This is an application u/s.12 of the C.P. Act, 1986.
Complainant by filing this complaint has submitted that complainant purchased two mediclaim policies from OP1 being policy no.030600/48/11/97/00004670 for the period from 03-12-2011 to midnight on 02-12-2012 another policy being no. 030600/48/11/97/00004662 for the period from 03-12-2012 to midnight on 02-12-2013 for sum assured Rs.50,000/- for each policy and insured person is entitled the actual expenses for the cataract surgery or 25 percentof the sum assured whichever is less under Clause 1.2.1of policy document. OP1 have increased the amount of coverage for cataract surgery and fixed it Rs.15,000/- upto Rs.1,00,000/- sum insured for cataract surgery in place of earlier 25 percentmentioned in above para and if the surgery is done through preferred hospitals for that insurance company instituted a mechanism called preferred provider network(PPN) to rationalize healthcare cost on and from 15th January, 2012.
Complainant was admitted in Susrut Eye Foundation & Research Centre, Salt Lake, Kolkata on 16-03-2012 for cataract operation of left eye and the hospital charged Rs.15,000/- for the cost of left eye cataract surgery and OP2 released Rs.12,500/- instead of Rs.15,000/- and balance Rs.2,500/- has not been paid but OP is compelled to pay the same.
Complainant prayed for balance claim of Rs.2,500/- along with other medical expenses of Rs.1,193/- totaling Rs.3,693/- to OP1 on 30-03-2012 against policy no. 030600/48/11/97/00004670 and OP1 forwar4ded the complainant’s to OP2 and after waiting for two months complainant contacted with OP2 vide email dated 04-06-2012 and complainant got a reply to the effect on 05-06-2012 that the additional payment claim of CCN-MDI1235819 for Rs.3693/- is settled for Rs.1,193/- but they were silent about balance claim of Rs.2,500/- and further complainant intimated OP2 about that but no response was received.
Similarly complainant was admitted in Susrut Eye Foundation and Research Centre, Salt Lake Kolkata on 22-02-2013 for cataract and hospital charge was Rs.15,000/- for the cost of right eye cataract surgery but OP2 released and paid Rs.12,500/- instead of Rs.15,000/- for single eye cataract surgery and complainant submitted his claim of Rs.3,761/- including balance insurance claim of Rs.2,500/- to the OP1 on 04-03-2013 against policy no. 030600/48/11/97/00004662 for right eye cataract operation but OP2 remained silent for payment of balance amount
Accordingly, complainant lodged complaint before Assistant Director, CA&FBP, Kolkata Central Regional Office, and in the meting the representative of OP1 admitted the claim of the complainant but have not released the same.
In the above circumstances, complainant has prayed for relief and redressal and directing the OP2 to pay Rs.5,000/- as last paid as hospital bill for surgery of left and right eyes and compensation.
On the other hand, OP by filing written statement submitted that the claim was fully settled as per policy condition and complainant is entitled to 25 percentof the sum insured that is Rs.1 lakh or actual expenses which is less and complainant sum insured was Rs.50,000/-. So, 25 percentof the said amount was paid and there was no such clause for payment of highest amount of Rs.15,000/- so, the claim of the complainant is completely paid as per policy clause and admittedly the complainant made claim which is fully paid by the TPA as per policy terms so, further claim of the complainant is not tenable in the eye of law.
Decision with Reasons
On proper consideration of the argument as advanced by the Ld. Lawyers of both the parties and also considering the entire fact it is clear that the OP settled the claim of the complainant in respect of the mediclaim policy and claim and released 25 percentof the total sum insured and total sum insured is Rs.50,000/- and in both occasion OP released Rs.12,500/- for his each eye operation but complainant has produced one notification dated 06-01-2012 of United Insurance Company Ltd. wherefrom it is found that there is such notification if an insured opt for the entitled room category, no extra charge to be paid to the hospital other than the package rate as above except inadmissible expenses and in case of cataract surgery (including implant cost) highest amount shall be paid Rs.15,000/- in case of sum insured upto Rs.1 lakh and it is also noted that for cataract surgery this is the maximum allowable in PPN Hospital. Any amount paid and charged over and above will not be reimbursed.
It is also noted in that notification “in case of treatment in PPN Hospital for the treatment of procedure listed in annexure B the insured needs to pay as per the rates agreed with the hospitals and in such cases sub-limits/cappings under the policies will not be applicable”. Considering that notification it is clear that in case of cataract surgery payment of Rs.15,000/- as medical claim is allowable up to sum insured Rs.1 lakh and in that case sub-limits or cappings under the policy will not be applicable and when this is the fact then it is clear that the present complainant is entitled to Rs.15,000/- each for each operation for cataract surgery which should be paid by the OP as per that notification when complainant’s insured limit is Rs.50,000/- that is within the range of upto Rs.1 lakh and in view of the above notification of the United India Insurance Company published by United India House 24, Whites Road, Chennai – 600 014 and on regional office Himalaya House(2nd floor), 38-B, J.L. Nehru Road, Kolkata – 700 001 and notification dated 06-01-2012 APW-1/2012 we are confirmed that complainant is entitled to get balance Rs.2,500/- each in respect of two mediclaims when in both the cases complainant is entitled to Rs.15,000/- each for his cataract operation for his right eye and left eye but the OP authority has paid Rs.25,000/-. So, invariably complainant is entitled to Rs.5,000/- and so, OPs are directed to pay the sum and settled the matter finally and no further claim of the complainant in this regard shall be entertained by the OP in future.
In the result, the case succeeds.
Hence,
Ordered
That the case be and the same is allowed on contest against the OPs with a cost of Rs.1,000/-.
OP1 is hereby directed to pay a sum of Rs.5,000/- (unpaid amount against the mediclaims filed by the complainant) within one month from the date of this order and on payment of both the claims of the complainant in respect of mediclaim against both the eyes operation shall be treated as finally settled.
OP1 is hereby directed to comply the order and finally pay Rs.5,000/- that is including cost as awarded within the stipulated period of one month failing which for non-compliance of the Forum’s order OP shall have to pay a penalty at the rateRs.100/- per day till full satisfaction of the decree and even if it is found that the OP is reluctant to comply the order prosecution shall be started against them for implementation of the order and further penalty and fine may be imposed.
