FINAL ORDER/JUDGEMENT

Smt. SAHANA AHMED BASU, Member,

Brief facts of the case, is that, Complainant’s wife admitted in Shri Aurobinda Seva Kendra on 16.07.2019 for knee replacement and as such an amount of Rs,2,46,276/- has been incurred by the Complainant and accordingly the Complainant submit the claim on 19.05.2019 with all supporting documents  to the OPs for reimbursement. But the OPs reimbursed only Rs.1,36,610/- out of Rs.2,46,276/- on 04.02.2020. In the claim settle letter dated 25.06.2020 OPs declined to accept genuine claim of Rs.1.01,000/-. The Complainant has submitted all the documents to the OPs in support of expenditure incurred by him against the amount of Rs.1,01,000/- and subsequently as per email dated 23.10.2019 of the OPs it is  verified by the OPs that vide receipt No.1900214104 an amount of Rs.1,000/-  and vide receipt No.1900217950 an amount of Rs.1,00,000/- has been incurred by the Complainant towards expenses of treatment of his wife. The Complainant has also enquired about the validity of the demand of money receipt raised by the OPs to the IRDAI authority by way of application under RTI Act 2005 and accordingly by a reply dated 25.08.2020 the IRDAI Authority duly disclosed that there is no such rule. Therefore, finding no other option the Complainant has compelled to file this case before this Commission.

OP3 contested the case by filing WV and denied all the allegations of the Complaint. Specific case of the OP1 is that any claim made by an insured is subject to the policy conditions and entire amount cannot be reimbursed until covered under subject policy. Complainant’s wife admitted in the hospital from 16.07.2019 to 24.07.2019. The claim of the Complainant was settled for Rs.1,36,610/- against the amount of Rs.2,46,276/- incurred towards medical expenses vide NEFT Transaction Number 20019535236 dated 04.02.2020. It was also informed the Complainant through email dated 25.06.2020 that several amount of money asked by the Complainant was not payable because money receipts, prescription of the doctor was not submitted as required to substantiate the claim. Moreover pharmacy items and others were not payable as it was not covered under the policy. Due to non - receipt of money receipts for Rs.1,00,000/- and rs.1,000/- as claimed could not be considered. An amount of Rs.1,36,610/- was paid to the Complainant and duly received by him. The Complainant has failed to establish the alleged claim for Rs.1,00,000/- and rs.1,000/- and in absence of separate money receipt the same is not payable to the Complainant. Hence the Complaint Petition is liable to be dismissed.

Upon service of notice OPs 1, 2 & 4, 5 did not file WV within stipulated period. Thus the case runs ex parte against them.

Contesting parties have tendered evidence supported by affidavit. We have gone thoroughly evidence adduced by the parties including documents on record and gave careful consideration to the arguments advanced by the Ld. Advocates for the parties.

Admittedly the Complainant is insured under OP3 and there is also evidence that the wife of the Complainant was admitted in the Sri Aurobindo Seva Kendra from 16.07.2019 to 24.07.2019 for OA LEFT KNEE for which an amount of Rs.2,46,276/- has been incurred by the Complainant and the Complainant claimed the abovementioned amount from the OP3 by submitting the Claim Form on 19.08.2019. It is also admitted fact that the OP3 has settled the claim with Rs.1,36,610/- which is duly received by the Complainant. Ld. Advocate for the Complainant alleged that despite submitting all the documents, OPs 1 to 3 have illegally declined the genuine claim of Rs.1,01,000/- of the Complainant. On perusal of the record it is found that Hospital Bill of Rs.1,29,451/-(Bill NO.1900227659), Pharmacy Bill of Rs.31,090/-(Receipt No.1900227645) , Tax Invoice issued by  Medequip of Rs.60,921/- are adduced by the Complainant.In support of the case Ld. Advocate for the Complainant has placed a reply under RTI Act, 2005 to the query of the Complainant wherein Query 1 was:

Please advise in details, existing rules regarding submission of money receipt and bills for reimbursement claim of Health Insurance.

Reply to Query 1:

It is to inform that every claim shall be settled as per the terms and conditions of policy contract. You may refer the policy contract in this regard.

You may also refer the following provisions of IRDAI(Health insurance) Regulations 2013:

27. Settlement/Rejection of claim by insurer:

ii. Except in cases where a fraud is suspected, ordinarily no document not listed in the policy terms and conditions shall be deemed ‘necessary’. The insurer shall ensure that allthe documents required for claims processing are called for at one time and that the documents are not called for I a piece-meal manner.

Query 2:

 Please also advise, if there is any specific IRDA rule/regulation/order which mandates the claimant to submit separate money receipt for each part of the payment, over and above total itemized money receipt for the same payment along with all supporting bills and medical documents.

Reply to Query 2:

No.

Ld. Advocate for the OP3 argued that vide email dated 25.06.2020 the Complainant was informed that several amounts of money claimed by the Complainant was not payable because money receipts, prescription of the doctor were not submitted as required to substantiate the claim. It is also argued by the Ld. Advocate for the OP3 that pharmacy items and others were not payable as it was not covered under the policy. Photocopy of the email dated 25.06.2020 reveals that:

Your claim bearing NO 2543708 against policy issued by United India Insurance Co Ltd has been settled for Rs.136610/- (One Lac Thirty ix Thousand Six Hundred Ten Only) against the amount claimed for Rs.246276 towards Medical Expenses incurred or treatment of OA LEFT KNEE at Sri Aurobindo Seva Kendra, Kolkata, West Bengal for the period from 16 Jul 2019 to 24 Jul 2019 vide NEFT transaction number 20019535236 dated 04 Feb 2020.

Following claim amounts are disallowed due to the following reasons:-

Surgeon / physician

Rs.60585.00 Not payable money receipts not submitted

Consultation

Rs.400.00 Not payable no prescription of Dr. dated 04/07/2019

Pharmacy

Rs.12338.00 Not payable easyfix, needle, syringe, adj against MR Rs.101000:966.00 not payable cool pack, knee imboiller etc: Rs.1300.00 Not Payable double layertubifix for legs

Others

Rs,6000.00 Not payable aya/nurse ch: Rs,735.00 Not payable ripple mattress ch adj against MR

Labs / Bio / Micro / Pathology

Rs.5000.00 Not payable money receipts not submitted

Procedures

Rs.22342.00 Not payable money receipts not submitted.

Please submit the necessary documents to process the claim.

In view of the above it appears that OP3 has categorically explained the reasons behind the disallow of Rs.1,09,666/-. There is no submission or any counter explanation is placed with documentary evidence on the part of the Complainant in this regard. Under such Circumstances our considered view is that Terms and Conditions of the said Policy is binding upon the parties. The Complainant has miserably failed to establish his case.

Therefore, we find no merit in the instant Complaint Petition and dismissed the same without any cost.