Order-13.

Date-30/11/2015.

In this complaint Complainant Sabir Hossain Molla by filing this complaint has submitted that complainant purchased a mediclaim policy from the ops namely Individual Mediclaim Policy being No.311200/48/2015/2940 to cover the health his self and his wife namely Sakila Bibi, for the period from 07.10.2014 to 06.10.2015 with the sum of Rs.1,00,000/- for each policy holder.

During the policy period complainant felt seriously ill and he had been examined by Dr. S.D. Roy at TRA General Hospital of Dr. Biresh Guha Street, Kolkata-700017 on 18.12.2014 and after examination of the complainant, the said doctor advised him for immediate admission to TRA General Hospital.

Accordingly the complainant was admitted at TRA General Hospital on 18.12.2014 under the supervision of Dr. Siddrtha Chakraborty (MD) and the said doctor diagnosed for a LRTI Septicemia Dyseletrolytemia Type-II Resp Ferlove – Manage-e Memi Ventilation and after through treatment complainant was discharged on 28.12.2014.

After admission into the Hospital complainant’s wife sent a letter to ops on 18.12.2014 informing for such admission in the hospital and regarding treatment and after discharging from the hospital complainant himself intimated by hand to the insurance company about hospitalization and complainant submitted claim form in respect of reimbursement of medical expenditure of Rs. 86,109/- on 28.01.2015 to the ops.Ops received the relevant documents relating to documents of the complainant along with claim form.But ops did not settle the claim and repudiated the same and in spite of repeated reminder from the complainant, ops did not pay any heed.Thereafter complainant met with ops and requested many times for consideration the claim but the ops did not settle the claim.

In such circumstances, complainant suffered a severe loss, mental agony and harassment for which complainant filed this complaint before this Forum for redressal and also for compensation.

On the other hand op no.1 by filing a written version submitted that complainant filed the instant complaint with ill motive and with malafide intention to have some monetary gain from the op no.1.The fact is that the claim form of the complainant was received by the op no.2 and as a result the claim of the complainant has been settled.But it is specifically denied that the ops did not settle the claim of the complainant in spite of repeated reminder. But ops stated that the claim of the complainant was under process and ultimately the same was settled and a cheque being No. 551426300077 of Rs. 79,993/- drawn on State Bank of India in favour of complainant which has been paid by the ops as full and final settlement of the claim according to the terms and conditions.

Further ops submitted that the claim form had never approached to the ops by the complainant to enquire about the claim and complainant had not filed any documents to show that complainant requested the ops at any time for settlement of the claim.The ops were processing the claim of the complainant and finally the claim was settled which has been communicated to the complainant.But complainant claimed a sum of Rs. 86,109/- out of which ops sanctioned Rs. 79,933/- after deducting Rs. 6,176/- and Rs. 5,750/- was deducted as per terms and conditions of the policy i.e. Room, Boarding and Nursing Expenses as provided by the Hospital authority not exceeding 1 percent of the sum insured or Rs. 5,000/- whichever is less.Ops further stated that the sum insured of the policy of complainant was Rs. 1,00,000/- and room charge was paid Rs. 1,000/- i.e. 1 percent of the sum insured and further Rs. 426/- was deducted for non-medical expenses.So ops stated that complainant is not entitled to get a sum of Rs. 86,109/-.

Fact remains that ops submitted that as per policy terms and conditions of the policy they finally settled the claim amount which complainant has not intended to accept.In such circumstances, ops have no negligence and deficiency in service and also submitted that complainant did not able to show any documents relating to medical expenses for which this complaint should be dismissed against both ops.

Decision with reasons

On a comparative study of the complaint and written version and also considering the argument as advanced by the Ld. Lawyers of both the parties, it is undisputed fact that complainant is a Mediclaim Policy Holder of the op and admitted position is that during validity period of the said policy, complainant felt seriously ill and was examined by Dr. S.D. Roy at TRA General Hospital on 18.12.2014 and after that examination the said doctor advised for immediate admission to the said Hospital.

Accordingly complainant was admitted at TRA General Hospital on 18.12.2014 under the care of Dr. Siddrtha Chakraborty (MD) where doctor diagnosed and patient was discharged on 28.12.2014.

No doubt after admission of the Hospital of the wife of the complainant, it was informed to the op for such admission and sent a letter on 18.12.2014 and after discharge from the hospital, complainant intimated to the insurance company by hand about such hospitalization during the period of his stay and also submitted the claim form in respect of reimbursement of the medical expenses on 18.12.2014 for an amount of Rs. 86,109/- to the op.Op received all documents and other papers, but they did not settle the claim that is the allegation of the complainant.

Whereas we have gathered that complainant filed E-chief but no way they have admitted that the claim was settled and he has already received Rs. 79,993/- out of claim amount of Rs.86,109/-.But at the time of argument it is revealed that complainant received the settled amount of Rs.79,993/- and op deducted Rs. 5,750/- only as per policy condition.

So, considering the above fact, we are convinced to hold that that present complainant even after receipt of the said amount of Rs.79,993/- has not admitted it in evidence-in-chief that he received that amount but only Rs.5,750/- is deducted but he has not bothered to disclose this fact in his evidence.So, considering the above fact and also the reason for deduction of Rs. 5,750/- out of total claim Rs. 86,109/-, we find that the said amount was deducted as per Insurance Clause because Nursing Expenses as provided by the Hospital authority not exceeding 1 percent of the sum insured or Rs. 5,000/- whichever is less.Accordingly as per Insurance Policy,room charge was paid Rs. 1,000/- i.e. 1 percent of the sum insured and further Rs. 426/- was deducted for non-medical expenses.So, deduction is made by the op is correct and in fact complainant’s claim had already been settled and complainant received that money already which was transmitted in his account.But complainant suppressed it even during pendency of this case.

So, in the above circumstances, we are convinced to hold that claim of the complainant has already been settled for which there is no laches on the part of the op and no negligence and deficiency on the part of the op is proved but claim of the complainant is settled.

So, this complaint fails.

Hence, it is

Ordered,

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