BEFORE THE DIST.CONSUMER DISPUTES REDRESSAL COMMISSION, KHURDA, BHUBANESWAR:
-ooOoo-
C.D.CASE NO.27/2018
Basanta Manjari Pattnaik, aged about 70 years,
W/o Bhramarbar Pattnaik, At – House No. A/E, 276.
VSS Nagar, PS – Saheed Nagar, Bhubaneswar,
Dist – Khurda
…. Complainant
-Vrs.-
- Amri Hospitals Limited, through its
Vice President, At Plot No.1, Satyasai Enclave,
Khandagiri, Bhubaneswar , Dist – Khurda
- Medical Superintendent, Amri Hospitals Limited,
At Plot No.1, Satyasai Enclave,
Khandagiri, Bhubaneswar , Dist – Khurda
- Administrative Officer, Amri Hospitals Limited,
At Plot No.1, Satyasai Enclave,
Khandagiri, Bhubaneswar , Dist – Khurda
- National Insurance Company Ltd., through its
Regional Office, A7, IDCO Tower, 6th Floor, Janapath,
Bhubaneswar, Rupali Square,Dist – Khurda
- Family Health Plan Insurance (TPA) Ltd.,
A1, Srinllaya, Ground Floor, CyberSpazio,
Road No.2,Banjar Hills, Hyderabad – 500034,
Telengana, through its Managing Director.
…. Opp. Parties
For the complainant : K.C.Prusty (Adv.)
For the O.Ps 1 to 3 : S.K.Mohanty&Associates (Adv)
For the OP No.4 : B.Behera & Associates (Adv.)
For the OP NO.5 :
DATE OF FILING : 20/01/2018
DATE OF ORDER : 24 /05/2022
ORDER
K.C.RATH, PRESIDENT
1. This is an application U/s 12 of the C.P.Act, 1986.
2. The contention of the complainant is that her son had a health insurance policy in which the complainant was a beneficiary. The insurance policy was issued for Rs.5,00,000/-. The complainant was admitted on 17/12/2017 as an indoor patient in AMRI hospital. She had undergone operation in the said hospital. The total expenditure incurred for the treatment of the complainant in AMRI hospital came around Rs.95,018/-. As per the insurance policy, the complainant claimed the said amount of Rs.95,018 from the insurance company. The OP No.1 i.e. AMRI Hospital, presented the details of the treatment and expenditure incurred for the purpose to the TPA who in turn submitted the claim before the National Insurance Company Ltd., who had issued the policy. The National Insurance Co.Ltd. i.e. (OP.No.4) deducted an amount of Rs.32,214/- from the gross amount of Rs.95,018/- and settled the claim for Rs.62,799/- after deducting 20% there from and TDS of Rs.5024. The Insurance Company paid Rs.45,215 to the claimant/ complainant. The complainant disputed the amount so released in his favour and filed this complaint for deficiency in service. Hence this case.
3. On the other hand, the OPs 1 to 3 filed their written version challenging the maintainability of the complaint before this Commission. They also disputed the claim of the complainant.
Similarly, the OP Nos. 4 & 5 filed their written version explaining therein the details of deduction made by them from the gross amount of the claim and submitted that as they have deducted Rs.32,214/- from the gross amount of the claim as per the terms & conditions of the policy, the claim of the complainant bears no merit and as such, it is liable to be dismissed.
4 Perused the materials on record. As it appears, the OP.4 has deducted some amount from the gross amount of the claim on the basis of the terms & conditions embodied therein in the insurance policy. It is also stated by the OP No.4 that so far as the expenditure on laboratory head is concerned, as some bills are not available to support the expenditure, it has deducted Rs.7392/- from the total claim. It is further stated in the written version that if such bills are produced before the court, there is no embargo in releasing the deducted amount (Rs.7392) in favour of the complainant. Apart from this point, the calculation made in respect of other expenditure is found to be correct. The Insurance Company (OP No.4) is justified in rejecting those claims which are not supported by appropriate bills. It was the duty of the OP.1 (Hospital) to make the bills available to the Insurance Company so as to enable it to settle the claim in favour of the complainant. The OP.1 has defaulted in discharging its duty. It amounts to deficiency in service on the part of the OP.1. Hence it is ordered.
ORDER
The complaint is hereby dismissed on contest against the OP Nos.4 & 5 and allowed on contest against the OP Nos. 1 to 3. The OP Nos. 1 to 3 are hereby directed to pay a sum of Rs.7,392/- (Rupees seven thousand three hundred ninety-two) only to the complainant along with interest @ 9% per annum thereon from the date of filing of this case till the date of payment. They are further directed to pay a sum of Rs.5000/- (Rupees five thousand) only towards mental agony suffered by the complainant and a further sum of Rs.2000/- (Rupees two thousand) only towards litigation expenses. The order be complied with by the OP Nos. 1 to 3 within thirty days from the date of communication of this order, failing which the complainant will be at liberty to execute the order against them in accordance with law.
The order is pronounced on this day the 24th May, 2022 under the seal & signature of the President and Members of the Commission.
(K.C.RATH)
PRESIDENT
Dictated & corrected by me
President
I agree I agree
(S.Tripathy) (B.R.Swain)
Member (W) Member
Transcribed by Smt. M.Kanungo, Sr.Steno
