JUDGEMENT

          Complainant by filing this complaint has submitted that complainant and his wife Madhuri Goenka purchased one Individual Health Insurance Policy being Policy No.030300/48/12/97/00008802 risk covered for the period from 27.03.2013 to midnight on 26.03.2014 subject to maximum limit of Rs.7,50,000/- as per policy during valid period of the said policy Madhuri Goenka was hospitalized as per advise of qualified physician of Woodlands Multispeciality Hospital Ltd. on 09.07.2013 within risk covered period and during treatment in the said Woodlands Multispeciality Hospital Ltd. total expenditure was incurred by the insurer to the extent of Rs.3,88,541/- including surgent fees out of which the op no.2 only paid a sum of Rs.2,22,422/- and balance sum of Rs.1,66,119/- had not yet been paid.  But op by a letter dated 27.08.2013 reported that the details deduction and paid Rs.2,22,422/-.  Practically such sort of reduction of Rs.1,16,119/- is arbitrarily and whimsically ignoring terms and conditions of the Policy and without any basis.  Fact remains that op no.3 Dr. Anil Poddar conducted surgery 3 times in the Hospital and charged his fees of Rs.1,46,000/- which was paid by the insured against proper and valid money receipt No.235 dated 01.08.2013 by account payee cheque No.005049 dated 01.08.2013 drawn on Bank of Maharashtra, Chowringhee Branch, Kolkata.

          Complainant submitted entire bills including final bill for Rs.3,88,541/- out of which the op nos. 1 and 2 in collusion with each other paid a sum of Rs.2,22,422/- and balance amount of Rs.1,66,119/- has yet been paid though complainant submitted several reminders for reconsideration the same.  Fact remains Woodlands Multispeciality Hospital Ltd. did not include the surgery fees or doctor’s fees and so the op denied the payment and the reasons shown in the op’s letter dated 27.08.2013 and in the above circumstances, for negligent and deficient manner of service and for arbitrary reduction of Rs.1,66,119/- complainant has prayed for redressal along with compensation.

          On the other hand op Insurance Company by filing written statement submitted that no doubt complainant is a holder of the said Individual Health Insurance Policy under the op and fact remains that complainant submitted a bill of Rs.3,88,541/-.  But after due consideration of the entire claim and also considering the terms and conditions of the policy, it was settled to the tune of Rs.2,22,422/- as full and final settlement and rest amount of Rs.1,66,119/- has been deducted from the claim bill which are inadmissible as per the rules laid down in the policy and details deduction and settlement of claim was duly informed to the complainant vide letter dated 27.08.2013 which was duly acknowledged and accordingly the said amount was paid in favour of the insured which is an admitted fact.

          When the matter has already been finally settled there was no laches on the part of the op and so it is not a consumer dispute and fact remains op disclosed everything about in details parawise about their deduction and fact remains as per terms and conditions the deduction was made.  So, complainant was not entitled to any further amount and another factor is that the claim of the complainant is baseless and without any foundation for which the complaint should be dismissed.

                                                     Decision with reasons

          On hearing the argument as advanced by the Ld. Lawyers of both the parties and also considering the full and final settlement of the claim of the complainant as made by the op (page 19 of the complaint) it is clear that the claim was in respect of Rs.3,88,541/- and op paid Rs.2,22,422/- and details of deduction from item Nos. 1 to 19 have been made.  It is specifically mentioned against item No.20 of the details deduction.  It is specifically mentioned that Rs.1,46,000/- of Money Receipt No.235 dated 01.08.2013 (Surgeon Fees) for no payment shall be made under clause 1.2C, Note No.2 other than part of the hospital bill and other bills of deduction are there and in this regard after considering the terms and conditions of the policy including the deduction details of Page 1 to 19 we found that same are quite okay and as per terms and conditions of the policy, the said amount was rightly deducted by the op authority.

          In the present case practically the complainant has challenged the deduction of item No.20 of details of deduction i.e. Rs.1,46,000/- as Surgeon Fees which was paid to the doctor op no.2 for such operation.  Op has already reported the matter to the complainant stating that the said amount of Surgeon fees has not been made part of the bill of Woodlands Multispeciality Hospital Ltd. and fact remains as per terms and conditions of the policy, it shall not be treated hospitalization cost.

          But truth is that Woodlands Multispeciality Hospital Ltd. submitted bills (in patient discharged bills) i.e. page 29 to 37 were not deposited along with claim application by the complainant and same were issued by the Woodlands Multispeciality Hospital Ltd. as in patient discharge bill.  In the said bill there is no inclusion of the surgeon charges though doctor’s assistance charges are there.  Fact remains the patient was admitted in the said Woodlands Multispeciality Hospital Ltd. under Dr. Anil Kumar Poddar and in column doctor’s fees only fees of doctor assistance are there.  It was a surgical operation but no fees of Dr. Anil Kumar Poddar is there.  But as per provision of the terms and conditions of the policy it is mandatory on the part of the hospital to submit a bill including the surgeon fees etc. otherwise the insurance company is not liable to pay any bill of any doctor if he received such amount outside the hospital.

          Fact remains in this case Dr. Anil Kumar Poddar received that amount directly from the patient party without including it as his surgeon fees/charge for which there was no scope on the part of the insurance company to grant that amount and that is argument of the Ld. Lawyer for the op.

          Fact remains op submitted a detailed of statement amount wherefrom it is found that two operation theatre rate/charges were granted and professional doctor/consultant fees are paid, but surgeon fees are not in the said column.  Fact remains both the parties are guided by the terms and conditions and as per policy condition 1.2C read with section the Note-1, it is clear that as per said clause the amount payable under 1.2C & D shall be at the rate applicable to the entitled room category and in case the insured person opts for a room with rent higher than the entitled category as in 1.2A, the charges payable under 1.2 C & D shall be limited to the charges applicable to the entitled category.  This will not be applicable in respect of medicines and drugs and implants and in the said clause it is specifically mentioned in Note 1.2C, Note-2 no payment shall be made under 1.2C other than as part of the hospitalization bill.

          Considering that mandatory clause and terms and conditions of the policy we are convinced to hold that Woodlands Multispeciality Hospital Ltd. submitted the bill without surgeon fees for operation as part of the hospitalization bill.  So, as per clause 1.2C Note-2, op rightly refused to pay Rs.1,46,000/- as received by Dr. Anil Kr. Poddar as his fees outside the hospital.  But it is mandatory provision of law that if any patient is hospitalized in any hospital or nursing home or any private hospital and if he possesses an Individual Health Insurance Policy Scheme of any insurance company the entire charges of operation etc. shall be submitted by the said hospital and doctor’s fees and surgeon fees shall be included in the said bill of the nursing home or the hospital and if same would not be part of the hospitalization as per terms and conditions of the policy no payment shall be made under clause 1.2C (fees of surgeon, anesthetist, medical practitioner, consultants, specialists fees).

          But peculiar factor is that other doctor’s fees are included in the bill of Woodlands Multispeciality Hospital Ltd. that had been paid by the op.  But for some obvious reasons the payment of Rs.1,46,000/- as paid by the complainant to Dr. Anil Kr. Poddar is not part of the hospitalization bill.  So as per terms and conditions of the policy rightly op deducted the said amount as already noted in detailed list of deduction as item No.20 and that was received by the complainant.

          Now question is whether such payment can be released by this Forum.  On the other hand the terms and conditions of the policy in this regard we are very much aware of the fact and also we are aware of the legal position that parties of any agreement cannot go outside the terms and conditions of the policy and in any case the Forum cannot interpret or cannot include any new word for giving any relief to either of the parties and in this regard the ruling reported in 2013 (4) CPR 165 (NC) is guideline principal in this regard and so relying upon that ruling we are convinced that the parties shall be strictly governed by the conditions and no exception or relaxation can be made on the ground of equity and truth is that in this case the complainant has violated the terms and conditions of the policy 1.2C Note-2 and fact remains that in the patient discharged bill issued by Woodlands Multispeciality Hospital Ltd. the said amount is not included when that is the fact, then as per conditions of the policy, clause No.1.2C Note -2 op rightly deducted that amount and the total deduction against each item 1 to 20 as specifically described in the letter dated 27.08.2013 was received by the complainant and that has been submitted by the complainant.  So we are convinced to hold that detailed deduction were supplied and reasons for deducting of Rs.1,46,000/- was also reported to the complainant in details and after considering the pros and cons of the conditions of the policy and detailed deduction item wise we have found that details deduction as made by the op is/was legal and valid and as per terms and conditions of the policy.

          In the present case practically Ld. Lawyer for the complainant tried to convince that it is a social legislation.  But fact remains any social legislation is enacted with conditions for getting certain benefit and if the principal conditions are not complied with by any relief seeker invariably he must not have to get such relief even if it is for social legislation.  Most probably the complainant is not aware of the fact that Consumer Forum has no legal authority to interpret the terms and conditions of the policy by which parties are strictly guided and as per observation of the State Commission and National Commission, the Forum has no authority to give any alms to any relief seeker outside the terms and conditions of the policy.  Whatever may be the amount spent by the patient holding the mediclaim policy or health insurance policy is not always entitled to get entire amount as per terms and conditions of the policy and in the present case if for the sake of the argument if it is accepted that complainant spent Rs.1,46,000/- for the surgeon fees, that cannot be paid by the op as per terms and conditions of the policy.

          But only the complainant is entitled to such percentage of the fees as per terms and conditions of the policy 1.2C with exclusion Note-1 if the said amount is included in the hospitalization bill but when in the present case the said amount is not part of the hospitalization bill, then there is no scope to grant any relief in favour of the complainant.  But anyhow nowadays it has become a practice of some Fora to grant ex-gratia relief to the mediclaim policy holder brushing aside the terms and conditions of the policy which is no doubt a negligent approach of any Forum and disobeyance of the mandatory provision of law at the same time the verdict of National Commission and State Commission in this regard.  In this case it is clear from the terms and conditions of the policy that complainant is not entitled to get this item No. 20 which is noted in detailed of deduction of the op and op rightly deducted it. 

          Truth is that in the present case complainant has failed to prove that as per terms and conditions of the policy he or she is entitled to get Rs.1,46,000/- as balance amount of the mediclaim policy.  Most interesting factor is that the Ld. Lawyer for the complainant was asked again and again to show the clause and terms and conditions of the policy by which the parties of this case are guided and op acted illegally and arbitrarily deducted such amount.  The Ld. Lawyer for the complainant only uttered one word ‘social legislation’.  So, it can be said that this Forum is not aware of such legislation, that Forum has his authority as per article 141 of the Indian Constitution.  But the highest authority the Hon’ble Supreme Court has observed that Forum has no authority to interpret any provision of contract or terms of the contract and Forum has no authority to go outside the contract and terms and conditions of the policy.  Forum cannot hire a new thought to give relief but Forum shall have simply to grant relief as per terms and conditions of the policy.

          But anyhow the Ld. Lawyer for the complainant has miserably failed to satisfy the legal barrier as created by law. No doubt we have realized the grievance of the Ld. Lawyer of the complainant. But if there is any legal grievance regarding the conditions of the policy, the complainant may go before the Hon’ble High Court challenging the Constitution and validity of such conditions and if Hon’ble High Court Constitutional Bench declare it as ultravires in that case this Forum can grant any relief whatever it may be with such power in this regard.

          Truth is that this Forum has no legal authority to grant any ex-gratia outside the legal Bond that is terms and conditions of the policy for which the present complaint is not maintainable and there is no laches or deficiency or negligence on the part of the op.

          In the result, complaint fails.

          Hence, it is

                                                               ORDERED

          That the complaint be and the same is dismissed on contest against op but without any cost.