Rajasthan

StateCommission

A/248/2021

Sunil Kumar Jain S/o Bhanwarlal - Complainant(s)

Versus

United India Insurnce Company Limited - Opp.Party(s)

Gopal Shastri

16 Feb 2023

ORDER

RAJASTHAN STATE CONSUMER DISPUTES REDRESSAL COMMISSION,JAIPUR

 

FIRST APPEAL NO: 248/2021

 

Sunil Kumar Jain s/o Sh. Bhanwarlal Jain r/o 44 Indira Nagar, Tonk Road, Jaipur.

Vs.

1.United India Insurance Co. Ltd. 12, Manu Marg, Govind Nagar, Amer Road, Jaipur 302002.

2. E-Meditek, 307 3^rd floor, Paradise Appartment, Behind Hotel Park Prime, Sarojini Marg, C-Scheme, Jaipur 302001

Date of Order 16.2.2023

Before:

Hon'ble Mr. Atul Kumar Chatterjee- Member(Judicial)

Hon'ble Mrs. Shobha Singh- Member

Present:

Mr. Gopal Shastri learned counsel for the appellant

Mr. Vimal Sharma learned counsel for the respondent no.1

 

BY THE STATE COMMISSION ( PER HON'BLE MR.ATUL KUMAR CHATTERJEE, MEMBER ( JUDICIAL):

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This appeal has been filed by appellant/ complainant against the judgment of learned District Consumer Commission, Jaipur 1^st Jaipur dated 18.1.2021 passed in its Complaint Case No 181/2016 whereby the complaint filed by the appellant/complainant has been dismissed.

 

Briefly stated the relevant facts of the case are that the appellant/complainant has filed a complaint with the facts that the appellant/complainant has procured a personal health insurance policy from respondent no.1/ non-complainant no.1 United India Insurance Co. in the year 1999 and it was continued upto 2014. According to the complainant the complete terms and conditions of the insurance policy were not made available to the complainant. The main grievance of the appellant/complainant in the complaint is that he underwent cataract operation of his both eyes in which he incurred Rs.65,000/- as expenses for which a claim was submitted before the respondent no.1/non-complainant no.1 insurance company but only an amount of Rs. 26,600/- was paid whereas the total claim amount was Rs.65,000/-. According to him the amount of Rs. 38,400/- could not be deducted. According to the complainant upon inquiry it was conveyed to him that

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complainant was entitled for reimbursement of actual expenses incurred on cataract operation or 25% of the sum insured. According to the complainant the actual expenses for both the eyes were Rs. 65,000/- as such in view of the terms and conditions of the policy he was entitled to get reimbursement of Rs. 65,000/-. According to the complainant he had never given receipt of Rs. 26,600/- as full and final payment. In this way the complainant has prayed for granting the entire amount of Rs. 65,000/- alongwith compensation and litigation expenses.

 

Respondent no.1/ non-complainant no.1 insurance company stated in its reply that neither any 'consumer dispute' has arisen between the complainant and non-complainant no.1 insurance company nor any 'deficiency in service' has been committed by the insurer. According to respondent no.1/ non-complainant no.1 insurer a claim for Rs. 26,790/- was filed by the complainant regarding his cataract operation of right eye on 14.10.2013 and 15.10.2013 wherein a discount of Rs.190/- was given by the hospital itself as such the amount of Rs. 26,600/- was allowed as claim and the payment was made to the complainant. Receipt of which is available on record as

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Ex. R 2. According to respondent no.1/ non-complainant no.1 insurer this fact has been suppressed by the appellant/complainant in his complaint. It has further been averred by respondent no.1/non-complainant no. 1 insurer that the complainant got his left eye operated on 6.11.2014/ 7.11.2014 wherein the total expenses claimed was Rs. 67,400/- out of which the expenses incurred on operation was credited in the account of appellant /complainant on 14.1.2015 but the amount of Rs. 30,400/- incurred for intraocular lens was deducted and in this way the amount of operation i.e. Rs.32,200/- was paid to the complainant by the respondent no.2/non-complainant no.2 E-Meditek. As per reply the amount of both the claims for both the eyes of cataract operation has been paid to the appellant/complainant. The complainant has suppressed the material facts and in this way the prayer has been made to dismiss the complaint of the complainant.

 

None had appeared for respondent/ non-complainant no.2 E-Meditek therefore, the learned DCC had proceeded in ex-parte manner against it.

 

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We have heard the learned counsels of appellant/complainant as well as respondent no.1/non-complainant no.1 insurer.

 

The learned counsel for the appellant/ complainant has more or less reiterated the facts contained in the memo of appeal as arguments whereas the learned counsel for respondent no. 1/ non-complainant no.1 insurer while opposing vehemently the contentions of the learned counsel for the appellant/complainant has supported the impugned judgment as being factually and legally correct on the basis of record and has prayed for dismissal of the appeal.

 

We have pondered upon the rival contentions and have gone through the entire record.

 

The learned DCC in the impugned order has firstly observed that in fact the operation of cataract for both the eyes was not connected with the appellant/complainant himself but the same was connected with the eyes of his wife Smt. Usha Jain but every where in the complaint the appellant/complainant has referred as if his own eyes have

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been operated for cataract. Besides this the learned DCC has also observed that even if this fact is ignored it is revealed that the operations of cataract of both the eyes was not done in a single occasion but were separately operated and the complainant's averment that an amount of Rs. 65,000/- was incurred on operation of both eyes is also not found to be true because on first occasion for right eye the operation was done on 14.10.2013/15.10.2013 whereupon the expenses of Rs.26,790/- was incurred out of which Rs. 190/- was deducted as discount by hospital itself and remaining amount of Rs. 26,600/- was paid. Subsequently in the month of November i.e. on 6.11.2014 and 7.11.2014 operation of cataract of left eye was done and for this an amount of Rs. 67,400/- was claimed out of which Rs. 32,200/- was deducted which was incurred for intraocular lens and reason of deduction was “ As per reasonable and customary under clause 3.33”.

 

During the course of arguments in the appeal we have enquired from the learned counsel for the appellant/complainant about the discrepancy in the averments and the record but the learned counsel for the appellant/complainant has contended that even though it is

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assumed that the pleadings of the appellant/complainant were not correct even though on the basis of the pleadings and documents of respondent no.1/ non-complainant no.1 insurer, it is desirable that the insurer shall justify how they have deducted the amount of Rs. 30,400/-. In our humble view, we find that the above contention of the learned counsel for the appellant/complainant is not tenable because admittedly from the averments and documents of respondent no.1/ non-complainant no.1 insurer, it is clear that firstly the patient was not complainant himself but his wife Smt. Usha Jain was the patient. Though she was also one of the insured under the policy but we are unable to understand as to why the appellant/ complainant has shown himself to be the patient instead of the original patient, his wife Smt. Usha Jain. Besides this from the complaint it appears that both the eyes were operated at one occasion but from the record it revealed that as stated above right eye and left eye were separately operated in the month of October and November on the given dates as stated above respectively. It is also not explainable as to what was the occasion that the complainant had instead of stating truth about separate operations of both eyes and incurring different amounts on both occasions had averred that both the eyes

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have been operated at one occasion and for that cumulatively Rs. 65,000/- was incurred. As stated above from the record it is revealed that on first occasion an expenses of Rs.26,790/- was shown to have been incurred out of which Rs. 190/- was discount given by the hospital and remaining amount of Rs.26,600/- was paid by the insurer through respondent no.2/ non-complainant no.2. In the second operation of cataract of left eye total amount claimed was Rs. 67,400/- out of which Rs.32,200/-had been paid and Rs. 30,400/- was deducted. As stated above since the appellant/complainant has failed to reveal true facts in his averments as well as evidence therefore, there is no occasion to ponder upon as to why the deduction of Rs. 30,400/- allegedly incurred on intraocular lens has been deducted.

 

Based on the above discussions we also find that the learned DCC, Jaipur 1^st Jaipur has rightly observed that the complaint of complainant is based on suspicious and untrue facts which would mean that he has not come with clean hands before the learned DCC. In this way we do not find any illegality or perversity in the impugned judgment which has

 

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been rightly passed on the basis of averments and evidence of either sides.

 

Therefore, we find that the appeal filed by the appellant/complainant deserves to be dismissed and the same is hereby dismissed. No costs.

 

(Shobha Singh) (A.K.Chatterjee)

Member Member Judicial

 

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