Advocate Shridhar Kasbekar for the complainant
Advocate Sanjay Gaikwad for the Opposite Parties
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Per Hon’ble Shri. V. P. Utpat, President-
:- JUDGMENT :-
Dated 25/02/2013
This complaint is filed by beneficiary of Insurance Policy u/s 12 of the Consumer Protection Act, 1986 against the Insurance Company for deficiency of service. Brief facts are as follows-
[1] The complainant was working with Steel Authority of India Ltd. as Assistant General Manager. When he was in service he had enrolled for himself and his spouse in the Group Medical Scheme 2008 for retired employees and their spouses. He paid Rs. 1114/- annual premium on 14/11/2007 and his membership was continued till filing of the complaint.
[2] There was an agreement between the Insurance Company and Company to give medi-claim to retired employees of the said company. As per the policy it was agreed that Insurance Company shall reimburse the bills of expenses incurred for the treatment by the beneficiary. In the month of February 2010 the complainant had been at Bururpur, West Begngal and he had consulted with Ophthalmologist and taken treatment at M/s. Disha Eye Hospital situated at Barrackpur in the outskirts of Calcutta. Doctor administered him intravitreal macagen injection to his left eye for arresting macutar degeneration of retina. He had spent Rs.48,800/- for his medical treatment. On 21/4/2010 he lodged claim alongwith supporting documents but the Insurance Company wrongly rejected his claim citing a reason that the medi-claim for the said treatment is not available as per the terms and conditions. On 04/06/2010 letter from M. D. India Health Care Services Pvt. Ltd. [TPA] was received by the complainant. Complainant was informed that the reimbursement for Avastin injection is not payable. According to the complainant his claim is wrongly repudiated by the Insurance Company and there is clear cut deficiency in service rendered by the Insurance Company. He has claimed reimbursement of the said amount along with interest as well as compensation for mental torture, agony, pain , conveyance, own charges and expenses of the litigation.
[3] The said claim is resisted by the Insurance Company by filing written statement. According to the Insurance Company the claim is not at all maintainable. The complainant was informed that as per the terms and conditions of the policy he is not entitled for the reimbursement of the bill of injection which was administered to him. He took treatment at Calcutta hence this Court has no jurisdiction. The Insurance Company has considered his claim sympathetically but as due to breach of terms and conditions, claim is not settled and repudiated. Insurance Company has also contended that the false complaint is filed against the Insurance Company hence compensatory cost be awarded. Insurance Company has prayed for dismissal of the complaint.
[4] After considering the documentary evidence which is adduced by both the parties and affidavits as well as hearing the argument of both Counsels following points arise for my consideration. Points, findings and reason thereon are as follows-
POINTS FINDINGS
1. Does complainant prove that
Opposite party has repudiated
the claim of the complainant
wrongly and thereby caused
deficiency in service ? Affirmative
2. What order ? Complaint is allowed.
REASONS-
Complainant has produced voluminous documents along with list dated 21/04/2011 vide page no. 9 and he has produced enrollment form, group medical scheme booklet, I card, papers regarding medical treatment, bill of injection, policy claim form and the letter dated 03/06/2010 of Insurance Company by which it has repudiated the claim. The Insurance Company has produced the policy which was valid on the date of alleged medical treatment. According to the Insurance Company in view of clause 7.13 treatment for Age Related Macular degeneration with inj. Avastin/ Lucentis/ Macugen. is excluded from the medi-claim. According to the complainant he never took treatment for age related macular degeneration but he took treatment from ophthalmologist as there was problem in his left eye. He has produced ample record to show that he took treatment for his eye and not for age related macular degeneration. Thus it is crystal clear that claim of the complainant is wrongly repudiated.
It is pointed out by the complainant that when he entered into an agreement with the Insurance Company for medi-claim there was no such clause and the Insurance Company has amended the terms and conditions of the policy without informing him. Hence the said amended clause is not binding upon him. It is significant to note that it is not in dispute that the complainant has paid premium regularly as per the terms and conditions of the policy. Whenever there had been amendment or corrigendum in the policy terms, he is bound to know those terms. But it reveals from the record that there was an agreement between Steel Authority of India Ltd and the Insurance Company and there was no agreement between the individual insured person and the Insurance Company. However the complainant is not only beneficiary but also party to the said contract as it is a Tri-partite contract as he has paid premium to the Insurance Company regularly. However certain terms and conditions in the policy are suppressed by the Insurance Company and the complainant cannot be blamed for the same.
Even though it is referred in the policy that reimbursement for the said bill is not available to the complainant this repudiation is illegal as the reference of disease which has been shown in clause 7.13 is different than disease which was caused to the complainant. On both counts defence of the Insurance Company is not acceptable. Hence I held that the complaint is bound to be allowed.
The complainant has claimed reimbursement of bill amount Rs.48,800/- along with interest. He has also claimed compensation for mental and physical torture and cost of the litigation. In the light of the above discussion I held that the complainant is entitled for reimbursement of medical bill as well as compensation on the ground of physical and mental torture and cost of the litigation. I answer issue No.1 in the affirmative and pass the following order-
:- ORDER :-
1. The complaint is allowed.
2. It is hereby declared that the opposite party No.1 and 2 caused deficiency in service by repudiating insurance claim of the complainant.
3. The complainant is entitled to receive from the opposite party No.1 and 2 jointly and severally Rs.48,800/- along with interest @ 9% p.a. from the date of filing of the complaint till its realization by way of reimbursement of medical treatment.
4. The complainant is entitled to receive from the opposite party No.1 and 2 jointly and severally Rs.5,000/- for mental torture, agony and pain and Rs.2,000/- by way of court expenses.
5. The opposite party No.1 and 2 shall jointly and severally comply with the aforesaid order within 60 days from the date of receipt of copy of order.
