PER SHRI. G.H. RATHOD – HON’BLE  MEMBER

  1)        The Complainant by this complaint has prayed that the Opposite Parties may be directed to pay the amount of Rs.3,796/- towards the balance of claimed amount which is wrongly repudiated by the Opposite Parties.  The Complainant has also prayed that the Opposite Parties may be directed to pay the Complainant Rs.2 Lacs as compensation towards the mental agony and stress suffered by the Complainant and also prayed to direct the Opposite Parties to pay 50,000/- towards the legal and incidental charges incurred by the Complainant.

 2)        As per the Complainant, the Complainant he was employee of the Opposite Party No.1. He is also one of the members of Life Insurance Police of Group Medical Scheme Policy.  The Complainant submitted that as per the scheme prevailing at the relevant time all employees of Opposite Party No.1 including their family members were insured under Group Insurance Policy.  For that purpose the Opposite Party No.1 obtained Group Insurance Policy from Opposite Party No.2.  The Complainant and his wife Mrs. Kalpana Karulkar were insured under the said Group Insurance Policy from the year 1988 till filing of complaint.  The insured policy initially was of Rs.70,000/-.  The Complainant renewed his Group Mediclaim Insurance Policy for the period 01/04/2009 to 31/03/2010 for the sum of Rs.2 Lacs.  The Complainant submitted that on 14/08/2009, his wife was not feeling well and as per the Doctor’s advise the Complainant purchased medicines from Bharat Medico, Dadar for the period of one month for the sum of Rs.4,067/-.  The copy of bills is marked at Exh. ‘C-1’. 

 3)        The Complainant further stated that the health of his wife became worse and she was admitted in Lilavati Hospital in Research Centre, Mumbai on 16/09/2009 for the treatment.  After the treatment she was discharged on 27/09/2009 for which the further expenses of Rs.53,164/- paid by the Complainant.  The copy of the discharged card is marked at Exh.‘C-2’.  Then the Complainant filed claim for Rs.57,235.30 paise.  The copy of the same is marked at Exh.‘C-3’.  Out of Rs.57,235.30 paise the Opposite Party said that the bill available with them are of Rs.49,675/- only and therefore, they allowed the payment sum of Rs.49,675/- which was received by the Complainant on 11/11/2009.  Thereafter the Complainant provided again the bill of Rs.3,400/- to the Opposite Party and the Opposite Party had settled the claim of Rs.3,400/- which is annexed at Exh.‘C-4’.

4)        The Complainant submitted that the balance amount of Rs.4,067/- is still not settled by the Opposite Parties. The Complainant states that the medicines are prescribed for the period of 30 days and the amount of Rs.4,067/- of medicines prior to the admission of patient this claim not settled by the Opposite Parties, hence, the complaint lodged before this Forum.

 5)        The notice of this complaint is issued to the Opposite Party No.1 & 2 to file the written statement.  Accordingly, Opposite Party No.1 & 2 contested the claim by filing written statement.

 6)        As per the Opposite Party No.1, the Opposite Party No.1 is a Statutory Body established by the Life Insurance Corporation Act, 1956.  The Opposite Party No.1 denied all the allegations made in the complaint by the Complainant.  It admitted by the Opposite Party No.1 was an employer of the Complainant.  It is contended that the Opposite Party No.1 has not rendered any service to the Complainant and as such, question of deficiency of service on the part of Opposite Party No.1 does not arise.  It is submitted that the Opposite Party No.2 repudiated the claim of the Complainant of Rs.4,067/- as per the policy condition.  The Opposite Party No.1 had availed a Group Mediclaim Insurance Policy from the Opposite Party No.2 under policy No.121400/34/09/12/00000329 for covering the medical risk of their employees which is annexed at Exh.‘A’ to the written statement.  The contents of para No.1,2& 3 of the complaint are denied by the Opposite Party No.1.  It is denied that there is any deficiency of services and the Opposite Party No.1 has indulged into unfair trade practices as alleged or otherwise. The Opposite Party No.1 contended that the Complainant is entitled for the claim as per the condition of the policy, the Complainant is entitled to claim pre-hospitalization covered only 30 days prior to the hospitalization. The Bill No.1135, 1136 & 1137 under which the Complainant claimed the reimbursement issued by Bharat Medico on 14/08/2009 which are beyond the period of coverage.  The Opposite Party No.1 also denied that the Opposite Party No.1 can deduct the amount of 2 days i.e. 14/08/09 till 16/08/09 and remaining amount of 28 days shall pay to the Complainant.  This claim made by the Complainant is unjustified and unlawful. The Opposite Party No.1 also prayed that the representation of the Complainant was turned down as per the terms and condition of the policy.  It is further submitted that as the Opposite Party No.1 has not committed any deficiency in service and the complaint is not maintainable against the Opposite Party No.1 and it should be dismissed with compensatory costs.

 7)        In the written statement of Opposite Party No.2 it is contended that the Complainant availed the services of Opposite Party No.2 through Opposite Party No.1 by obtaining the Group Mediclaim Policy bearing Policy No.121400/34/09/12/ 00000329 for the Complainant and his family and was renewed for the period from 01/04/09 to 31/03/2010.  As per this policy the Complainant lodged his claim for Rs.57,235/- with Opposite Party including the pre-hospitalization expenses. After scrutiny and as per the terms and condition of the policy the said claim was settled for Rs.49,657/- and 3,400/- against the total claim amount for Rs.57,235/- and the deduction was follows as per the Clause No.3.1 of the policy.  Opposite Party No.2 stated that the wife of the Complainant was admitted on 16/09/02 whereas 30 days prior to hospitalization start form 17/08/09 to 15/09/09 and therefore, pre-medical bills all dtd.14/08/09 amounting to Rs.4,067.69 paise which are prior to pre-hospitalization expenses being not admissible are deducted as per the policy Clause No.3.1 the Complainant has accepted this Group Mediclaim Policy alongwith said clause. The medicines bill dtd.14/08/09 are before 30 days, hence, it is not admissible under the claim as per clause 3.1. The Opposite Party No.2 thus, settled the claim of the Complainant and paid Rs.49,657/- and Rs.3,400/- against the total claim Rs.57,235/- and the said amount accepted by the Complainant. The Opposite Party deducted 3 medicine bills dtd.14/08/2009 amounting to Rs.4,067.69 which were prior to           pre-hospitalization admission period start from 17/08/2009.  The Opposite Party No.2 denied all the other allegations which are made by the Complainant in his complaint and contended that all the rightful claim was allowed except the amount Rs.4,067/- which is not covered by the clause of policy Clause No.3.1.  The Opposite Party No.2 further stated that the complaint filed by the complainant is not maintainable and the same is liable to be dismissed with cost.  

 8)        The Complainant and Opposite Party No.1& 2 have filed their written arguments. As per the written argument of the Complainant it is stated that repudiation of balance claim of Rs.4,067/- is unjustified. It is also requested the amount of medicines of Rs.4,067/- and remaining claim must be directed to be paid by the Opposite Party No.2.  It is also prayed that as per the clause 3.1 of the policy relevant medical expenses incurred/medicines to be consumed during the period upto 30 days prior to hospitalization on disease/illness/injury sustained of which the insured was hospitalized will be considered as part of claim.

 9)        The Opposite Party No.1 & 2 in their written argument denied the claim by in view of terms and condition of the policy. 

 10)      In this complaint we heard the oral argument of Ms. Rashmi Manne, Ld.Advocate for the Complainant and Ld.Advocate Mr. Navinkumar for the Opposite Party No.1 and Smt. Kalpana Trivedi, Ld.Advocate for the Opposite Party No.2. 

 11)      We have gone through the all the documents submitted by all the parties.  From the document at Exh. ‘C-1’ it appears that the Complainant submitted the medicine bill dtd.14/08/2009 for which he has not submitted any prescription of the Doctor.  The prescription of the doctor is not on the record and the bill of medicine of Bharat Medico which are submitted by the Complainant do not bear the signature of Pharmacist which is necessary under the Drug & Cosmetic Act, 1940.  Hence, it creates the doubts that the bills submitted by the Complainant are whether valid or not.  By considering these facts and the clause No.3.1 of Group Mediclaim Policy the claim rejected by Opposite Party No.2 in our view is justifiable.  The said bills are not within the period of one month prior to the hospitalization of Complainant’s wife and thus, the same cannot be considered as covered under the terms & conditions of the policy. The submission of Ld.Advocate for the Complainant for grant of proportionate claim of 28 - 29 days medicines also cannot be accepted for the aforesaid reasons.  In the result we find that the Complainant is not entitled for any reliefs.  Hence, we pass the following order -

O R D E R

i.                    Complaint No.188/2011 is dismissed with no order as to cost.

ii.                 Certified copies of this order be furnished to the parties.