State Consumer Disputes Redressal Commission
The United India Insurance Company Ltd. vs K. P Desai on 31 January, 2013
BEFORE THE HON'BLE STATE CONSUMER DISPUTES REDRESSAL
BEFORE THE HON'BLE STATE CONSUMER DISPUTES
REDRESSAL
COMMISSION, MAHARASHTRA, MUMBAI
First Appeal No. A/04/843
(Arisen out of Order Dated 19/04/2004 in Case
No. 1259/1997 of District DCF, South Mumbai)
1. The United India
Insurance Company Ltd.
Divisional Office No.
8, Union Co. Operative Insurance Building, P. M. Road, Fort,
Mumbai 400 001
........Appellant(s)
Versus
1. K. P Desai
501/502, Oceanic II,
Versova Oceanic Co. Operative Hsg. Society, Andheri (East), Mumbai 400
061
........Respondent(s)
BEFORE:
HONBLE Mr.Justice
S.B.Mhase PRESIDENT
HONBLE MR. Narendra
Kawde MEMBER
PRESENT:
Adv. Smt. Urmila Sanil
for the Appellant
Adv. S. N. Chataule
proxy advocate for Adv. Harshad Trivedi for the Respondent
ORDER
(Per Shri Narendra Kawde, Honble Member ) (1) This appeal takes an exception to the order passed in Consumer Complaint No.1259/1997 passed by South Mumbai District Consumer Disputes Redressal Forum,, Mumbai on 19/04/2004. The District Forum holding deficiency in service against the appellant/opponent in the consumer complaint directed to pay an amount of 50,000/- along with costs of 1,000/- within a period of 2 months failing which the payable amount was to carry interest @9% p.a. from the date of the complaint. i.e. 01/10/1997.
(2) Aggrieved thereby the appellant/opponent insurance company preferred this appeal on the ground that the Lasik therapy carried out on for the correction of the eyes by the complainant is not a surgery for medical treatment, but it is to enhance cosmetic aesthetic looking of a person. The District Forum has erroneously held that the said lasik therapy carried out on the complainants eyes was not the one which is covered under the terms & conditions of the insurance policy.
(3) Undisputed facts are that :-
The respondent/complaint had regularly subscribed to the mediclaim policy issued by the appellant/opponent insurance company from the year 1990 onwards till 1997. During the validity period of the last such mediclaim policy covering the period from 02/08/1996 to 01/08/1997, the complainant had undergone the corrective lasik surgery for his eyes under the advice of eminent eye surgeon Dr.Keiki Mehta. Accordingly, the lasik eye operation was carried out by Dr.Banaji and the hospital charges amounting to `50,000/- were paid. The insurance claim was filed for reimbursement of hospital charges which came to be repudiated by the appellant/opponent insurance company on the ground that the operation was purely cosmetic aesthetic not falling within the purview of the insurance policy and the claim was ultimately repudiated under the exclusion clause 4.5 of the terms and conditions of the policy. Aggrieved thereby, the respondent/complaint preferred consumer complaint which was decided upholding the contention of the complainant in his favour.
(4) Heard the Mrs.Urmila Sanil-advocate for the appellant and Mr.S.N.Chataule, proxy advocate for Mr.Harshad Trivedi for the respondent. The mediclaim policy has been subscribed by the respondent/complaint continuously from 1990. There is no documentary evidence led by the appellant/opponent to demonstrate that lasik surgery is not a corrective therapy, especially when the complainant was experiencing serious problem in the eyes. Under the provisions of mediclaim hospitalisation expenditure including surgery is admissible after 5th year of the completion of the mediclaim policy in continuity. We find that there is no statement by the appellant/opponent insurance company as to how exclusion clause 4.5 of the mediclaim comes into operation denying reimbursement of the expenses to the respondent/complainant after completion of 5th year of continuous insurance coverage of mediclaim policy. We do not find any substance in the appeal. We cannot take a different view than what has already been taken by the District Forum. Holding accordingly, we pass the following order.
ORDER (1) Appeal stands dismissed.
(2) Under the given circumstances, no order as to costs.
(3) Certified copies of this order be furnished to both the parties.
Pronounced on 31st January, 2013.
[HON'BLE Mr.Justice S.B.Mhase] PRESIDENT [HON'BLE MR. Narendra Kawde] MEMBER pgg