Judgment:
Debasis Bhattacharya, Member
This appeal is directed against the order dated 21.06.2013 passed by the Ld. District Forum, Unit-II, Kolkata in Case No. 254/2011 by which the same has been dismissed on contest but without cost against the OPs 1 and 2 and dismissed ex parte against OP 3. Being aggrieved and dissatisfied with it, the Complainant thereof has preferred this appeal.
The case of the Complainant, in short, is that he made one Mediclaim Policy for self, his wife and two sons, being no. 100400/48/10/8500004359 w.e.f. 22.11.2010 to 21.11.2011 from the OP National Insurance Co. Ltd. His son, namely, Shri Abhisek Bhattacharya, underwent Lasik Surgery at Infants Better Sight Centre Pvt. Ltd. under Dr. Sudip Chowdhuri on 17.05.2011. He incurred an expenditure to the tune of Rs.34,050/ for his treatment, which claim has been repudiated by the OP No.3 by a letter dated 10.07.2011 in misconception, unreasonably irrationally and arbitrarily. He appealed against such repudiation to the OP No.2, by a letter dated 18.08.2011, who, without applying his mind and the correct interpretation of the surgery, affirmed the repudiation by a letter dated 06.09.2011. In fact, the treatment does not fall within the category of cataract, but a devise for correction of eyesight, instead of reduction of eye power. Accordingly, the case for compensation, interest and litigation cost from the OPs due to deficiency in service and harassment.
On the contrary, the case of the OP Nos. 1 and 2 in their W.V. is mainly that they have very justifiably repudiated the claim of the Complainant as hit by mischief of the Exclusionary Clause 4:6 of the Policy Condition, which bars insurance coverage in cases of œcorrection of eyesight?, which is on the basis of and very much in conformity with the opinion of the attending Surgeon, Dr. Sudip Chowdhuri, who has certified that the surgery was for œreducing his eye power?. So, the complaint petition be dismissed with exemplary costs.
It is to be considered if the impugned order suffers from any anomaly as to fact and in law, or not.
Decision with reasons.
Ld. Advocate for the Appellant has submitted that the claim was repudiated by the TPA on the ground of Exclusion Clause No. 4.6 stating that the Lasik surgery operated was for correction of eyesight, but it is actually not so, which the Surgeon concerned gave out for the purpose of reducing eye power. Against the repudiation, the Appellant made a representation to the Insurance Company on 18.08.2011, but the same was negatived by a letter dated 06.09.2011. It has been further contended that when a claim for treatment of cataract is available after one year of policy, why this one is not entertainable and maintainable.
Ld. Advocate for the Respondent Nos. 1 and 2 has submitted that it is in full agreement with the decision arrived by the Ld. District Forum in the matter, and there is no any shortcoming in that finding. In fact, the contention of the Surgeon itself, which is post repudiation, is very clear on the point that the said operation involved reduction of eye power, which was very high, but the patient was intolerant to Contact Lens. It is a mere ploy and a play with words and at best a jugglery of words. The case can well be thus termed as a chance case.
On behalf of the Respondent No.3, its Authorized Representative has supported the contention as made by the Ld. Advocates for the Respondent Nos. 1 and 2.
The contention in the repudiation is a well founded one. The refraction procedure involved in Lasik is only to correct a myopia, which, in other words, is nearsightedness or short-sightedness. Generally, myopia is corrected by eyeglasses with concave lenses. But, in this case, the patient is having intolerancy to Contact Lens. Thus, in no uncertain term, it can be said that it is a procedure followed to correct the eyesight, and the same is a bar under Exclusion Clause No. 4.6 of the Medicalim Insurance Policy. Accordingly, there is no wrong in such repudiation in this matter, and also in the decision of the Ld. District Forum, which cannot be altered.
In the result, the appeal fails.
Hence,
ORDERED
that the appeal be and the same is dismissed on contest, but in the facts and circumstances of the case without any order as to cost. The impugned order is hereby affirmed.