DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi- 110016
Case No.114/2022
Sh. Ravinder Kumar Khattar
Son of Shri Shri Nand Lal Khattar
Resident of B-2/17, Safdarjung Enclave,
New Delhi-110029
….Complainant
Versus
1. M/s United India Insurance Company Limited,
501-503, Vikrant Tower,
Rajender Place,
New Delhi-110008
2. M/s Heritage Health TPA Pvt Ltd.
411, Laxmideep Building,
Laxmi Nagar District Centre,
Laxmi Nagar,
New Delhi-110092
….Opposite Party
Date of Institution : 29.04.2022
Date of Order : 31.07.2024
Coram:
Ms. Monika A Srivastava, President
Ms. Kiran Kaushal, Member
Present: Adv. Kusum Lata along with Adv. Sushmita Chaudhary and
complainant.
None for OP.
ORDER
Member: Ms. Kiran Kaushal
1. Facts of the complaint as pleaded by the complainant are that complainant had purchased Mediclaim Insurance Policy from United India Insurance company, hereinafter referred to as OP-1 and M/s Heritage Health TPA Pvt Ltd as OP-2.
2. It is stated that during the subsistence of policy complainant was advised to undergo cataract surgery in his left eye on 31.03.2019 at Centre for Sight. Doctors therein recommended the ‘Comprehensive Femto Cataract package with Zeiss Trifocal lens’ to be best suited for the complainant. The total cost of the said cataract surgery was Rs.1,32,000/-.
3. Complainant submitted claim form with OP for the said amount but to utter shock and dismay OP approved only meagre sum of Rs.34,000/-. Complainant was left with no option but to pay balance Rs.98,000/- and undergo the recommended surgery on 31.03.2019. Complainant wrote an email dated 16.04.2019 seeking clarification regarding the amount approved to which OP replied that the cost of Femto laser Cataract Surgery was very high and the highest outgo for cataract surgery under PPN for MICS in the hospital was Rs.34,000/-.
4. It is stated that Doctor had recommended Femto, which is a laser cataract surgery and is a surgical method in which incision is made in the eye with the help of tools/instruments. It is stated that complainant cannot be expected to choose a surgical method or lens other than what was recommended by the Doctors, therefore, the claim of the complainant was wrongfully restricted by OP without any sufficient cause.
5. It is further stated that the complainant encountered similar fate when he got the cataract surgery for his right eye on 11.05.2019. The complainant’s claim for Rs.1,32,000/- was once again restricted to Rs.34,000/- by OP. Complainant was forced to pay the balance amount of Rs.98,000/- despite having subsisting medical insurance cover of last 25 years. Therefore, complainant sent an email dated 15.05.2019 to OP, disputing the restricted claim, however, OP again cited the same reason and approved only Rs.34,000/-.
6. Complainant to support his claim has relied on Clause 1.2.1 of the Insurance Policy which states that in case of Cataract, the insured is entitled to ‘ actual expenses incurred or 25% of the sum insured whichever is less’. Thus, as per Clause 1.2.1 complainant is fully entitled to claim up to Rs.1,25,000/- for the medical expenses incurred by him. Copy of the terms and conditions of the policy are appended at Page No. 18 of the complaint.
7. Aggrieved by the wrongful and arbitrary act of OP, complainant prays for direction to OP to reimburse sum of Rs.91,000/- each for the two claims filed by the complainant along with interest @18% p.a; to pay compensation of Rs.5,00,000/- towards mental agony and harassment and Rs.55,000/- towards the cost of litigation.
8. OP filed its written version stating inter alia that the instant complaint is with respect to two claims filed on account of left eye and right eye cataract surgery on 31.03.2019 and 11.05.2019 respectively. OP had reimbursed Rs.34,000/- which is approximately 1/4th of the total bill amount of Rs.1,32,000/- each in both surgeries as per the terms and conditions of the policy.
9. As per Clause 1.2.1 which states that ‘ actual expenses incurred or 25% of the sum insured whichever is less’ it is submitted that OP had paid 25% of the total bill amount. It is next stated that as per Email dated 16.05.2019, OP informed the complainant that the highest outgo for cataract surgery under PPN for MICS in this hospital is Rs.34,000/-. As per the terms, such claims are to be restricted up to PPN packages of cataract surgery under reasonable and customary clause. OP had already informed the complainant regarding the same and complainant had agreed to pay the excess amount beyond the PPN package for cataract and signed PPN declaration form. As per PPN Declaration, the insured wished to avail another better facility and agreed to pay the amount over and above the agreed PPN tariff of the hospital.
10. In view of the submissions made, it is prayed that the complaint is liable to be dismissed as no cause of action has arisen against OP.
11. Rejoinder has been filed on behalf of complainant, wherein most of the averments made in the complaint have been reiterated. Complainant replying to the preliminary objection raised by OP states that the Clause 1.2.1 mentions ‘25% of the sum insured’ and not ‘25% of bill amount’ to be paid for cataract surgeries. OP has paid 25% of the Bill amount wrongly restricting the claim amount.
12. Evidence and written arguments have been filed on behalf of both the parties. Submissions made are heard. Material placed on record is perused.
13. It is not in dispute that complainant had under gone cataract surgery for both his eyes and had paid Rs.1,32,000/- each for both the surgeries. Dispute between the parties arose when OP passed partial claim of the complainant and paid Rs.34,000/- each for the surgeries.
14. As per the details provided in the Individual Health Policy Schedule, complainant had taken Policy Type ‘Gold’, for which he paid premium of Rs. 20,036/- wherein the sum insured for the complainant and his wife was Rs.5,00,000/- each. It is noticed that the inception date of the first policy is mentioned as 23.11.2006. It was during the subsistence period of the policy i.e 23.11.2018 to 22.11.2019 that the complainant had undergone Femto laser Cataract Surgery as advised by the Doctor.
15. Though, OP states that the complainant was informed regarding the highest outgo for cataract surgery under PPN for MICS in this hospital is Rs.34,000/- and complainant had agreed to pay the excess amount beyond the PPN package for cataract and signed PPN declaration form agreeing to the same. It is noticed that the terms of PPN packages were not provided to the complainant initially, instead complainant along with the policy was provided the terms and conditions which clearly show that as per Clause 1.2.1 expenses in respect of cataract surgery was to be restricted to ‘actual expenses incurred or 25% of the sum insured whichever is less’.
16. In this case 25% of the sum insured would be less and as mentioned above, the sum insured is Rs.5,00,000/- and 25% of the sum insured amounts to Rs.1,25,000/-. This Commission is of the view, that having a clause stating that the cataract surgery is to be restricted to the amount stated above, OP is bound by the terms and conditions of the policy.
17. The Hon’ble NCDRC in the matter of National Insurance Co. Ltd., versus Vinod Puri as reported in I [2014] CPJ 341 (NC) is pleased as under:
Insurance contract has to be construed like any other contract on basis of its terms and conditions and outside aid for construction of insurance policy is impermissible.
18. OP cannot be allowed to change its stance later and restrict the claim by stating that ‘highest outgo for cataract surgery under PPN for MICS in this hospital is Rs.34,000/-’ .OP is found to be deficient in service by not abiding to the terms and conditions of its policy and by way of such omission, complainant has been put to financial loss. Hence, OP is directed to pay Rs.1,25,000/- for each surgery. As Rs.34,000/-each has already been paid by OP for both the eyes surgeries, the said amount is deducted and OP is directed to pay Rs.91,000/- each for both the claims.
19. In light of the discussion above, OP is directed to pay Rs.1,82,000/- with interest @6% p.a from the date of filing of complaint within 03 months from the date of order, failing which OP shall be liable to pay the above stated amount with interest @9% p.a till realization.
20. Additionally, OP is directed to pay Rs.10,000/- as compensation towards mental agony and litigation cost.
Parties be provided copy of the judgment as per rules. File be consigned to the record room. Order be uploaded on the website.
