National Consumer Disputes Redressal
Mohan M. Karlekar vs United India Insurance Co. Ltd. & 3 Ors. on 4 August, 2023
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI REVISION PETITION NO. 832 OF 2022 (Against the Order dated 04/02/2021 in Appeal No. 495/2019 of the State Commission Gujarat) 1. MOHAN M. KARLEKAR ...........Petitioner(s) Versus 1. UNITED INDIA INSURANCE CO. LTD. & 3 ORS. ...........Respondent(s)
BEFORE: HON'BLE MR. JUSTICE A. P. SAHI,PRESIDENT HON'BLE MR. JUSTICE RAM SURAT RAM MAURYA,MEMBER
FOR THE PETITIONER : IN-PERSON FOR THE RESPONDENT : MR. PRANG NEWMAI, ADVOCATE
Dated : 04 August 2023 ORDER
PRONOUNCED ON 04th August, 2023
ORDER
A. P. SAHI, J (PRESIDENT) This is a short dispute that has travelled through this Revision Petition at the National Commission with regard to the claim made by the Revisionist in respect of the medical laser treatment of the eyes that was allowed by the District Forum but was reversed by the State Commission.
The Petitioner appearing in-person submits that the District Consumer Disputes Redressal Commission (hereinafter referred to as, 'District Commission'), had rightly allowed the claim but in the Appeal the State Consumer Disputes Redressal Commission (hereinafter referred to as, 'State Commission') reversed it on erroneous grounds. It was submitted that laser treatment undertaken was covered under the Joint Medical Health Policy. It was on medical advice that the laser treatment from an expert doctor was undertaken for which expenses were incurred and a certificate was issued indicating that the said treatment was necessary in order to "balance both the eyes". The certification as contained in Annexure - G is extracted here as under:
"This is to certify that Mr. Anirudha Karlekar was examined at this clinic on 21/07/10. He was found to have high myopic astigmatism with anisometropia in both eyes. He is advised for LASIK treatment in both eyes. He could not wear glasses & is intolerant to contact lenses. It is an essential procedure to balance both the eyes."
It is urged that not only this, the Maharashtra State Consumer Commission has also taken the view to that effect in First Appeal No. A/04/843 (United India Insurance Company Limited versus K. P. Desai). It is urged, the very same plea of exclusion was taken on behalf the Insurance Company contending that such a claim was not admissible but the State Commission of Maharashtra allowed the claim and therefore the claim of the Revisionist being similar, the same relief should be extended. A copy of the judgment has been produced before us for perusal and consideration.
The State Commission came to the conclusion that the District Commission had overlooked the relevant provisions of the policy and had erroneously granted the benefit to the Revisionist. The decision of the District Forum was therefore reversed.
We have perused clause 4.5(b) of the exclusionary clause under the policy and the same is extracted herein as under:
4.5(b) Vaccination of Inoculation or change of life or cosmetic or aesthetic treatment of any description such as correction of eyesight, etc. From the comparison of the certification, relied on by the Revisionist, extracted herein above, it is clear that the laser treatment was given in both eyes on a diagnosis of high myopic astigmatism with anisometropia. While describing the procedure, it is stated therein that it is an essential procedure to balance both the eyes. Astigmatism is a refractive deformity when the lens of the eye does not curve in the usual way and the eyes consequently squint. Anisometropia is a visionary defect when the eye vision of one eye is comparatively worse than the vision in the other eye due to a difference in refractive error. For example one eye may be farsighted or nearsighted. The said diagnosis can be treated by correcting the eye sight either through glasses, contact lenses or surgery. Consequently, the treatment is of the description of correction of eye sight.
The Exclusionary clause 4.5(b) categorically indicates that any such liability stands excluded in relation to "correction of eyesight, etc."
It is thus evident that the exclusionary clause takes within its fold the treatment given to the policyholder namely balancing both the eyes.
Learned Counsel contended that later on the policy has been changed by the Insurance Company and therefore it should be presumed that such amendment can also apply retrospectively.
We are unable to agree with this proposition as the contract of policy as it stood admitted between the Parties contains the unamended exclusionary clause which will continue to apply and bind both the Parties.
Any subsequent change of policy will have no impact nor can it be given any retrospective effect. The contention raised on this ground cannot be accepted.
The Order of the State Commission is upheld and the Revision Petition is dismissed.
.........................J A. P. SAHI PRESIDENT ..................................................J RAM SURAT RAM MAURYA MEMBER