Order-17.
Date-22/04/2015.
Complainant Asim Kumar Ganguly by filing this complaint has alleged that he purchased a National Insurance Policy for the health plus medical expenses of the complainant bearing No. 15430014811318500001356 on 21.05.2013 under the name Health Plus Medical Expenses Policy/Sampoorna Arogya Bima Policy” for a sum assured of Rs. 1,50,000/- + Rs. 90,000/- Cumulative Bonus i.e. total Rs. 2,40,000/- and the premium paying term for the policy was annual with the premium amount of Rs. 2,687/- with the coverage period from 26.05.2013 to 25.05.2014.
Practically on the first occasion complainant was hospitalized to Desun Hospital & Heart Institute in Kasba, Golpark, E.M. Bypass, Kolkata – 700107 for the treatment against heart attack and was treated in Rabindranath Tagore International Institute of Cardiac Sciences at 124, Mukundapur, E.M. Bypass, Kolkata – 700099 and the total cost for the treatment of Rs. 3,14,195/- including the hospital cost and medicines and on 05.09.2013, complainant submitted his claim (claim settlement no. 20130909B011R3A5979) to the op no.1 along with all the original bills for a sum of Rs. 3,14,195/- and filed all necessary documents as desired by the TPA Medsave.
But unfortunately out of the total claim and entitlement about of Rs. 2,40,000/-. Op has paid part of amount and balance amount of Rs. 44,352/- has not been settled and it is no doubt an arbitrary decision for which complainant again and again asked the op no.1 for the final settlement of his claim. But op no.1 refused and in fact for the above reason, complainant filed this complaint for redressal.
On the other hand op by filing written statement submitted that no doubt the sun assured was Rs. 2,40,000/- (Rs. 1,50,000 + Rs. 90,000/- CB) and as per limit and reimbursement as mentioned in the Section A & B of the Policy, 25 percentof sum assured that is Rs. 60,000/- in each Section when 50 percentof sum assured i.e. Rs. 1,20,000/- and the insured preferred three claims and that was paid i.e. Rs. 15,210/- as room charge, doctor’s fees Rs. 60,000/- (maximum payable) medicine and laboratory charge etc. total Rs. 1,20,000/- and accordingly out of total Rs. 2,40,000/-, Rs. 1,95,210/- has been paid and there is no scope to pay any further amount even to be the sum assured is Rs. 2,40,000/- and not only that op reported the matter to the complainant in details along with details chart for deduction and entitlement.
So, there is no negligence and deficiency on the part of the op but it has become a practice of the consumers/customers anyhow claim percentage, the insured amount which cannot be given by the op in view of the fact as per terms and conditions that can be allowed. So, there is no deficiency or negligence, but only for the purpose of grabbing money from the op. So, same should be dismissed.
Decision with reasons
On proper consideration of the Insurance Policy including the terms and conditions, it is clear that complainant is entitled to highest amount and Rs. 2,40,000/- (Rs. 1,50,000/- + Rs. 90,000/- Cumulative Bonus). But as per terms and conditions of the policy, the reimbursement cannot be made as per clause Section A, B & C.
Truth is that three claims were made by the complainant for room charge, doctors’ fees, medicine charges, laboratory etc. and as per terms and conditions of the policy, doctors’ fees is maximum payable to the extent of Rs. 60,000/- and against medicine and laboratory, maximum amount payable is Rs. 1,20,000/- and same are paid by the op to the complainant and complainant has received it.
So, there is no scope to give any relief for giving any further amount when maximum payable amount has been paid, regarding room rent, complainant claimed Rs. 8,750/- against first claim, against third claim Rs. 6,460/-. Op has paid the total amount of Rs. 15,210/- and by that way, op has paid Rs. 1,95,210/- which has been accepted by the complainant. Admittedly complainant received it. Then how the complainant can claim excess amount? No doubt it has become a practice of the customers/consumers to file such claim and truth is that the consumers/customers who have their mediclaim are not aware of the fact that against claim what they are not entitled the entire sum assured. But there are such provision that in respect of doctors’ fees highest amount is Rs. 60,000/- against sum assured of Rs. 2,40,000/-, against medicine and Laboratory etc. cost highest payable amount is Rs. 1,20,000/- and in respect of room charge, 1 percentof the sum assured, any consumer is entitled to such amount and that amount has been paid in toto as per terms and conditions of the policy.
Fact remains that complainant was served with details of deduction etc. including the reason for deduction etc. But even after receipt of the same a complaint was filed by the complainant to get relief and fact remains that many Fora are not considering the legal position and allowing, but that cannot be when already Hon’ble Supreme Court has observed that Forum cannot go beyond the contract or Agreement of any insurance policy or mediclaim policy and contract in between the parties.
So, parties shall be guided by the contract as prescribed in the agreement. But in this case practically the complaint is filed for the purpose of grabbing more money knowing fully well that he has no claim at all but a chance is made by the complainant. In fact there is no negligence, no deficiency or any sort of act which may harass the complainant by the op and for which this complaint bears no merit in the eye of law and thus this complaint fails.
Hence, it is
ORDERED
That the complaint be and the same is dismissed on contest against the ops but without any cost.
