This C.C. is coming on before us for hearing in the presence of      Sri. K.V.S. Pundarikakshudu, Advocate for complainant; and of Sri. K. Uttam Kumar, Advocate for Opposite party No.2; and of Sri. S.V.R. Gupta,  Advocate for Opposite party No.3; opposite party No.1 served called absent; upon perusing the material papers on record; upon hearing and having stood over for consideration, this Forum passed the following:-

O  R  D  E  R

(Per Sri R. Kiran Kumar, FAC President)

          This complaint is filed u/s.12-A of Consumer Protection Act, 1986. 

2.        The averments made in the complaint are that the complainant is resident of Khammam and he had taken Mediclaim policy bearing No.613201/34/09/11/00000239 from the opposite party company in the year 2000.  The complainant submitted that initially the complainant had taken policy for his father with Jupudi Hanumantha Prasad, later his wife and daughter were also included as family members.  The policy is in force by renewing the premium from time to time and the policy is covered for all the family members of the complainant and the policy is for reimbursement of hospital expenses.  The complainant further submitted that his father Sri. Jupudi Hanumantha Prasad was hospitalized for knee operation in the March 2010 at Care Banjara Hospital, Hyderabad and he was treated as inpatient from 01-03-2010 to 17-03-2010 and spent an amount of Rs.2,83,942/- towards hospitalization expenses.  The complainant further submitted that  the expenditure incurred by the complainant is below the sum insured and the entire amount is payable by the opposite parties as per the conditions laid down in the policy.  After the discharge from the hospital, the complainant submitted claim form along with the bills to third party registration and requested to settle the claim, after verifying the medical record an amount of Rs.1,38,773/- was only sanctioned and the balance amount of Rs.1,45,159/- was rejected on the pretext that the complainant opted a room at high cost accordingly the complainant had received a letter dt.30-09-2010 from the office of opposite party No.2.  The complainant further submitted that as per the policy conditions the complainant and his family members are eligible for the reimbursement up to the insured amount, here the amount spent by the complainant below the sum assured as such the opposite parties are liable to pay the remaining amount to the complainant without assigning any reason.  And also there was no such condition at the time of taking policy and the policy is continuously in force without any break for the year 2000, any later amendments in the policy are not applicable to the complainant.  The complainant further submitted that though he approached the opposite parties, they failed to settle the claim which amounts to deficiency of service for that he got issued notice to the opposite parties on 21-03-2011, inspite of receipt of notice the opposite party did not choose to give reply nor paid the balance amount, for that the complainant filed this complaint.     

3.        On behalf of the complainant, the following documents were filed and marked as Exhibits A1 to A4.

Ex.A1:-Office copy of legal notice addressed to the opposite party No.2 along with postal receipt dt. 21-03-2011.

Ex.A2:-Office copy of legal notice addressed to the opposite party No.1 along with postal receipt dt. 21-03-2011.

Ex.A3:-Copy of letter issued by the opposite party no.2,                      dt. 30-09-2010.

Ex.A4:-Policy bearing No.610902/48/99/20/00008746 issued by the opposite party No.1.

4.        On receipt of the notice, the opposite party No. 2 appeared through their council and filed counter.  In their counter the opposite party No 2 admitted the obtaining the Mediclaim policy by the complainant, for his father by name Jupudi Hanumantha Prasad, the complainant submitted hospital expenses for his father for Rs.2,83,942/-.  After thoroughly persuing the medical bills submitted by the complainant and verified the same, the opposite parties had sanctioned an amount of Rs.1,38,773/- to Care Hospitals, Banjara Hills Hyderabad, in which the father of the complainant was treated as the policy is cashless policy.  The opposite parties further submitted that the opposite parties calculated the medical expenses incurred by the complainant as Rs.1,38,773/- as per prescribed terms and conditions of mediclaim policy, by not accepting the remaining claim of Rs.1,45,159/-.  The opposite parties further submitted that the M.D India on behalf of the opposite parties rejected the claim amount as “the amounts payable under 2.3 and 2.4 shall be @ applicable to the entitled room category, in case, insured opts for a room with rent higher than the entitled category as under 2.1, the charges payable under 2.3 and 2.4 shall be remitted to the charges applicable to the entitled category.  Applicable room plus nursing category is of Rs.3,000/-, but patient opted for room plus nursing category is of Rs.6,080/-, hence excess charges as per applicable room category deducted”.  The opposite parties further submitted that as per condition 2.1 of mediclaim policy – room, boarding and nursing expenses as provided by the hospital / nursing home not exceeding 1.0% of sum assured (excluding cumulative bonus) per day or actual amount, which over is less.  Sum insured of the policy is Rs.3,00,000/-, as per above said condition the policy holder is entitled for Room category is Rs.3,000/- per day i.e. 1.0% of sum insured amount, but the complainant submit the bills for room rent per day Rs.6,050/-.  The opposite party No.2 also submitted that in fact the complainant is entitled for room category is Rs.3,000/-, but he claimed Rs.6,050/- under room category, for that the opposite parties deducted the amount of Rs.95,150/- from total claim amount of Rs.2,83,942/- towards excess room rent against the condition number 2.1 of mediclaim policy, the remaining amount is Rs.1,88,792/-.  From that amount the opposite parties deducted the amount of Rs.2,860/- under luxury tax and Rs.5,970/- under non medical expenses as the complainant is entitled to claim amount under luxury tax and non medical expenses, since the policy is only for medical expenses, after deducting the same the remaining amount is  Rs.1,79,962/-.  From that amount the opposite parties deducted the 50% excess amount as the father of the complainant has available all excess facilities under room rent of Rs.6,050/- provision for per day instead of Rs.3,000/- per day and remaining amount is Rs.89,981/-.  The opposite parties calculated the room rent for Rs.3,000/- per day as Rs.43,500/-, by adding the said amount, the entitled amount comes to Rs.1,33,481/-, the opposite parties added the amount of Rs.892/- under medical bill to that amount and also added the amount of Rs.4,400/- under ICU expenses, the total entitled amount by the complainant is Rs.1,38,773/- and has paid by the opposite parties.  The opposite parties further submitted that they have no power to sanction the amount against the conditions of the mediclaim policy and the complainant has no right to claim excess amount.  The opposite parties also submitted that they sanctioned the total entitled amount to the complainant, which he is entitled as per the terms and conditions of the mediclaim policy, by knowing the fact that he is not entitled to claim repudiated amount of Rs.1,45,159/- under mediclaim policy and filed this false complaint, as such prayed to dismiss the complaint.     

5.      On behalf of the opposite party No.2 the following documents are filed and marked as Exhibits B-1 and B-2.

Ex.B1:-Photocopy of claims payment statement.

Ex.B2:-Photocopy of policy terms and conditions.

6.      Written arguments of both parties filed.

7.      Heard oral arguments from both sides.

8.      Upon perusing the material available on record, now the point that arose for consideration is,

Whether the complainant is entitled for the claim?

Point:-

In this case the complainant obtained Mediclaim policy bearing No.613201/34/09/11/00000239 from the opposite party company.  According to the complainant initially he had taken policy for his father with Jupudi Hanumantha Prasad, later his wife and daughter were also included as family members.  According to the complainant the policy is in force by renewing the premium from time to time and the policy is covered for all the family members of the complainant and the policy is for reimbursement of hospital expenses.  The father of the complainant was hospitalized for knee operation in the month of March 2010 at Care Banjara Hospital, Hyderabad and he was treated as inpatient from 01-03-2010 to 17-03-2010 and spent an amount of Rs.2,83,942/- towards hospitalization expenses.  According to the complainant the expenditure incurred by the complainant is below the sum insured and the entire amount is payable by the opposite parties as per the conditions laid down in the policy.  The complainant submitted claim form along with the bills to third party registration and requested to settle the claim, after verifying the medical record an amount of Rs.1,38,773/- was only sanctioned and the balance amount of Rs.1,45,159/- was rejected on the pretext that the complainant opted a room at high cost accordingly the complainant had received a letter dt.30-09-2010 from the office of opposite party No.2.  As the opposite parties failed to settle the claim which amounts to deficiency of service for that the complainant got issued notice to the opposite parties, inspite of receipt of notice the opposite party did not choose to pay the balance amount, for that the complainant approached the Forum for redressal.

From the documents and material available on record as per Exhibit B-2 Mediclaim policy (2007), as per schedule, clause 2.0 - following reasonable, customary & necessary expenses are reimbursable under the policy:-

1. Room, boarding and nursing expenses as provided by the Hospital / Nursing Home not exceeding 1.0% of the sum insured (excluding Cumulative Bonus) per day or actual amount, whichever is less.

2.3 Surgeon, Anesthetist, medical practitioner, Consultants’ specialist fees.

2.4 Anesthesia, Blood, Oxygen, Operation Theatre charges, Surgical Appliances, medicines & Drugs, Dialysis, chemotherapy, Radiotherapy, Artificial Limbs, Cost of Prosthetic devices implanted during surgical procedure like pacemaker, Relevant Laboratory / Diagnostic test, X-Ray and other medical expenses related to the treatment.

          As per conditions 2.1 of Mediclaim policy – room, boarding and nursing expenses as provided by the Hospital / Nursing Home not exceeding 1.0% of sum insured per day, or actual amount, whichever is less?  As per the policy the sum insured is Rs.3,00,000/- and the policy holder is entitled per room category is Rs.3,000/- per day i.e. 1% of sum insured amount.  It is indisputable that the father of the complainant remained in Hospital from 01-03-2010 to 17-03-2010 and for which the complainant has paid as per policy and therefore, for the purpose of reimbursement as provided under last 2.1, 2.3 and 2.4 of the policy only the complainant entitled to get the reimbursement.  The complainant submitted the bills for room rent per day @Rs.6,050/- but the complainant is entitled for room category is Rs.3,000/-, for that the opposite parties deducted the amount of Rs.95,150/- from total claim amount of Rs.2,83,942/- towards excess room rent.  From the record we observed that the opposite party insurance company paid Rs.892/- under medical bill and Rs.4,200/- under ICU expenses, as the complainant is eligible as per the policy terms and conditions. The opposite party insurance company has already paid the amount of Rs.1,38,773/- to the complainant as per the terms and conditions of the policy, and thus there remains nothing left payable under the policy.  In view of the above circumstances this point is answered against the complainant.

9.      In the result, the complainant is dismissed.  No costs.

          Typed to dictation, corrected and pronounced by us, in the open forum on this the   22nd   day of March, 2017.       

        FAC PRESIDENT                      MEMBER

   DISTRICT CONSUEMR FORUM, KHAMMAM

APPENDIX OF EVIDENCE

WITNESSES EXAMINED:-

For Complainant:-                                                 For Opposite party:-   

       -None-                                                                       -None-

DOCUMENTS MARKED:-

For Complainant:-                                                           For Opposite party:-   

FAC President              Member

District Consumer Forum, Khammam.