The case of the complainant in a nutshell is that complainant purchased Health Insurance Policy for himself and for his family members from the Op no.1 on 10.09.2001 and uninterruptedly purchasing health Insurance Policy in every year till date. The policy under which the claim was made i.e. Policy no. 030702/48/13/97/00002601 for the period of 10.09.2013 to 09.09.2014 and the sum assured of Rs.1,75,000/- for each person. The further case of the complainant is that due to his knee problem he was admitted in C.M.C.Vellore on 17.2.2014 for knee replacement . Operation was done in the said hospital on 20.2.2014 and he was discharged on 1.3.2014 from the said hospital. The complainant before operation intimated the Op no.2 Heritage Health T.P.A. Pvt. Ltd for cashless facility of the entire operation expe3nses before the C.M.C. Vellore . But the said Op no.2 granted Rs.70,000/- and paid the said amount against the final hospitalization bill of Rs.2,01,869.57 and no further amount was paid by the said oP no.2. On returning home the complainant lodged a claim before the op no.2 by filing a claim form for the rest amount of Rs.1,31,869.57 (Rs.2,01,869.57 (-) Rs.70,000/-). The OP sent a reply to the complainant dated 2.4.2014 and repudiating the claim of the complainant of the rest amount of Rs.1,31,869.57. Hence, this complaint.
The Opposite parties contested the case by filing Written statement denying inter alia all material allegations. The Ops submit that the petitioner did not submit all the documents to the oP Insurance company accordingly the amount of Rs.70,000/- has already paid as cashless benefit against the policy, as such the Heritage Service Pvt. Ltd i.e. Op no.2 paid the said amount as per terms and condition of Mediclaim policy. So the petitioner /claimant is not entitled to get any further claim from the oP party Insurance Co. As per terms and condition of the policy of Mediclaim policy the oP Insurance company has already paid the amount of Rs.70,000/- to the petitioner in time as such deficiency of the service does not arise at all. Ops pray for dismissal of the complaint.
Complainant filed photo copy of Insurance policy of Dipak Kumar Chakraborty, copy of authorization letter of TPA and final bill of CMC Vellore, copy of letter dated 2.4.2014 , Photo copy of lawyer’s letter dated 8.7.2014, photo copy of letter dated 15.7.2014 of Insurance Ombudsman and Photo copy of letter dated 27.7.2014 by TPA to Mr. N.R.Das, Advocate. Complainant also filed Evidence in chief and Written Notes of Argument. Opposite parties on the other hand filed Evidence in chief, Written version and Written Notes of Argument.
POINTS FOR DECISION :
- Whether the complainant is a consumer ?
- Whether there is any deficiency in service on the part of the oP ?
- Whether the complainant/petitioner is entitled to get relief as prayed for ?
DECISION WITH REASONS :
Point no.1
It is admitted fact that the complainant purchased Health Insurance Policy from the Opposite party and paid due premium for the said policy to the OP. So the complainant is a consumer under the Opposite Party U/s 2(d)(i) of the C.P.Act, 1986. The point no.1 is thus answered in favour of the complainant.
Point no.2 and 3
Both the points are taken up together for easiness of discussion.
It is admitted position that the complainant was under Insurance policy for the relevant year when the operation was done in the Christan Medical College, Vellore. At that time the sum assured was Rs.1,75,000/- for the Policy no……..00002601 . Complainant has adduced evidence and filed also total expenditure sheet. Op does not controvert this. As per Op the complainant is
entitled 70% of the sum assured. At that relevant time sum assured was Rs.1,75,000/-. Op intends to say , complainant is entitled 70% of Rs.1,00,000/- which was sum assured amount for the year 2009 -2010. But as per clause 1.2.1 embodied in the Insurance policy the patient is entitled to get as per wording of that clause for major surgeries actual expenses incurred or 70% of the sum assured whichever is less. Here as per complainant’s case actual expenditure was Rs.2,01,869.57 and sum insured was Rs.1,75,000/- for the year 10.9.2013 to 9.9.2014. So, 70% of Rs.1,75,000/- is Rs.1,22,500/- approx which the complainant is entitled as per provision of 1.2.1 of the policy condition. It appears that company has already paid Rs.70,000/- to the complainant. So , the remaining amount should be paid by the Insurance company i.e. Rs.1,22,500/- (-) Rs.70,000/- = Rs.52,500/-.
So, after deliberation over the material on record before us including documents and Written Notes of argument filed by both side before , after discussion as above we are to opine that complainant’s case succeed on contest. Complainant is entitled to get cost of hospital calculated at Rs.52,500/- plus compensation and litigation cost. Hence it is –
Ordered
That the CC no. 228 of 2014 be and the same is allowed on contest. The Ops are jointly and severally liable to pay Rs.52,500/- to the complainant along with Rs.10,000/- for compensation and litigation cost of Rs.10,000/- totalling Rs.72,500/-.
Op is directed to pay A/c payee cheque in the name of the complainant within 45 days . Ops are also directed to pay interest @ 9% p.a. from 7.4.2015 till full payment is made on the sum of Rs.52,500/- to the complainant i.d. Rs.200/- shall be imposed upon the oP per day and that amount will be deposited in the Consumer Legal Aid Fund .
Let a copy of this order be made over to the parties free of cost.
