Complainant by filing this complaint has submitted that he is the holder of Insurance Policy named Family Medicare Policy along with his wife Nibedita Sarkar and daughter Urmi Sarkar since long back and also subsequently complainant purchased one Super Top Up Medicare Policy making payment of the premium every year and said policy is continuing every year till date and the policy  of Family Medicare is 030300/48/13/06/00003096 which was valid from 01.08.2013 to midnight 31.07.2014 and policy No. of Super Top Up Medicare Policy  is 030300/48/12/36/00005707 which was valid from 27.11.2012 to 26.11.2013 and the policy covers of sum of Rs. 2,00,000/- and second policy covers a sum of Rs. 5,00,000/-.

          All on a sudden the complainant on 13.10.2013 felt tremendous chest pain associated with sweating and as such the wife of the complainant on emergency basis admitted to the Apollo Gleneagles Hospitals at Kolkata on the same date and the complainant was admitted and treated under Dr. Bikash Majumder, eminent Cardiologist in Kolkata and he was treated there and discharged from the hospital on 19.10.2013 with a treatment of Primary Percutanous Transluminal Coronary Angioplasty (PTCA) by following the interventional procedure and expenses huge amount of money about of Rs. 3,00,000/- and more.

          Complainant duly intimated to the ops for settlement of cash less mediclaim and after getting information the ops only settled the cashless facility to the complainant only of Rs. 1,40,000/- against the total bill amount of Rs. 2,66,533/- for which complainant was compelled to pay the rest of the amount of Rs. 1,26,553/- to the hospital authority and after discharge from the hospital  complainant lodged the claim form to the ops for reimbursement of the rest of the amount which the complainant already paid to the hospital authority and also claimed the amount of Rs. 7,004/- for medicine expenses after discharge from the Hospital and the ops by a letter dated 04.12.2013 intimated to the complainant that they have already transferred the amount of Rs. 7,004/- to the Bank Account of the complainant out of the claim amount of Rs. 1,26,553/- and Rs. 7,004/- and rest of the amount was inadmissible under rules laid down by the insurance authorities and the same have been deducted while processing the claim of the complainant but op failed to mention the rules and the reason for inadmissibility of the claim of the complainant.

           Thereafter complainant tried to enquire about the actual reason for inadmissibility with op of the insurance claim of the complainant when the ops stated verbally that the diagnostic process as followed for treatment of the complainant is a case of Major Surgery and complainant was confused over the issue and thereafter contacted with the concerned treating doctor to know the fact actually the treatment applied towards complainant is a “Major Operation of Primary Percutanous Transluminal Coronary Angioplasty (PTCA) on 13.10.2013 for acute myocardial infection and this is an interventional procedure and not a surgical procedure”. Complainant issued the said certificate to the ops by a letter dated 13.12.2013 and claimed the entire amount but op did not respond as such it is a gross deficiency and negligence on the part of the op for which for causing harassment and mental pain and agony, complainant has filed this complaint for necessary redressal.

          On the other hand ultimately op by filing written statement has submitted that no doubt complainant purchased two policies, 1) Family Medicare Policy being No. 030300/48/13/06/00003096 valid for the period from 01.08.2013 to 31.07.2014 and another Super Top Up Medicare Policy bearing No. 030300/48/12/36/00005707 valid for the period from 27.11.2012 to 26.11.2013.

          No doubt on 15.10.2013 a request for pre-authorisation cashless facility was received by the op no.2 M/s. Heritage Health TPA Pvt. Ltd. forwarded by Apollo Gleneagles Hospitals Ltd, Kolkata informing admission of complainant to the said hospital on 13.10.2013 for treatment of acute anterior wall myocardial infraction and immediately the claim was registered and op after considering the entire policy numbers and others approved cashless facility and ultimately released Rs. 1,40,000/- and a letter to that effect was issued to the said hospital stating specifically that the amount so settled is the maximum limit as per subject policy and that has been made in terms of clause (d) of limit for each hospitalization as contained in the said policy.

          Fact remains that complainant further submitted claim form along with treatment documents asking for disbursement of remainder balance of hospitalization treatment cost of Rs. 1,26,557/- beyond the disbursed amount of Rs. 1,40,000/- which has been paid to the hospital.  On receipt of the same TPA further settled the claim by disbursing another sum of Rs. 7,004/- as pre and post hospitalization part of treatment expenses on 04.12.2013 and in all total sum of Rs. 1,47,004/- has been paid to the complainant under the said policy which has been mentioned in the claim.

          Subsequently complainant claimed for disbursement of the remainder sum of Rs. 1,26,553/- of medical expenses from said TPA .  but as per clause of the policy, 70percent of the sum insured of that policy was disbursed and released and that was finally settled.  So there was no negligence and deficiency on the part of the op.  So far the Super Top Up Policy is concerned, this op without admitting anything on the contrary respectfully submits that out of total amount of Rs. 2,66,553/-, the coverage under the first policy was exhausted for sum of Rs. 2,00,000/- and the remainder amount of Rs. 66,553/- would come up under the ambit of the Super Top Up Policy and in that case after deducting the amount spent for misc expenses as provided under the said policy, the rest amount within said amount of Rs. 66,553/- would be payable.

          But fact remains that there is no reference of the said policy in the claim application.  Further it is submitted that the definition of Cardiac Surgeries as described under clause 1.2 in the chart for limit of each hospitalization at sub clause (d) noted and as because whatever it may be stent implant on the blocked arteriole of coronary vessel and thus an advanced mechanism of its earlier counterpart of open heart surgery but that can only be defined as a genre of surgery and nothing more.  So, the entire claim of the complainant cannot be entertained for which the complaint should be dismissed.

                                                      Decision with reasons

          On in depth study of the complaint and written version and also considering the document as filed by the complainant and op and further considering the argument of the Ld. Lawyers it is found that Ld. Lawyer for the complainant has tried to submit that terms and conditions of the policy was not sent along with the original document and in view of the ruling passed by Hon’ble Supreme Court by a judgement dated 22.02.2000 by S. Ahmad and S.N. Phukan in Case M/s Modern Insulators Ltd. – Vs – The Oriental Insurance Co. Ltd. that it is the responsibility of the op to supply the terms and conditions of the policy even if same are not sent by the op in that case it is the laches on the part of the op for which complainant shall not be deceived from his claim.

          On proper study of the said judgement including the present fact and circumstances, we have gathered that this argument as advanced by the complainant is completely out of the heart of the complainant because complainant has tried to convince that reasons for non admissibility of Rs. 1,26,553/- and rules of inadmissibility of the claim is not noted that means complainant’s allegation is that rules and regulation of the policy is not supplied is completely false because we have gathered that complainant has filed Annexure-A Pages-12 & 13 wherefrom it is found that up to Family Medicare Clause up to 3.3 are there that means other pages are being permitted by the complainant for someother parties and it is no doubt a practice adopted by so many consumers in the Medicare Policy to remove certain pages of the policy and in this case it has been adopted.

          Moreover this policy Annexure-A, Pages 12 & 13 is related policy bearing No. 030300/48/13/06/00003096 and most interesting factor is that complainant has suppressed unscrupulously the fact that he submitted claim but Health Heritage TPA Pvt. Ltd. in respect of present policy covering Rs. 2,00,000/- sum assured.  But there is no mention of another policy that is Super Top Up Medicare Policy being No. 030300/48/12/36/00005707 and from that letter dated 04.12.2013 issued by op Health Heritage TPA Pvt. Ltd. it is clear that complainant submitted claim in respect of first policy ending No. 3096 that is Family Medicare Policy and sum assured was Rs. 2,00,000/- and no doubt Health Heritage TPA Pvt. Ltd. considered the claim and ultimately released in total Rs. 1,47,004/- out of sum assured of Rs. 2,00,000/- and in the said claim application or in the cashless facilities prayer as made by the complainant through Apollo Gleneagles Hospitals, this policy number was mentioned.  But there was no mention of Super Top Up Medicare Policy.

          So, invariably ops roamed within that threshold of Rs. 2,00,000/- and considering that fact we find that there was no laches on the part of the op to settle the claim and in fact if complainant had his desire to get the benefit of balance Rs. 1,26,557/- in that case complainant ought to have been filed a fresh application form mentioning both the policy numbers and thereafter prayed for statement of remainder balance amount of Rs. 1,26,557/- but that has not been done.  So we are convinced that there was no fault on the part of the complainant for not mentioning the Super Top Up Policy number for settling his remainder balance of hospitalization.  So, we find that in this regard there was no deficiency and negligence or any deficient manner or illegal activities on the part of the ops and complainant has failed to prove beyond any manner of doubt in short for negligence and deficient or any other act on the part of the ops to settle the claim of the complainant in respect of his claim as made against policy of Family Medicare ending No. is 3096 because there was no mention of another policy of Super Top Up Policy ending number is 5707.

          Peculiar factor is that complainant has not filed the copy of the claim application.  So, that he mentioned both the policy numbers.  We have failed to understand how in zigzag way complainant prepared a complaint and presented before this Forum to accuse the ops. So, we are confirmed that fault was on the part of the complainant for not filing of fresh claim application mentioning both the policy numbers.

          Another factor is that Ld. Lawyer for the complainant tried to convince that the treatment was done and in the present case by Bikash Majumder was not on surgical one.  But as per medical science and intervention procedure because it was coronary Angioplasty not of surgery no doubt, intervention was there and as per report of the discharge summary, it is found that coronary angioplasty with stenting to restenosed proximal LAD done in the same operation and this term simply proves that stenting was placed by perfection and without restoration it cannot be pushed up to the heart area and practically in the insurance policy the definition of surgery has been defined otherwise and such sort of treatment came under the purview of surgical part as defined under the clause of the policy.

          In this regard we have gone through the policy conditions wherefrom we find that clause 2.2 specifically mentioned “ Surgical Operation means manual and or operative procedures for correction of deformities and defects, repair of injuries, diagnosis and cure of diseases, relief of suffering and prolongation of life” and if the said clause is taken into account with the opinion of Dr. Bikash Majumder an eminent Cardiologist, it is clear that it is manual procedure for correction and cure of a disease to give relief from sufferings or from prolong of life.  So, as per clause 2/2 of the policy conditions, it is no doubt a surgical operation and as per medical science previously it was surgical and now it is the way of intervention procedure.

          In this regard we have gone through certain books wherefrom we have gathered that new methods are adopted by scientific researchers for repairing the heart blood vessels and other co related part of the heart for repairing without pain and bye-pass surgery.  The stent are being placed by adopting some intervention through some vein and to place it to that place where there is fraction or infraction etc. only name has been changed and now this procedure is adopted and we are well aware of the fact that act of Anesthesist is nothing but intervention at process.  But for that reason the definition as included in the clause cannot be thrashed out.  But we have gathered that may be or it is not surgical intervention but specific clause of the policy. Specifically it is no doubt the procedure for correction or care of disease for which Angioplasty was done and it is related to heart.  So, we are convinced to hold that the op authorities decided the matter as per clause 2/2 read with Clause 1/2/d and also other clauses and in this regard the findings of the Heritage Health Care Pvt. Ltd. is not at all illegal.

          On the other hand we have gathered for pages 12 & 13 of Heritage Health Care Pvt. Ltd. that they sent a reply in respect of the claim of the complainant being No. HH45140100 against policy number ending 3096 and in the said report details of the bill and reason for deduction are vividly described and complainant received the same.  But that letter has not ben submitted by the complainant.  It is another act of suppression of the fact by the complainant.

Considering all the above fact and circumstances we are convinced to hold that the complainant suppressed the truth portion as complainant was aware of the fact the reason for deduction as per clause.  But nowadays it has become a practice of all the customers to get the entire amount.  But fact remains all the customers or mediclaim policy holders are guided by the policy conditions.

On overall evaluation of the entire materials on record we have gathered that complainant is over powered and ultimately suppressed the truth and made allegation against the ops.  Fact remains ops have submitted that they shall have to consider his remainder balance in respect of the new top up policy if complainant files fresh application that is no doubt a good defence on the part of the op. 

Fact remains in the present case the entire matter has been packed with some false allegations by the complainant.  If complainant would say before this Forum with clean hand and honest approach that he failed to mention the top up policy number and give him a chance in that case such an order can easily be passed.  But only he filed false statement against the ops in the complaint to prove that op is at fault and op has appeared with some false story.  But we are satisfied that complainant has not appeared with clean hand and truth is that consumer must be honest in his/her expression before the Forum and this is the first criteria.  Consumer must have to state actual reason for which he is going to be deprived and get relief.  But after studying the consumer’s psychology in the present case we are confirmed that he has adopted negative attitude and such a consumer should not be tolerated by any Forum.  All over the world consumers other than India does not suppress truth before the Forum for getting relief but only in India, consumers appeared before the Forum with some false plea in so many cases.  So, in this regard the consumer behavior is one of the vital factor for giving relief.  So, awareness is highly required for all consumers to educate the consumer to know that he must not have to suppress any truth before the Forum.

But in this case that education is not there rather he has been educated person otherwise to suppress the truth ultimately.  This Forum does not know when the consumer shall be educated.  When the consumer behavior shall be up to the mark to get relief and who shall have to educate the consumer at larger.   It is to be mentioned in this regard that before Forum no education is required by the consumers but he must have to tell the truth and the entire fact in respect of which the consumer fora can decide a dispute properly. 

In view of the above fact and circumstances, we are convinced to hold that complainant has miserably failed to prove any sort of negligence and deficiency adopted by the op or adoption of any illegal procedure for settlement of the claim and for which we find that in fact in respect claim against policy ending number is 3096 (Family Medicare Policy) was properly decided and released without any delay the entire amount as admissible out of total sum assured of Rs. 2,00,000/- and reasons for deduction of the amount out of total expenditure is clearly stated in settlement of claim dated 04.12.2013.

          So, the present complainant has miserably failed to prove the allegation against the ops.  But we are not unmindful to the fact considering ops’s written version that op shall consider after receipt of fresh application along with both the policies i.e. Family Medicare Policy and Super Top Up Policy from complainant in respect of balance amount of Rs. 1,26,557/- as per terms and conditions.   So, as per expression of the op in their defence we are passing such necessary order to give the complainant a chance to be more honest in future for getting any relief from any case.

Hence, it is

                                                  ORDERED

          That the complaint be and the same is dismissed against the ops without any cost.  But we are giving the complainant a chance to file a fresh claim application mentioning both the policy numbers for getting the relief from the ops in respect of the remainder amount of claim and op/insurance company shall have to decide the same on receipt of such claim application from the complainant within two months from the date of the order and dispose of the matter and after disposal of the said matter, complainant shall have to know further right to file any further complaint against the present ops and in respect of fresh application of remainder claim amount the final order of the ops shall be the final order and against that complainant shall have to get any relief from any Forum.