State Consumer Disputes Redressal Commission
Dr.S.K.Nawal vs Oriental Insurance Co.Ltd. on 12 October, 2023
Daily Order STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA First Appeal No.897 of 2017 Date of Institution: 28.07.2017 Date of Decision: 12.10.2023 Dr. S.K.Nawal aged about 66 years S/o Shri Moti Sagar, R/o Nawal Nursing Home, Tayal Garden, Barwala road, Hisar. .....Appellant Versus 1. The Oriental Insurance Company Ltd., through its Divisional Manager/Authority Signatory, Divisional Office Railway road, Hisar. 2. Regional Manager, Regional Office, Oriental Insurance Company Ltd., 2nd floor, LIC Building Jagadhri Road, Ambala Cantt. Ambala. .....Respondents CORAM: Mr.S.P.Sood, Judicial Member.
Present: ShriJagdeep Singh, Advocate for appellant. Sh.S.S.Sidhu, Advocate for the respondents. O R D E R S.P.SOOD, JUDICIAL MEMBER:
Delay of 43 days in filing the appeal is condoned for the reasons stated in the application filed for condonation of delay.
2. The present appeal No.897 of 2017 has been filed against the order dated 04.05.2017 of the District Consumer Disputes Redressal Forum, Hisar (In short "District Commission") in consumer complaint case No.255 of 2015, which was dismissed.
3. The brief facts of the case as per the complainant-appellantherein are that heused to purchase medi claim policy from the opposite party and get to renew from year to year for the last fifteen years. The complainant got renewed his said policy from 25.08.2014 to 24.08.2015 as usual. The complainant and his wife covered under the above said policy. The wife of the complainant was diagnosed with Cystodial Macular Oedema which was a macular degenerative disease (an ailment of eye) in the month of October 2014. Due to the above said ailment, the eye sight of the patient gets weak with passage of time. Complainant informed the OP vide letter dated 18.11.2014 regarding their going to Arihant Hospital for treatment. On 18.11.2014, the wife of the complainant was admitted and pre-surgical tests were conducted. After operation, she was discharged on the next day i.e. 19.11.2014. The claim of Rs.91044/- was lodged by the complainant with the OP vide claim dated 06.12.2014, but, after seeking opinion from the other doctors, the OP vide endorsement dated 18.02.2015 approved the claim of Rs.88434/- but thereafter the claim of the complainant was repudiated by making another endorsement dated 24.03.2015. The repudiation of the claim was intimated to him vide letter dated 25.03.2015. The complainant again requested the OPs to pass the claim, but, again OP vide its letter dated 12.06.2015 repudiated the claim illegally and unauthorizedly.This is how alleging deficiency in service on the part of the OPs, hence the complaint.
4. Upon notice OPs No.1 and 2 appeared and filed its written statement whereinthey submitted that the injection was administered in cases of age related macular degeneration ARMD. It cannot be allowed as the procedure involved was within OPD protocol only and the same was excluded under policy terms and conditions being OPD treatment. The respondent No.1 vide letter dated 25.03.2015 had informed the complainant in this regard by giving him one more opportunity to prove his claim. However complainant tried to explain that when the injection was given under analgesia in a well sterilized operation theatre how could it be an OPD procedure but same was again not found to be feasible and tenable by the competent authority of the OPs therefore OP No.1 vide its letter dated 12.06.2015 again repudiated the claim of the complainant. The amount spent in the OPD protocol, was specifically excluded under policy terms and conditions. The repudiation was legal as the injection lucentis was administered in cases of age related macular degeneration ARMD and the procedure involved was within OPD protocol only which was not covered under the terms and conditions of the policy. All other allegations were also denied. Hence, the complainant was not entitled for any claim amount as prayed for.So the claim was rightly rejected by the OPs-insurance company. Thus there was no deficiency in service on the part of the O.Ps and prayed for dismissal of the complaint.
5. After hearing both the parties, the learned District Commission, Hisardismissed the complaint vide order dated 04.05.2017.
6. Feeling aggrieved therefrom, complainant-appellant has preferred this appeal.
7. These argumentswere advanced by Sh.Jagdeep Singh, Advocate for the appellant as well as Sh.S.S.Sidhu,Advocate for the respondents. With their kind assistance entire records of appeal as well as the original record of the District Commission including whatever evidence led on behalf of both the parties wasproperly perused and examined.
8. It is true that complainant obtained medi-claim policy from the opposite parties. It is also true that during the subsistence of the medi-claim policy, wife of the complainant suffered with some eye problem and gotadmitted in a hospital for a day. It is also true that complainant spent Rs,91044/- on her treatment. Perusal of the record shows that the injection lucentis was administered to her wife and that the above said injection is administered in cases of age related macular degeneration ARMD cases and the procedure involved is within OPD protocol only. Though OPs did give another opportunity to complainant to explain as to how the procedure undergone by his wife was not covered under the exclusion clause but the explanation furnished by him did not found favours with the think tank of the OPs. In view of the above, the complainant was not entitled for any relief. Learned district Commission has rightly dismissed the claim of the complainant. The impugned order dated 04.05.2017 is legally sustainable in the eyes of law. Hence, the appeal being devoid of merits the same stands dismissed.
9. Applications pending, if any stand disposed of in terms of the aforesaid judgment.
10. A copy of this judgement be provided to all the parties free of cost as mandated by the Consumer Protection Act, 1986/2019. The judgement be uploaded forthwith on the website of the commission for the perusal of the parties.
11. File be consigned to record room.
12th October, 2023 S. P. Sood Judicial Member (S.K.,Pvt.Secy)