USHA JHUNJHUNWALA Vs. ORIENTAL INSURANCE COMPANY LTD

JUDGEMENT

(1.) Petitioner has filed this writ application for quashing the letter dated 8.8.2011 (Annexure-6 with the writ application) issued by respondent No. 3, the Divisional Manager of the Oriental Insurance Company Limited, by which her husband was informed that her claim was not found payable on the ground that "Injection Lucentis is not payable under the scope of the Policy." However, by the letter "one more opportunity" was given to substantiate her claim within 2 weeks from the date of receipt of the letter, before a final decision was taken, failing which her claim was to stand repudiated on the said ground, without further advices from them. She has also made a prayer in the writ application for quashing the letter dated 17.8.2011 (Annexure-8) issued on behalf of respondent No. 4, The Medicare T.P.A. Services (1) Pvt. Ltd., Kolkata, by which she was informed that her medical claim documents were processed, but, as per the opinion of its adjudication department and the doctors' panel, her claim was adjudicated as "No claim" in nature because of the reason that "Treatment/procedure related to inj Lucentis is not covered as per Insurance Co. guidelines. Hence the claim repudiated". It was also mentioned in the letter that "the respective Divisional Officer has recommended repudiation vide letter dated 30.6.2011. Therefore the claim stands rejected". These two letters show that, as far back as on 30.6.2011, the respondent Divisional Manager had recommended to respondent No. 4 for repudiation of claim of petitioner, on which respondent no. 4 acted, resulting into issue of Annexure-8. Still respondent Divisional Manager issued letter dated 8.8.2011, Annexure-6, by which, though holding that her claim was not found payable, she was given "one more opportunity" to substantiate her claim. Petitioner, in response of the said letter of the respondent Divisional Manager Annexure-6, indeed, availed that opportunity and filed her application dated 1.9.2011 (Annexure-7). A reply dated 27.10.2011 of the respondent Divisional Manager of her said application, addressed to her husband, is Annexure-5 with the counter affidavit. The present writ application was presented in the Stamp Report Section of the High Court on 9.11.2011. Still the application is conspicuously silent about this reply, nor there is a pleading that petitioner had not received any final decision of the Insurance Company on her said application, Annexure-7. Since all previous communication and stand of the respondents stand merged in this final reply of the respondent Divisional Manager dated 27.10.2011, petitioner was required to challenge the same also before this Court, either through a prayer in the main writ application, or through an I.A. for liberty to do so, at least after filing of the counter affidavit in the case, which she has apparently not done.

(2.) Be that as it may, coming to the merits of the case and issues involved, this Court finds that there is no dispute of the fact that, as appearing from the doctor's prescription dated 4.10.2010 (Annexure-1) also, petitioner was examined at Infiniti Eye Hospital at Mumbai. The diagnosis and advice to her was as under:--

(3.) The above diagnosis and advice contains medical terms and abbreviations. Hence, with the help of internet and medical books this Court could find their full form or explanations as under:--