This is a case under section 12 of the Consumer Protection Act filed by the Complainant Shri Ranajit Kumar Sarkar against the O.P United India Insurance Company Limited claiming a sum of Rs. 35,050/- spent out for operation of the cataract of the right and left eyes of the Complainant, a sum of Rs.25,000/- towards mental pain and agony and Rs.25,000/- towards litigation cost and has also claimed interest on the amount to be awarded.
The case of the Complainant, inter alia, is that the Complainant and the beneficiary (his wife Smt. Anita Sarkar) made Health Insurance Policy bearing Policy No. 035100/28/17/P101/429721 remaining valid from 28.04.2017 to 27.04.2018 and Policy No. 035100/28/18/P101088138 remaining valid from 28.04.2018 to 27.04.2019 for an insured sum of Rs.2,50,000/- and Rs.3,00,000/- respectively. Said Smt. Anita Sarkar was suffering from vision difficulty at her right eye and as such went to Siliguri Greater Lions Eye Hospital at 2nd Mile, Sevoke Road, Siliguri, on 21.4.2018. The consulting Ophthalmologist advised removal of her cataract by operation and thus prescribed various tests before operation and medicines. On 27.04.2018 Smt Anita Sarkar after completing various tests and taking medicines was admitted in the Siliguri Greater Lions Eye Hospital for operation of her right eye. Dr. M.M. Chowdhury conducted the operation and discharged Smt. Anita Sarkar with advice for medication. On 03.05.2018 Smt. Sarkar after following the advice of the Ophthalmologist went for check up of the operated right eye. She was also suffering vision difficulty at her left eye. After consultation and check-up Doctor advised, as patient needs distance as well as near correction for the regular work. Consequent upon direction she was advised operation of her left eye on 11.05.2018 at the said hospital. Operation was conducted on the very date and the patient was discharged on 12.05.2018 with the advice of medicines and first follow-up review on 17.05.2018. As per terms of Policy the Complainant opted to go through the package of Rs.50,000/- for cataract surgery keeping in mind the maximum limit for insurance amount which was Rs.56,250/- per eye. As the Policies being cashless, the Complainant presented her documents for payment of claims directly to Siliguri Greater Lions Eye Hospital for surgery of right eye and Rs.22,475/- for surgery of left eye. The Complainant intimated to the insurance company about the details of the eye surgery of Smt. Anita Sarkar at the aforesaid hospital. Curiously, the insurance company did not make any payment for the surgery of both eyes using multifocal lens. The complainant was compelled to make payment for better eye-vision and convenience and thereby the insurance company did not honour its own terms and conditions of the Policy. Therefore, it was unfair. Consequent upon the O.P remitted Rs.3,475/- and Rs.5,000/- in addition to payment made earlier and as such there remained due of Rs.35,050/- from the insurance company. So, they have prayed for direction to pay a further sum of Rs. 35,050/- for cataract operation of Smt. Anita Sarkar and implanted multifocal lens therein. Further they have prayed for a sum of Rs.25,000/- towards mental pain and agony, besides prayer of litigation cost.
Denying all material allegations made in the complaint the O.P has filed Written Version stating, inter alia, that in case of cataract surgery as per health insurance Policy – Gold, the Complainant is entitled to get – a) actual expenses incurred or 25 % of the sum insured whichever is less; b) actual expenses incurred or 70% of the sum insured whichever is less.
So, in case of cataract surgery the liability to be restricted to the cost of MONOFOCAL Lens and not for MULTIFOCAL lens. Multifocal lens is used to avoid using of glasses or spectacles. Hence, this falls under the correction of eye-sight which does not cover under the Mediclaim Policy. Unless for treatment of disease or necessitated due to an accident, vaccination or inoculation, change of life, or cosmetic or aesthetic treatment of any description such as correction of eye-sight etc., Plastic surgery other than as may be necessitated due to an accident or as part of illness. Hence, both the CCN of cashless claim was settled at Rs. 56,733/- which was just and proper. As per Police guidelines the cost of the multifocal lens was not payable by the Insurance Company. The claim can be considered upto the expenses Micro Phaco with IQ Lens at Rs.27,475/- as per SOC (As per restricted to the cost of Monofocal Lens). If the Insurance Company gives confirmation for multifocal lens, then the insurance company process the claim as per actual medical bill submitted by the complainant. In the instant case the Complainant has not submitted the bill showing cost of multifocal Lens used by Anita Sarkar to the O.P. So, the present case has restricted the liability to the cost of Monofocal Lens. There is no specific word as multifocal lens and it is excluded in the terms and conditions of the Mediclaim Policy, but all the Insurers not to pay the cost of multifocal lens in a cataract claim. There is no dereliction of duty or any unfair trade practice on the part of the O.P upon the Complainant in any way or at all. In general the insurer would not pay more than reasonable or customary fee for a particular service regardless of how much medical provider bills.
Negotiated rate is similar to reasonable and customary bill, but it varies from one provider to another in same geographic area and for the same insurance company. There are other factors involving in setting negotiated rate including things like the volume of business that the insurance company is expected to send to the provider and provider’s track record of successful outcome. When a patient in a managed care plan receives treatment from and in network medical provider on the amount the patient has to pay negotiated rate and is limited by the amount of the deductable, copay, coinsurance or out of pocket maximum. The Opposite Party has paid a sum of Rs.56,773/- in respect of medical Policies to the Complainant towards full and final settlement for cataract operation. Thus the Complainant will not get any further money from the Opposite Party in any way. Therefore, the case is liable to be dismissed with compensatory cost.
In the instant case both the Complainant and the O.P have filed evidence-in-chief. But they have not depicted about having Policy to implant multifocal lens in lieu of monofocal lens. Both the parties have filed Brief Notes of Arguments, but the Complainant did not clarify as to whether terms and conditions of the Policy allowed to implant multifocal lens in lieu of monofocal lens.
Having regard to the evidence supported by documents it is clear that the Complainant for himself and his wife made two Medical Insurance Policies under the O.P United India Insurance Company.
The complaint is maintainable under the provision of the Consumer Protection Act since the claim amount of the claimant is within the pecuniary jurisdiction of this Forum. Also this Forum has territorial jurisdiction to entertain the case. The claimant has prayed for excess amount of Rs.35,035/- for implanting multifocal lens implanted on both the eyes of Smt. Anita Sarkar. If the multifocal lens was implanted in both the eyes of Smt. Anita Sarkar then she would have no claim before this Forum but the Insurance Company claimed to have paid full amount as if monofocal lens implanted in both eyes of Smt. Anita Sarkar.
According to GOOGLE, Multifocal lens means and includes experiencing comfort of varilux lenses. High resolution lenses vision at any distance. Lens in all distances clear vision lens best permissive lens of easy adaptation. It is made of high quality lens correction and correct performance in cataract patient. Further, the Google speaks that monofocal lens corrects vision of cataract patient. High quality lens material and performance of u.v. filtering 360 degrees square edge glistening free clear and yellow.
Multifocal lens is of better quality than monofocal lens in quality standard and vision distance at all angles -used by Smt. Anita Sarkar. The O.P cannot deny to provide such facility to Smt. Anita Sarkar, otherwise there would be future vision difficulty. Eye is sensitive or touchy organ of human body with which no quality compromise can be done. Mediclaim means the claim which will provide better facility and services to Smt. Anita Sarkar in respect of eye-operation and implantation of lens having better in quality in all respect than monofocal lens. No-one wants to damage its own eyes considering her future and physique. Therefore, the claim of the claimant is justified. Also she is entitled to get the differential amount claimed towards the cost of differential amount for implanting multifocal lens. In the result, the case succeeds.
Accordingly it is
O r d e r e d :
that the case be and the same is allowed. The O.P is hereby directed to pay a sum of Rs.35,050/- only. If the O.P fails to pay that amount within one month from the date of order, it will carry interest thereon @ 9% per annum from the date of Award.
