Order No. 15 dt. 02/02/2017
The case of the complainant in brief is that the complainant had a mediclaim policy in the year 2006 from o.p. no.2 and paid the premium regularly. In the month of Nov. 2012 the wife of the complainant developed gynecological complications resulting in consultation of Fortis Hospital which is PPN hospital approved by the insurance company. The complainant’s wife was examined by Dr. Sujata Dutta. After various tests she was advised for surgery along with biopsy, subsequently she was admitted to Fortis Hospital. The complainant collected money for the treatment of his wife since he had the impression that the medical expenses shall be reimbursed by insurance company. On 28.1.14 one Dr. Bhaskar Pal examined the complainant’s wife and advised for surgery, accordingly the operation was made on 6.2.14 and she was discharged on 7.2.14. The complainant submitted the claim form for reimbursement of medical expenses to o.p. no.1 on 22.2.14. On 8.3.14 the complainant noticed that a sum of Rs.24,735/- was transferred to the account of the complainant by o.p. no.2. The complainant claimed the amount of Rs.17,349/- towards the unpaid amount by o.p. no.2 as well as compensation of Rs.1 lakh and interest and litigation cost.
In spite of receipt of notice the o.p. no.1 did not contest this case by filing w/v and as such the case has proceeded ex parte against the o.p. no.1.
The o.p. no.2 contested this case by filing w/v and denied all the material allegations of the complaint. It was stated that o.p. no.2 paid an amount of Rs.24,735/- to the complainant towards the reimbursement of the medical expenses and the said amount was paid on the basis of the justifiable deduction in the medical bills of the complainant towards reimbursement of medical expenses and the deductions have been made according to the terms and conditions of the mediclaim policy. It was stated that an agreement related to the mediclaim policy was made between the complainant and o.p. insurance company wherein certain terms and conditions were contained and which were accepted by the complainant while executing the agreement. The TPA considered the insurance claim according to the terms and conditions of the policy which was accepted by the complainant at the time of taking the policy. The clause 2.6(1) of the mediclaim policy 2007 it was stated that the amount payable under 2.3 and 2.4 shall be at the rate applicable to the entitled room category. In case of insured opts for a room with higher than 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. On the basis of the said chart the claim of the complainant was provided and accordingly o.p. no.2 stated that the complainant will not be entitled to get a sum of Rs.17,349/- as reimbursement and there was no deficiency in service and accordingly o.p. no.2 prayed for dismissal of the case.
On the basis of the pleadings of parties the following points are to be decided:
- Whether the complainant was insured with the insurance company.
- Whether the complainant’s wife was treated in the hospital and the claim made by the complainant was excessive one.
- Whether the o.p. no.2 paid lesser amount than the actual amount the complainant was entitled to get.
- Whether there was any deficiency in service on the part of insurance company.
- Whether the complainant will be entitled to get the relief as prayed for.
Decision with reasons:
All the points are taken up together for the sake of brevity and avoidance of repetition of facts.
Ld. lawyer for the complainant argued that the complainant had the policy at the relevant point of time while the wife of the complainant became ill and she was admitted to Fortis Hospital for surgery. After release from the hospital the complainant asked for reimbursement of the medical bills from o.p. no.1, subsequently the complainant found that o.p. no.1 sent a cheque directly in the account of the complainant to the tune of Rs.17,435/- less than the amount claimed by the complainant. Being aggrieved by and dissatisfied with the amount paid by insurance company through TPA the complainant had to file this case. Ld. lawyer for the complainant emphasized that the amount paid by the complainant to the hospital was much higher than the amount paid insurance company towards the reimbursement of the medical bills, accordingly, the complainant prayed for balance amount as well as other reliefs.
Ld. lawyer for the o.p. insurance company argued that the policy was accepted by the complainant on the basis of the terms and conditions mentioned in the policy. As per the clause 2.3 and 2.4 of the said policy it was specifically stated that the amount payable at the rate applicable to the entitled room category. In case insured opts for a room with 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. In support of the said contention ld. lawyer for insurance company prepared a chart showing that the entitlement of the claim of the complainant as per assured sum of the policy and after necessary calculation it was shown that though the claim made by the complainant to the tune of Rs.42,284/- and after deduction as per clause 2.3 and 2.4 the amount was deducted of the amount of Rs.17,549/- and the rest amount was paid to the complainant within the short span of time. Since there was no deficiency in service on the part of o.p. no.2 therefore o.p. insurance company prayed for dismissal of the case.
Considering the submissions of the respective parties it is found that the complainant was the policy holder in respect of the mediclaim policy as claimed by him and it is also found that the policy was valid at the relevant point of time. The o.p. no.2 has not disputed that the policy was valid. Since the policy was valid the complainant was paid an amount of Rs.24,735/-. It is also found from the materials on record that the complainant claimed room charges @ Rs.2200/- but the insurance company paid Rs.1250/- and deducted Rs.950/-, the reason was also mentioned that excess room charges as maximum limit 1% of sum assured i.e. 1% of Rs.1,25,000/- (sum insured) = Rs.1250. The doctor fee was paid though claimed Rs.12,700/- and it was paid Rs.7216/- i.e. the deduction was made in respect of Rs.5484/-. The said deduction was made as per policy proportion under clause 2.3 (12,700 / 2200 x 1250) = Rs.7216. OT charges was also claimed by the complainant to the tune of Rs.6000, paid Rs.3409/- and deduction was made in respect of Rs.2591/- and the said deduction was also made as per policy proportion under clause 2.4 (6000 / 2200 x 1250) = Rs.3409/-. The entire price of medicines of Rs.969/- was paid. Investigation claimed by the complainant Rs.1990, actually paid Rs.1131, deducted Rs.859/-, the said deduction was made as per proportion as per clause no.2.4 (1990 / 2200 x 1250) = Rs.1131/-. Miscellaneous expenditure was deducted since it was not admissible. Other charges were paid and the medicine for pre hospitalization was paid, only Rs.100/- was deducted because of improper medicine bill. Considering the calculation sheet provided by the insurance company as well as the argument advanced by the complainant we hold that there was no irregularity committed by the insurance company and the amount paid by the insurance company as per the terms and conditions of the policy and the amount was paid as per the clause 2.3 and 2.4 of the said policy. There was no deficiency in service on the part of o.p. insurance company. Therefore we hold that the complainant will not been entitled to get any relief as prayed for. Thus all the points are disposed of accordingly.
Hence, ordered,
That the CC No.393/2014 is dismissed ex parte against the o.p. no.1 and dismissed on contest against the o.p. no.2 without cost.
Supply certified copy of this order to the parties free of cost.
