ORDER

BY SRI.H.R.SRINIVAS, PRESIDENT.

This is the Complaint filed by the Complainant U/S Section 35 of Consumer Protection Act 2019, against the Opposite Parties (herein referred in short as O.Ps) alleging the deficiency in service in not paying the entire hospital expenses incurred by the complainant while getting operated for her cataract of both eyes and for payment of the balance of the amount paid by her to the hospital in respect of the said two cataract operation i.e., Rs.93,672/- along with interest at 18% p.a., and Rs.25,000/- as damages for causing mental agony, harassment and Rs.10,000/- towards legal expenses and for other reliefs as the Commission deems fit.

2.      The brief facts of the complaint are that;

The complainant obtained mediclaim policy from OP1 being administered by OP2.  She obtained the mediclaim policy for the last twenty years and has been renewing the same.  The said recent renewed policy is from 31.12.2018 to 30.12.2019 and the same renewed for the further period of 31.12.2019 to 30.12.2020.

3.      It is further contended that after receiving the premium fixed OP1 issued the certificate with terms and conditions with no specific qualification.  

4.      She underwent cataract operation on her right eye in Prabha Eye clinic as per their advise.  A certificate was also issued to that effect. She incurred a sum of Rs.88,772/- as expenses for her cataract operation including the surgery charges, medicines, medical tests.  The hospital issued a bill for Rs.85,000/- dated 11.03.2019.  She made a claim with OP for Rs.88,772/- against which OP paid Rs.32,000/- only by disallowing the remaining amount of Rs.56,772/-.  When sought explanation and clarification for such an act, OP sent an email stating that they ought to have paid further sum of Rs.5,772/- by mistake the same was not paid and sought for approval/consent for paying the same.  The act of OP in not paying the entire amount of hospital medical expenses amounts to deficiency in service.  Complainant had to undergo cataract operation as per the recommendation of the expert doctor and it was not her choice to choose surgery and medicine. 

5.      Further no rider or qualification has been mentioned in the mediclaim insurance contract. The act of declining to settle the entire amount is arbitrary and without application of mind amounts gross deficiency in service and so also unfair trade practice.

6.      Further when she had undergone cataract operation for her left eye in the same hospital the bill was for Rs.68,900/-.  Against the claim made for the said amount, OP has paid only Rs.32,000/- which is again an unfair trade practice and further deficiency in service. Inspite of several correspondences OP did not pay the amount and hence the complaint.

7.      Upon the service of notice, OP1 remained absent, placed exparte, so also OP2.

8.      In order to prove the case, complainant filed their affidavit evidence and produced documents. Arguments Heard. The following points arise for our consideration:-

1) Whether the complainant has proved deficiency in service on the part of the Opposite Parties?

2) Whether the complainant is entitled to the relief prayed for in the complaint?

9.     Our answers to the above points are:-

POINT NO.1:            In the Affirmative

POINT NO.2:            Partly in the affirmative.

                                For the following.

REASONS

10.   POINT No.1:-

   Perused the complaint, affidavit evidence and the documents produced by the complainant.  Complainant has produced Ex.P1 the mediclaim insurance policy individual issued by OP1 in favour of the complainant and the sum insured is for Rs.3,00,000/- and the period of insurance is from 31.12.2018 to the midnight 30.12.2019 and premium paid certificate is for Rs.35,759/-.  Ex.P2 and 3 are the certificate and discharge summary issued by “Nethra Enterprises, Prabha Eye Clinic and Research Centre” dated 5.03.2019 and 11.03.2019, wherein the complainant was advised to go for “Femtosecond Laser Assisted Cataract Surgery with implantation of hydrophobic toric foldable intraocular lens in the right eye as she is having astigmatism(cylindrical power)” in the right eye.  Discharge summary as per Ex.P3 stats that she was operated and the lens was implanted and the post operative condition satisfactory and advised medication.  The total cost as per Ex.P4 for the said surgery is Rs.85,000/-.  As per Ex.P5, she has made a claim and as per Ex.P6, OP has settled the claim for Rs.32,000/-.  It is also mentioned therein that a sum of Rs.,56,772/- has been deducted.  A sum of Rs.66,344/- has been deducted restricted for “unifocal lens” for Rs.32,000/- and Rs.428/- NMI.  Ex.P7 is the email correspondences, wherein again OP on July 16^th 2019 mentioned that a difference of Rs.5,722/- is payable to the complainant and requested further process for the said amount.  

11.   Ex.P8 is the claim application for the operation she had undergone for her left eye cataract operation, she was admitted to the hospital “Prabha eye clinic” on 04.03.2020 operated and discharged on the same day, against which a bill of Rs.68,900/- was raised by the hospital authorities which was paid by her.  The claim was made for the said amount, whereas, OP only paid Rs.32,000/- in respect of the said operation also.  

12.   Complainant has produced the policy for the period 31.12.2018 to 30.12.2019 and 31.12.2019 to 30,12,2020 wherein the OP1 has collected Rs.35,759/- as the premium including service tax to cover a sum assured for Rs.3,00,000/-.

13.   When such being the case, having collected the hefty insurance premium of Rs.35,759/- on both the occasions, only paid Rs.32,000/- in each case i.e., only Rs.64,000/- against the claim of Rs.1,57,672/-.

14.   It do not lie in the mouth of OP to say that complainant has to have a particular type of lens and restrict the amount in respect of the said lens in the absence of any contract.  Further the insurance document produced, do not specify such a restriction.  Hence the act of OP 1 amounts to unfair trade practice and also deficiency in service in not paying the entire amount of claim made in respect of the operations the complainant had undergone. Complainant against OP2 is dismissed as it is only a third party administrator not liable to pay the amount and further OP1 to exercise its discretion in respect of the advise of OP2.  Hence we answer point No.1 and 2 partly in the affirmative and pass the following;

ORDER

1. Complaint is allowed in part with cost against OP1 only.
2. OP is directed to pay Rs.36,900/- with interest at 12% p.a., from 07.04.2020 (in respect of cataract surgery on her left eye)  and further Rs.56,772/- with interest at 12% p.a., from 19.03.2019 (in respect of cataract surgery on her right eye) till payment of the entire amount.
3. Further OP1 is directed to pay a sum of Rs.25,000/- as damages for causing unnecessary mental harassment, agony and hardship and further Rs.10,000/- towards litigation expenses for making the complainant to approach this commission unnecessarily which could have been avoided.
4. OP is further directed comply the above order within 30 days from the date of receipt of this order and submit the compliance report to this forum within 15 days thereafter.
5. Send a copy of this order to both parties free of cost.

Note:You are hereby directed to take back the extra copies of the Complaints/version, documents and records filed by you within one month from the date of receipt of this order failing which the same will be weeded out/destroyed.

(Dictated to the Stenographer over the computer, typed by him, corrected and then pronounced by us in the Open Forum on this 25^TH DAY OF AUGUST 2021)

MEMBER                                PRESIDENT

ANNEXURES

1. Witness examined on behalf of the Complainant/s by way of affidavit:

Copies of Documents produced on behalf of Complainant/s:

Ex P1: Policy of the insurance

Ex P2: Certificate issued by Doctor

Ex. P3: Discharge summary

Ex P4: Copy of the bill dated 11.03.2019 for Rs.85,000/-

Ex P5: Claim form

Es P6: Claim settlement letter

Ex P7: Email correspondence

Ex P8: Claim form along with claim details

2. Witness examined on behalf of the Opposite party/s by way of affidavit:

NIL

Copies of Documents produced on behalf of Opposite Party/s

NIL

MEMBER                                        PRESIDENT