State Consumer Disputes Redressal Commission
The Oriental Insurance Co. Ltd. vs Amarjit Singh on 27 November, 2024
ADDITIONAL BENCH
STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
PUNJAB, CHANDIGARH
First Appeal No.834 of 2022
Date of Institution : 03.10.2022
Date of Reserve : 13.11.2024
Date of Decision : 27.11.2024
The Oriental Insurance Co. Ltd., Office IV, Opposite Chhabra
Hospital, Boave fine Furniture, Bus Stand Road, Ludhiana through
its Regional Office at SCO 109-111, Sector 17-D, Chandigarh
through its Manager.
....Appellant/Opposite party
Versus
Amarjit Singh resident of H.No.1180, St. No.16, Field Ganj,
Ludhiana.
....Respondent/complainant
First Appeal under Section 41 of the Consumer
Protection Act, 2019 against the order dated
12.07.2022 of the District Consumer Disputes
Redressal Commission, SBS Nagar (decided at
Camp Court, Ludhiana).
Quorum:-
Mr.Harinderpal Singh Mahal, Presiding Judicial Member
Mrs. Kiran Sibal, Member Present:-
For the appellant : Sh.Abhishek Sharma, Advocate for Sh.Amit Jaiswal, Advocate For the respondent : Sh.Sudhir Kumar, Advocate First Appeal No 834 of 2022 2 HARINDERPAL SINGH MAHAL, PRESIDING JUDICIAL MEMBER This appeal has been preferred by the appellants/opposite party-OIC Ltd. against the order dated 12.07.2022 passed by District Consumer Disputes Redressal Commission, SBS Nagar (in short 'District Commission'), (decided at Camp Court, Ludhiana), whereby the complaint filed by the complainant under the Consumer Protection Act (in short 'the Act') was partly allowed and they were directed to pay the treatment expenses as per bills submitted with OP or paid by the complainant i.e. Rs.1,60,000/- along with interest @4% per annum from the date of filing of complaint till realization. They were further directed to pay Rs.5,000/- as compensation.
It would be apposite to mention that hereinafter the parties will be referred, as have been arrayed before the District Commission.
2. Briefly stated facts of the complaint are that the complainant is having a policy bearing No.233902/48/2016/2720 issued by the opposite party and was making the premium regularly. The son of the complainant namely Harmandeep Singh suffered from eye problem and having operated in Thind Eye Hospital having its admission on 02.08.2016 and on that treatment a sum of Rs.1,60,000/- was spent by the complainant for both the eyes. The said expenditure was covered under medical insurance policy issued by the opposite party and accordingly claim was lodged with them for claiming the amount spent on the treatment of First Appeal No 834 of 2022 3 Harmandeep Singh son of Amarjit Singh. Number of times, the opposite party was approached by the complainant to make the necessary payment but to no effect, resultantly the complainant filed the complaint before the District Commission seeking following reliefs:
i) to release the balance claim amount of Rs.1,60,000/-
along with interest @18% per annum; and
ii) any other relief which the complainant may found to be entitled in law for causing mental torture and agony.
3. Upon notice, opposite party appeared and filed their written reply taking preliminary objection that the complaint is not maintainable and is bad for non-joinder of the necessary party and there is no deficiency in service on the part of the opposite party. It is further pleaded that as per the policy conditions, if the complainant is not satisfied with the decision of the Insurance Company then he has right to appeal to the Regional Office of the Insurance Company or the Grievance Cell of the head office of the Insurance Company or the Ombudsman appointed by the Central Government. The claim of the claimant is not covered under the purview of exclusion clause 4.5 of OBC-Mediclaim Insurance Policy and according to that the claim of the complainant was not payable and the complainant was duly informed qua the same. It is admitted that the policy No.233902/48/2016/2720, valid for the period 27.08.2015 to 26.08.2016, which was issued to the complainant-Amarjit Singh, Smt. Kawaljit Kaur and Harmandeep First Appeal No 834 of 2022 4 Singh but the same was issued, subject to the terms and conditions of the policy. It is further pleaded that as per the claim document and other medical record, it was observed by Medi Assist India Pvt. Ltd. that as per the discharge summary the insured is admitted for treatment of High Myopia with Astigmatism (Refractive error). The treatment of refractive error is actually considered as correction of eye sight for cosmetic purpose as per the policy guidelines, which is excluded under clause 4.5 of the policy and accordingly the claim was denied.
4. The parties led their evidence in support of their respective contentions before the District Commission and after hearing the contentions of the parties, the complaint was partly allowed, vide impugned order dated 12.07.2022.
5. Aggrieved by the said order, this appeal has been filed by the appellant/opposite party for setting aside the impugned order dated 12.07.2022 and to allow their appeal.
6. We have heard the contentions of the parties and have carefully gone through the record as well as written arguments filed by them. We have also given our thoughtful consideration to the same.
7. The appellant/opposite party filed its written arguments as well as orally submitted that as per the discharge summary of the patient, he was diagnosed with High Myopia with Astigmatism, which is an eye sight problem and not a disease. He further referred that as per the clause 4.5, such type of eye treatment is First Appeal No 834 of 2022 5 excluded from coverage of the policy. He further pleaded that as per surgery i.e. TICL (which stands for Toric Implantable Collamer Lens), which is a surgery for correction of nearsightedness (Myopia) and astigmatism is not covered under the policy terms and conditions but these facts are not taken into consideration by the District Commission and it wrongly allowed the complaint on the irrelevant pleas taken by the respondent/complainant.
8. Per conta, learned counsel for the respondent/complainant contended that the District Commission has correctly allowed the complaint of the respondent/complainant because the policy is issued by the Insurance Company and then they started relying upon the clauses of the policy, which was not in the notice of the insured and they rejected the claim of the respondent/complainant by relying upon those clauses, which is totally illegal. He further pleaded that the District Commission has rightly allowed the complaint of the respondent/complainant by taking into consideration the law point on this score.
9. No doubt, it is admitted by the appellant/opposite party that the Insurance Policy was issued to the respondent/complainant for covering the medical claim. However, the perusal of the impugned order shows that the District Commission after relying upon the case laws titled as 'Dharmendra Goel Vs. Oriental Insurance Co. Ltd.,' III (2008) CPJ 63 (SC) and 'New India Assurance Company Ltd. Vs. Smt. Usha Yadav & Others' 2008(3) RCR (Civil) Page 111 has observed that at the time of issuing the policy, the Insurance First Appeal No 834 of 2022 6 Companies shows the green pastures to the insured without making them aware about the general conditions and other hidden clauses and similarly it is done in the present case. In such eventuality, law is also clear that the Insurance Policy is a contract between the two parties and that also is governed by the terms and conditions of the policy, which are applicable to the parties in toto. Before proceeding further, we have to look into the terms and conditions, which is pressed by the appellant/opposite party, on the basis of which the claim of the respondent/complainant was rejected. The relevant clause 4.5 is reproduced as under:
"4.5 Surgery for correction of eye sight cost of spectacles, contact lenses, hearing aids etc."
10. The perusal of the above clause does not prove that the disease of High Myopia with Astigmatism (Refractive error) is not covered under the terms and conditions of the policy. Further, we have to see that which eye disease Harmandeep Singh was suffering from and for the said disease what treatment was given to him. For that purpose, discharge summary, Ex.C-5, of the same is also as under:
"This is to certify that Mr.Harmandeep Singh S/o Sh.Amarjit Singh was registered with us vide Registration No.404611. He complained of diminution of vision in his both eyes. On examination anterior and posterior segment was within normal limits and intra ocular pressure was within normal limits. His best -corrected visual acuity was 6/6p in right eye with 6.50/Dsph-3.50/Dcyl at 30/axis and 6/6p in left eye with
-5.75/Dsph-2.50/Dcyl at 140/axis. He was diagnosed to First Appeal No 834 of 2022 7 have High Myopia with Astigmatism with Post C3R in both eyes. He was advised Toric Phakic IOLI (TICL) in both eyes. He was operated upon both eyes for TICL on 2nd August 2016 in our hospital, which costed him Rs.1,60,000/- inclusive all."
11. As per the above mentioned discharge summary, it is clear that Harmandeep Singh i.e. son of the respondent/complainant was operated upon for his eyes when he was diagnosed with High Myopia with Astigmatism, whereas learned counsel for the appellant/opposite party laid much stress upon the fact that this type of surgery is not covered under the policy as per clause 4.5. However, the perusal of the above said clause 4.5 reveals that there is no such bar that the disease like High Myopia with Astigmatism is not covered under the policy. On the other hand, in the medical terms, the definition of High Myopia with Astigmatism is defined as under:
"High myopia with astigmatism is a combination of two eye conditions that can cause blurred vision and make it difficult to see:
• Myopia Also known as nearsightedness, myopia occurs when the eyes are too long and images are focused in front of the retina, resulting in blurry distance vision. High myopia is when a patient has more than 6 diopters of myopia. • Astigmatism Causes blurry vision at all distances. Astigmatism and myopia can occur together in one eye, and this combination can make vision even more complicated.First Appeal No 834 of 2022 8
An optometrist can diagnose astigmatism and myopia with a comprehensive eye exam. LASIK surgery can correct astigmatism and has a high satisfaction rate, but it does carry some risks."
12. The perusal of above said definition clearly reveals that this is a disease of eye, which occurs at any stage and is only curable by surgery for which the treatment was taken by the respondent/complainant in Thind Eye Hospital on 02.08.2016 and the plea of learned counsel for the appellant/opposite party that this type of surgery is barred as per the terms and conditions of policy, does not carry any weight and is devoid of any merit.
13. Sequel to the above discussions, we do not find any infirmity and illegality in the order of the District Commission. Accordingly, the appeal filed by the appellant/opposite party is hereby dismissed being devoid of merits and the order of the District Commission is upheld.
14. The appellant/opposite party had deposited a sum of Rs.25,000/- at the time of filing of the appeal. It deposited another sum of Rs.74,754/- in compliance of the order dated 06.10.2022. Both these sums, along with interest accrued thereon, if any, shall be remitted by the Registry to the District Commission, after the expiry of 45 days of the sending of certified copy of the order to them. The concerned party may approach the District Commission for the release of the above amount to the extent of his/its entitlement and the District Commission may pass the appropriate order in this regard, in accordance with law.
First Appeal No 834 of 2022 9
15. The appeal could not be decided within the statutory period due to heavy pendency of court case.
(HARINDERPAL SINGH MAHAL) PRESIDING JUDICIAL MEMBER (KIRAN SIBAL) MEMBER November, 27th ,2024 parmod