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          The present appeal is directed against the Order, dated 13.05.2015 , passed by the Ld. District Consumer Disputes Redressal Forum, Kolkata , Unit -II, in CC No. 386 of 2014, whereby the complaint was allowed ( in part ) on contest against OP Nos. 1 to 3 with cost and dismissed against the OP No.4 without cost.

            The Complainant's case, in brief, was as follows:

            The Complainant obtained an individual Mediclaim policy from OP No 1 who issued the policy through OP No.3. The policy covered the risk of Rs. 3,00,000/- and it was valid for the period from 31.03.2010 to the midnight of 30.03.2011. The Complainant, having some problem in his eye contacted Dr. Zahir Abbas , MD. (AIIMS) , FRGS (UK) of Suryodaya Eye Centre of Calcutta Medical Research Institute, was  advised for 3 dozes of intravitreal injection lucentis in his left eye . Dr. Abbas planned surgical procedure for administering the injection . Three dozes of such injection were administered . He was discharged on the same date on each occasion, i.e., 07.08.2010 , 16.09.2010 and 30.10.2010. Subsequently, he was referred to Dr. T.P. Das. for opinion . As per advice  of the doctor he was admitted at CMRI , Kolkata on 18.12.2010 , 20.01.2011 and on 19.02.2011 when 3 more dozes of luecentis were administered in the left eye and he was discharged on the same date on each occasion. The Complainant submitted 6 claims for a total sum of Rs. 2,78,886/- to the O.P No. 4, i.e., the TPA of the Insurance Company. The claims were repudiated by the TPA on the ground that administering of intravitreal injection luecentis does not support the need of hospitalization. The Complainant requested the Divisional Manager of the OP Insurance Company, being OP No.3 for review but there was no response from them. The Complainant, having written to OP No.2 against repudiation of his claim,  was told that the repudiation stood confirmed. Insurance Ombudsman was approached with opinion of renowned doctors certifying that the issue of administration of intravitreal injection in case of CNVM should be performed in operating room in absolute sterile conditions which is a surgical procedure and can not be regarded as OPD based treatment. The said Insurance Ombudsman awarded the claim in part only which was grossly insufficient . The award could not be accepted by the Complainant . The decision of the OPs repudiating the claim was highly irregular , arbitrary and illegal as the treatment by injection lucentis was never excluded from the policy issued by OP No.1.  On the ground of gross deficiency in service , the complaint was filed before the Ld. Forum below .

        Ld. Advocate appearing for the Appellant/Complainant submitted that the impugned order is illegal and arbitrary in nature as the material facts were not taken into consideration by the Ld. Forum below. It was wrongly held by the Ld. Forum below that the case of the Complainant was not an eye surgery and as per clause 2.2 and 2.3 Complainant is not entitled to any benefit. It was also wrongly held by the Ld. Forum below that the Complainant suppressed the fact of choraidal neo vascular membrance (CNVM) though the OP Insurance Company made no such averment in their W.V. filed before the Ld. Forum below. Several expert opinions were submitted before the Ld. Forum below confirming the fact that intravitreal injection is a surgical procedure and can not be regarded as an OPD based treatment . But, no counter opinion could be produced by the OP Insurance Company before the Ld. Forum below in support of their contention that the administrating of intravitreal injection lucentis 'does not  support the need for hospitalization'. Such view taken by the TPA and endorsed by the Insurance Company is wholly wrong and deserves to be discarded . Again in the policy condition itself it has been stated vide clause 2.2. that in case of eye surgery among other ailments , the stipulation of stay in hospital for a  minimum period of 24 hours will not be applicable. As such , the repudiation of the claims by the OP Insurance Company was unjust and unfair . The compliant should have been allowed by the Ld. Forum below  in its entirety .

                                                    Decision with Reasons :

            The point for consideration is whether the impugned order suffers from any material irregularity, legal infirmity or jurisdictional error.

            There is no dispute that the Appellant/ Complainant took an individual Mediclaim policy for hospitalization benefit and the policy as renewed was valid between 31.03.10 and 30.03.11 .

            During the subsistence of the policy the Appellant / Complainant under went eye treatment with pushing of intravitreal injections ( 6 dozes)  in his left eye as advised by the treating doctor.

The TPA as well as the OP Insurance Company are found to have repudiated the claim on the ground that the hospitalization for LT eye  , CNVM i.e., intravitreal injection lucentis does not support the need of hospitalization . It is important to note that such view of the OPs has not been supported with any expert opinion and there is no reflection of such expert opinion in the impugned order. On the other hand  the Complainant/ Appellant has submitted several opinions,  namely, from Shroff Eye Centre , LV Prasad Eye Institute , Dr. Lalit Verma of All India Ophthalmological Society , Dr. S. Natarajan , Chairman and Managing Director , Aditya Jyot Eye Hospital Pvt. Ltd. and Dr. Zahir Abbas , MD. (AIIMS), FRCS, ( UK) , consultant vitreo surgeon , CMRI , all certifying  in more or less same tune that the intravitreal injection is surgical procedure which should be carried out under an aseptic condition and should be performed in the operating room. Such view appears to have been ignored by the Ld. Forum below who viewed  that the disease was in existence prior to purchasing the policy though such averment was never made by the OPs/ Respondents herein . Ld. Forum below took an adverse view that the treatment was, in no way, a surgery though the attending doctor in every pre-operative advice mentioned that the planned surgical procedure would be of one day's duration which may be extended in case of unforeseen complication . Such advice implies that the treatment was of surgical nature which may be done  in less than 24 hours or may take more time. In clause 2.2  of the policy schedule it has been clearly stated that the time limit of 24 hours is not applied in case of eye surgery among some other specified treatments .