BRIJ MOHAN Vs. NEW INDIA ASSURANCE CO. LTD.

JUDGEMENT

(1.) The present Revision Petition under Sec. 21(b) of Consumer Protection Act, 1986 has been filed by Petitioner against the impugned Order dtd. 9/4/2015 passed by the State Consumer Disputes Redressal Commission, Punjab, in First Appeal No. 19 of 2013 vide which the Appeal filed by the Respondent No. 1/Insurance Company Appeal was allowed.

(2.) Brief facts of the case are that the Complainant purchased a Mediclaim Policy bearing No. 360701/34/10/11/00000314 from the Insurance Company for the period from 10/11/2010 to 9/11/2011 and Respondent No. 2/TPA was appointed as Third Party Administrator for verification of the treatments. On 2/2/2011, the Complainant suddenly lost vision in his left eye and he immediately rushed to Dr. Som Nath Singla at Singla Nursing and Eye Hospital, Kotkapura, where he was admitted as an indoor patient on the same day. He was examined by the said Doctor and was diagnosed as suffering from 'vitreous haemorrhage' in the left eye. He was further told that some blood clot had affected the vision of the left eye. He was prescribed some medicines and was discharged on 3/2/2011, having spent Rs.3,880.00 during the treatment at Hospital. Thereafter he went to Amritsar on 4/2/2011 for further treatment at Sri Guru Ram Dass Institute of Medical and Research, Amritsar. The Doctors there examined his eyes and informed that the blood clot had badly damaged his left eye, and prescribed certain medicines. He was referred to Dr. Khurana for further treatment; After seeing the Test Reports he was prescribed some more medicines and was advised to re-visit after 15/20 days. He spent Rs.3,424.00 on medicines. On 23/2/2011, when he revisited Amritsar, the Doctors added some more medicines and he had to spend another amount of Rs.2,925.00. On 28/2/2011, he fell down unconscious and was taken to Dr. Pirthipal Memorial Hospital, Kotkapura, for treatment. He incurred additional expenses of Rs.1,698.00 for medicines. On 1/3/2011, he visited the CMC Hospital, Ludhiana where necessary tests were conducted and medicines were prescribed, and he spent Rs.21,382.00 during the treatment there. On 27/3/2011, he visited Singla Nursing and Eye Hospital for further consultations where he was informed that he needed laser treatment and he spent another amount of Rs.2,000.00. On 29/3/2011, he visited Dr. Sohan Singh Eye Hospital, Amritsar for further consultation where he was informed that there was no need for laser treatment. However, he was prescribed some medicines which cost him Rs.2,196.00. On 26/4/2011, he visited GGS Medical College and Hospital, Faridkot where he was advised Homocysteine Test and he spent Rs.2,377.00 on the Test and other medicines. Thus in total, he spent Rs.40,000.00 for the treatment of his left eye and thereafter submitted all the original bills along with necessary documents to the Insurance Company who sent the same for verification to the TPA. Thereafter, he received a letter dtd. 7/6/2011 from Respondent No. 2/TPA informing him that his claim has been refused. Aggrieved by the act of the Insurance Company and the TPA, he filed Complaint before District Forum, Faridkot.

(3.) The District Forum vide its Order dtd. 23/10/2012 allowed the Complaint. The relevant extracts of the Order of the District Forum are set out as below '