The main legal point established in the judgment is that an Insurance Company must provide a clear and justifiable basis for determining 'reasonable charges' and 'customary expenses' as per the policy conditions, failing which their actions may be deemed unfair trade practices.

ORDER :

Mrs. Jyoti P. Jani, Member-Being aggrieved by and dissatisfied with the judgment and order rendered by the Consumer Disputes Redressal Forum, Rajkot (Addl.) on 12.9.2014 in Complaint No. 96 of 2014, the original complainant has filed the present appeal. For the sake of convenience, parties to this appeal are hereinafter referred to by their original nomenclature.

2. It is the case of the complainant before the District Forum that he purchased Mediclaim Insurance Policy from the opponent Oriental Insurance Company Limited for him and his wife. The same has been renewed from time to time and lastly the policy was renewed wherein the sum assured was Rs. 50,000. It is further say of the complainant that his wife had to be operated upon for removal of cataract in both her eyes at the hospital of Dr. Vasant V. Sapovadiya. She was admitted to the said hospital on 24.9.2013 and discharged on 27.9.2013. The complainant had to incur expenses of Rs. 1,06,054 for the operation. The complainant lodged claim with the Insurance Company. The Insurance Company offered to settle the claim in the sum of Rs. 60,000 which the claimant did not accept. Upon inquiry the complainant was given to understand that the remaining amount was not paid by the Insurance Company in view of the provisions of exclusion Clause 4.6 of the mediclaim policy. The complainant therefore filed complaint before the District Forum for recovery of the entire medical expenses, interest, cost and compensation.

3. Upon service of notice, the Insurance Company filed its reply. The District Forum, after hearing the learned Advocates for the respective parties and the documents placed on record, the District Forum rejected the complaint of the complainant. Hence, the present appeal.

4. Heard the appellant party in person and Mr. Naresh Sinroja, learned Advocate for the respondent at length. We have also gone through the judgment and order of the District Forum, appeal memo and the documents placed on record.

5. It is the case of the complainant that his wife was operated for cataract in both her eyes and the claim was put before the Insurance Company. The Insurance Company, instead of paying the claim amount of Rs. 1,06,054, enclosed a full and final settlement voucher for Rs. 60,000 contending that the insured had used multi-focal lens which had added benefit of removal of spectacles which is not covered as per exclusion Clause 4.6 of the policy. The complainant argued that his claim amount was as per the expenses incurred for the operation. The claim was for indemnification of the claim amount; it was not for any benefit amount as observed by the Insurance Company.

6. The learned Advocate for the Insurance Company opined that decision of the District Forum is well reasoned and requires no interference in appeal. As per policy condition 4.6 and 13.2, the insured was disbursed a voucher for Rs. 60,000 as full and final settlement which was not accepted by the insured. Therefore there was no deficiency in service on the part of the Insurance Company.

7. Before we go to the merits of the appeal, we would like to reproduce exclusion clause No. 4.6 and 13.2, respectively appearing at page 82 and 85 of the appeal proceedings and they read as under:

“4.6. Surgery for correction of eye sight, cost of spectacles, contact lenses, hearing aids, etc.”,

‘13.2. For any other hospital it shall mean the cost of surgical/medical treatment that is necessary, customary and reasonable for treating the condition for which insured person was hospitalised to the extent that such cost does not exceed the reasonable and customary charges for which insured was hospitalized’.”

8. It is the case of the Insurance Company that the insured had used multi-focal 10L lens which had added benefit of removal of spectacles. This has increased the cost of lens and as per exclusion Clause 4.6, surgery for the correction of eye sight cost of spectacles is not payable. Reliance has been placed by the Insurance Company o