlement sanction of Rs.39,000/- only for the procedure to be accomplished on 11.2.2011. Left with no other option, the Complainant made the payment of the balance amount of Rs.28,000/- to the said Eye Institute on the day of procedure. Hence this complaint alleging that the aforesaid acts of the OPs amount to deficiency in service and unfair trade practice.

2.       The OP No.1 in its reply, while admitting the factual matrix of the case, pleaded that there was no deficiency in service on their part as it had authorized OP No. 2 to settle the claim on merits and as per terms and conditions of the Mediclaim Policy. The claim amount sanction was immediately conveyed by the OP No. 2 to the Complainant. All other material contentions of the complaint were controverted. Pleading that there was no deficiency in service on their part, a prayer has been made for dismissal of the complaint.

3.       The OP No.2 in his reply, while admitting the core facts of the case, pleaded that upon submission of the proposal for treatment of eye for the total package of Rs.67,000/- by the Complainant, the replying OP examined the proposal thoroughly and passed the claim as per terms and conditions of the Mediclaim Policy clause 2007. The Complainant was paid the claim amounting to Rs.43,017/- for the whole treatment. The Complainant underwent cataract surgery for eye with multifocal lens. Multifocal lens is used to remove glasses after cataract surgery and the removal of glasses being a cosmetic procedure, is out of the scope of the Mediclaim Policy. Under Section 2.0 of the Mediclaim Policy 2007 reasonable customary and necessary expenses are reimbursed. Denying all the material allegations of the Complainant and pleading that there has been no deficiency in service or unfair trade practice on their part prayer for dismissal of the complaint has been made.

4.       Parties led evidence in support of their contentions.

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

6.       The main contention of the complainant in this complaint is that OPs have illegally denied of making payment of Rs.28,000/- out of total expenses of Rs.67,000/- as spent on the said treatment under the aegis of the policy in currency, on the pretext of the issue of the unreasonableness of the Phaco Laser Surgery of the left eye of the complainant. He further asserted that the mediclaim insurance policy was issued to the complainant by the OPs in the year 2005, renewed without any gap till date, no exclusions or restrictive clauses were ever communicated to him on or after renewal made on 15.2.2010, whereas in fact procedure of eye surgery is squarely covered as per the terms of Clause 2.3 of the policy in question. So, the conduct of the OPs in denial of the sum of Rs.28,000/- amounts to unfair trade practice as well as deficiency on their part.

7.       On the other hand, OP No.1 had admitted to the extent that mediclaim policy No.350105/34/08/11/00000672 of the complainant was renewed for the period 3.3.2010 to 2.3.2011. The claim amount sanctioned was immediately conveyed to OP No.2, who is authorized to settle the claim on merits as per terms & conditions of the mediclaim policy.

8.       OP No.2 admitted to the extent that total package of Rs.67,000/- submitted by the complainant for treatment of the eye, did not tentamount to admission of liability for full amount, because such liability is limited to the treatment of Cataract Surgery only. He further submitted that it was after thorough examining of the proposal, the claim was passed as per terms & conditions of the mediclaim policy clause 2007; moreover, cataract surgery for eye by using multifocal lens to remove glasses, is a cosmetic procedure, which is out of the scope of Section 2.0 of the mediclaim policy.   

9.       In view of the facts & circumstances of the above mentioned case and perusal of the documents placed on file by both the parties, it has been observed that complainant has rightly obtained a mediclaim/hospitalization policy for which regular payment as well as the renewal by the OPs was duly made. The complainant when filed a mediclaim amounting to Rs.67,000/- for undergoing cataract operation in the left eye, the claim was partly allowed by the OPs and paid a sum of Rs.39,000/- to the complainant and denied the balance amount of Rs.28,000/- during the currency of the renewal policy. The complainant in terms of the procedure, accrual a claim under the policy in question, informed the OP No.2, vide admission request note dated 11.02.2011 (Annexure C-3), issued by the Operating Eye Institute, which was faxed to the OP No.2 for  approval for cashless settlement. OP No.2, on the other hand ordered a cashless settlement of Rs.39,000/- only (Annexure C-4), saying that payment has been made within the reasonable parameters of the charges to be incurred on the said treatment. The contention of the OP regarding exclusion or restrictive clauses regarding exclusion of treatment of Phaco - Multifocal Lens, has not been described anywhere in the insurance policy. Therefore, it has been observed that OP No.2, who assessed all such claims, is a specialized agency (instituted under the Insurance Act, 1938 by the IRDA) expertise to specifically deal with such like claims as the present mediclaim of the complainant. So, the justification of the OPs, by denying the full claim and deducting partially amount saying that the said amount is on the higher side, has no logic. Therefore, under the pretext of paying only reasonable charges and denying payment for multifocal lens as per terms & conditions has no ground to deny the claim; moreso is surely a lapse on their part because all the assertions by OPs have been repudiated by the complainant (Annexure C-1 to C-6). The only document on which the entire mediclaim of the complainant is based is the Insurance Policy, which did not find mention in any such clause as has been pretended by the OPs.

10.      Keeping in view the above discussions, we are of the considered opinion that the present complaint has a lot of merit, weight and substance and the same must succeed. So, the complaint is accordingly allowed. The Insurance Company-OP No.1 is directed to pay to the complainant the balance amount of Rs.28,000/- alongwith interest @ 9% p.a. from the date of filing of the complaint i.e. 28.2.2011 till its payment. OP No.1 is also directed to pay to the complainant Rs.5500/- as compensation for causing physical harassment, mental agony and also Rs.3500/- on account of litigation costs. The OPs shall comply with the said order within a period of 30 days from the date of receipt of its certified copy, failing which OP No.1 shall pay the aforesaid amount alongwith penal interest @ 12% per annum till realization of the awarded amount.

11.      Certified copies of this order be sent to the parties free of charge. The file be consigned.