Complainant by filing this complaint has submitted that he is a Mediclaim Policy holder being No. 5103003413010003015 which is a family policy for himself and his wife Pratima Bandyopadhyay of New India Assurance Company Ltd. (NIA Co.) op no.2 and as per policy condition complainant is entitled to benefit of hiring of service against the consideration/premium paid by the complainant and benefit of the said policy was started in the year 2002 and complainant has been regularly paying premium of the said policy and last premium was paid by the complainant to the extent of Rs. 12,071/- on 05.07.2013 and the said policy covers Rs. 1,00,000/- only for each for the complainant and also for his wife Pratima Bandyopadhyay.
On 20.10.,2013 the wife of the complainant Smt. Pratima Bandyopadhyay was admitted in the emergency in Peerless Hospital & Research Centre Ltd. Kolkata with chronic pain in her abdomen and complainant applied for cashless service of the ops through the concerned hospital on 20.10.2013 and initial amount was sanctioned by the op no.1 is Rs. 9,000/-. Subsequently the wife of the complainant was discharged from the aforesaid hospital on 24.10.2013 and final bill was raised by the hospital authority to the extent of Rs. 42,094/- and subsequently another bill of Rs. 721/- for medicines purchased from chemist. After submission of the final bill by the hospital to the ops for cashless treatment, op sanctioned another bill of Rs. 14,500/- and accordingly total bill of Rs. 42,094/- + Rs. 721/- i.e. total Rs. 42,815/- was submitted. But against that Rs.23,500/- was paid by the ops in two times. But the balance amount of Rs. 29,315/- has not been paid for which complainant submitted a bill for reimbursement of the same as payment of final bill being claimed complaint No. 241404095 to the op along with all documents etc.
On 18.08.2013 a letter of full and final settlement was received by the complainant from the ops in which it was written that Rs. 4,298/- was finally sanctioned by the ops against the claim of Rs. 19,315/- of the complainant and the said amount was already deposited in the bank account of complainant. But truth is that op has deducted Rs. 15,017/- out of total mediclaim of Rs. 42,094/- + Rs. 721/- i.e. total Rs. 42,815/- and against that complainant sent a letter through his Ld. Lawyer on 17.12.2013 claiming the reimbursement of Rs. 15,017/- which was illegally deducted by the op and that letter was received by the op on 20.12.2014 but even then op did not respond for which for negligence and deficient manner of service, complainant has filed this complaint for redressal.
On the contrary op/Insurance Company by filing written statement submitted that there was no negligence and deficiency on the part of the op. Op time to time released the bill i.e. Rs. 14,500/ + 9,000/- + Rs. 4,298/- i.e. total Rs. 27,798/- out of claim bill of Rs. 42,815/- and the deduction was made as per policy condition as made in clause 2.1, 2.3 & 2.4 and the calculation of deduction of the amount from the total claim amount of the complainant is based on valid reasons and is covered by the conditions as stated above.
Moreover in the settlement letter dated 18.11.2013 (vide Annexure-H is filed by the complainant) of op no.1 at the bottom of the said letter clearly stated the details of deduction which complainant has not mentioned and did not appreciate the same. So there is no question of any negligence and deficiency and for which the present complaint should be dismissed because claim is completely frivolous and baseless.
Decision with reasons
On overall evaluation of the complaint and the written version as filed by both the parties and also considering the written version including the admitted fact it is proved that complainant already received Rs. 27,798/- out of total claim of Rs. 42,094/- + Rs. 721/- i.e. total Rs. 42,815/- and in the present case complainant’s allegation is that op has not released Rs. 15,017/- the balance amount without any reasons. But fact remains that op already reported to the complainant in writing on 18.11.2013 (Annexure-H of the complaint) that Rs. 15,017/- was deducted as per policy condition 2.3 & 2.4 but complainant has not disclosed that fact in the complaint though complainant has submitted that documents Annexure-H along with this complaint. It is no doubt an act of unfair practice on the part of the consumer. But even then we are not unmindful of the fact that complainant raised a grievance for disbursement of Rs. 15,017/- in this regard we have gone through the details note of deduction wherefrom it is found that complainant enjoyed A.C. General bed and some semi critical bed from 20.10.2013 to 24.10.2013 i.e. for 4 days and for that 4 days actually complainant is entitled to Rs. 5,000/- and in view of the fact that he was admitted on 20.10.2013 at 02:16 AM and he was released on 24.10.2013 at 03:23 PM but bill was for the said bed charge of Rs. 9,000/- for which Rs. 4,000/- was deducted as per clause and that deduction is no doubt correct.
Similarly Rs. 213/- was deducted against X-ray as per policy condition 2.4, Rs. 90/- for ECG was deducted as per policy condition 2.4. Moreover Rs. 3,700/- was deducted for CT Scan and similarly Rs. 3,973/- was deducted from pathology tests and Rs. 530/- was deducted as RMO charges which is not at all payable and Rs. 1,033/- as professional fees was deducted and also deducted Rs. 1,239/- as non-medical item and this amount has been adjusted from pre-post claim as per policy. But question is that deduction is legal or not. In this regard we have gone through Mediclaim Policy 2007 wherefrom it is found that as per clause 2.1 and 2.6 it is clear that the amounts payable under clause 2.3 and 2.4 shall be at the rate applicable to the entitled room category. In case insured opts for a room with rent higher than the entitled category as under 2.1, the charges payable under 2.3 and 2.4 shall be limited to the charges applicable to the entitled category and no payment shall be made under 2.3 other than as part of the hospitalization bill and considering that clause and also the details of deduction during hospitalization as made by the op it is clear that complainant availed of the bed and paid higher rent than that of the entitled category as under 2.1 of the policy and at the same time charges payable under clause 2.3 and 2.4 is limited to the charges applicable to the entitled category. But in this case complainant paid more than that for enjoying a room with higher than the entitled category and as per policy same is deducted and after considering the Mediclaim Policy- 2007 we are convinced that complainant and op are bound by the terms and conditions of the policy and Forum cannot go beyond the terms and conditions of the policy and considering the entire material it is proved beyond any manner of doubt that complainant is not entitled to the said claim which has been deducted by the op as complainant is not entitled to any higher rent than that of the rent as fixed as per policy conditions as enumerated in Clause 2.1 and for which other charges payable under 2.3 and 2.4 shall be paid to the charges as applicable to the entitled category and for which excess charges which were paid by the complainant that was deducted and as per policy condition, op rightly deducted the same and details of the deduction as submitted by the op is no doubt correct and within the ambit of the terms and conditions of the policy.
But most interesting factor is that complainant is aware of the detailed deduction. But even then complaint is filed because complainant’s own documents Annexure-H reveals that it is nothing but the details of deduction as noted by the op.
In the light of the above observation we are convinced to hold that there is no laches and deficiency or negligence on the part of the op and deduction as made by the op is justified, legal and valid as per terms and conditions of the policy for which the complaint fails.
Hence, it is
ORDERED
That the complaint be and the same is dismissed on contest against the op but without any cost.
