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Facts of the case:

2. It is the case of the complainant that he was continuously taking mediclaim policy from the opponent insurance company from the year 2005 for himself and his family members. The complainant had the policy for the period 04.03.2017 to 03.03.2018 covering the complainant, his wife and his son for the sum insured Rs.2,50,000/-. During the existence of the policy, his wife Sumitraben was operated for left eye cataract. The operation was carried out on 15.05.2017 in the Raghudeep Eye Hospital at Ahmedabad. The total expenditure incurred was Rs.86,207/-. The complainant lodged his claim before the opponent insurance company. The opponent insurance company has settled the claim for Rs.24,000/-. The complainant has requested the insurance company to pay rest of the amount towards the cataract operation.

3. I have heard Ld. Adv. Mr. P. V. Patel for the appellant and Ld. Adv.

Haresh Parmar for the respondent.

Arguments of the appellant

4. Ld. Adv. appearing for the appellant has argued that the complainant was having mediclaim insurance policy for himself and his family members for Rs.2,50,000/- as sum insured. The wife of the complainant was operated for cataract in left eye and the total expenditure incurred was Rs.86,027/- which was much less than sum insured and there is no limit prescribed in the policy for awarding the amount at specific rate. The complainant has produced the invoice and bills for the amount paid to the hospital. These are the actual expenses which should be reimbursed by the insurance company. It is the choice of the insured that where and from whom he wants to take the treatment. The insurance company has failed to justify the amount of Rs.24,000/- for settlement of the claim and the Ld. District Commission has not justified that how the Forum is arrived at the rate of 60% as reasonable amount for the treatment taken by the insured. The Ld. District Commission has wrongly relied upon the zeiss cataract communities' report available on the internet. The opponent insurance company could not clarify that how this report is applicable in the case of the complainant. Hence, the complainant is entitled to the total amount claimed in the complaint and the order passed by the Ld. District Commission may be quashed and set aside and this appeal may be allowed.

7. It transpires from the judgment rendered in CC no.113/2018 dated 05.02.2019 by the Ld. District Commission that the insurance company has resisted the complaint on the basis of reasonable and customary expenses. It is further transpires that the respondent company has produced on record the zeiss cataract communities report about the expenses which may be incurred for the cataract operation in India. The insurance company has relied upon this report which was not carried out by the insurance company neither was considered at the time of awarding the settlement amount of Rs.24,000/-. This is just an afterthought and abstract taken from the internet produced before the commission. Insurance company has failed to establish that how this report is helpful to the insurance company. In the written statement, the insurance company has taken the stand that if the complainant could have opted for the lens manufactured in India, they could have paid the less amount. The insured has opted for the foreign lens which was much expensive than the Indian one. Complainant could have saved money by opting for the Indian lens. It is the privilege of the insured that from whom and from where he should take the treatment. The insurance company cannot have any say about the choice of the Doctor and hospital or the quality of lens to be used, when the limit for particular treatment is not fixed and the expenditure incurred by the insured are less then sum insured, the insured is entitled to entire amount for which the claim has been made.

9. I have considered the judgment of this Commission passed in Appeal No. 1378/2014, in the matter between Narendra D. Jobanputra Vs. The Oriental Insurance Co. Ltd. Para 11 of the judgment reads as under:

"As per policy condition 13.2, insured would be entitled to reasonable, customary and necessary expenses'. We fail to understand the meaning of 'reasonable charges'. What does the insurance company mean by 'reasonable, customary and necessary expenses' is also not clear. Hospitalization expenses and charges vary from person to person. As per the policy condition no amount or slab is fixed for cataract operation by the insurance company. It is the insurance company who will decide in each case of cataract operation what amount of claim to be settled for insured. We fail to understand the definition or criteria of reasonable charges and customary charges. The insurance company has not been able to explain us this term. The dictionary meaning of -