FACTS On being aggrieved by the amount of reimbursement paid to her by the respondents in connection with her policy, complainant filed the instant complaint praying for a direction upon the respondents/Opposite Parties to pay the remaining amount of her reimbursement claim and also compensation of Rs.15,000/- for deficiency in service and mental harassment and agony. According to the complainant, she was admitted to Microlap, Kolkata on 7/02/2022 for a surgery of Endometrial cysts and discharged on 11/02/2022. She submitted for reimbursement of pre-hospitalization expenses of Rs.17,639.07/-, expenses during hospitalization of Rs.97,023/- and also post-hospitalization claim of Rs.18,099/-. She raised no dispute about the settled amount for reimbursement of post-hospitalization claim but as regards her claim for reimbursement of pre and during hospitalization, she alleged a deduction of Rs.17,723/- out of Rs.97,023/- on account of reasonable and customary clause was unjustified and incorrect. She alleged that the claim of her pre-hospitalization expenses remained untouched and unaccounted for by the respondents. She also alleged that the date of discharge was misrepresented by the respondents on the complainant’s account (HITPA website). Likewise, they also misrepresented the procedure as per her discharge certificate which stated: “hysterescopy, bilateral ovarian cystectomy, Mirena insertion, reconstruction of both ovaries, pipelle curettage”. Respondent Nos. 1 & 3 contested the complaint by filing separate written version and also adducing evidence whereas this complaint was heard against respondent No. 2 ex parte. In his written version, respondent No. 1 admitted to be an agent of respondent No. 3 by whom the Mediclaim was obtained by the complainant with cashless facilities and the said policy was renewed through from 15/11/2018. According to him, he was falsely and illegally made a party to this complaint as the payment of Mediclaim amount is absolutely a matter between the policy holder and the insurance company and its TPA. Respondent No. 3- National Insurance Company Limited in their written version, claimed that they reimbursed the expenses incurred by the complainant as per her entitlement to the extent possible for pre-hospitalization and during-hospitalization period under PPN (Preferred Providers Network) method to the tune of Rs.79,300/- on 19/05/2022 in accordance with the terms and conditions of the Mediclaim policy of the complainant. According to them, there was no unfair trade practice or negligence on their part. Now, the point for consideration is whether the complainant is entitled to the relief(s) as claimed in this case. FINDINGS We have gone through the evidence on record and the documents filed by both the parties, also considered the respective arguments of the parties. Admittedly, the complainant got a Mediclaim policy from respondent No. 3 through their agent who is respondent No. 1 on payment of required premium and her policy number was 154400502110004451 and the effective period of the policy was from 00:00 of 08/12/2021 to the midnight of 07/12/2022. It is also admitted that the complainant submitted some claims with respondent No. 3 in view of her medical treatment at Microlap, Kolkata where she had been admitted for a surgery of Endometrial cysts. She got admitted there on 7/02/2022 and was discharged on 11/02/2023. Thereafter, we find from the materials on record that complainant submitted claims for reimbursement for pre-hospitalization expenses amounting to Rs.17,639.07/- and for during-hospitalization expenses of Rs.97,023/- on 15/03/2022 thus, totalling Rs.1,14,662.07/-. She also claimed to have submitted reimbursement for post-hospitalization expenses on 18/03/2022 for a sum of Rs.18,099/-. So far as the claim of post-hospitalization expenses is concerned, complainant stated that the said claim was settled at Rs.16,513/- which was paid on 06/05/2022 but in the paper submitted by respondent No. 3, the said date is found to be 10/05/2022. Be that as it may, there is no dispute with regard to this claim and settlement thereof between the parties. Now the dispute arose regarding the amount of reimbursement made by respondent No. 3. We find as admitted by respondent No. 3 that regarding pre-hospitalization expenses they paid Rs.16,093/- after deducting uber charges @ Rs.1546/- on conveyance and for expenses during-hospitalization, they paid Rs.63,207/- (deducting balance amount as per PPN rate/package). Thus, they paid in total, Rs.79,300/- on 19/05/2022. In fact, complainant did not deny having received that payment from respondent No. 3 but she raised question as to why so much amount was deducted by them and regarding this, she sent mails on repeated occasions. What we find from the papers submitted on behalf of the respondent No. 3 that (Annexure-A) they settled pre-hospitalization expenses for Rs.16,513/- being the settlement No.2168604004 dated 05/05/2022 and payment date was shown as 10/05/2022. This is with regard to claim No.1544005022984148020 shown in Annexure-A of respondent No. 3 and for expenses during-hospitalization (Annexure-E) the claim number is shown as 154400502198209414 and settlement number as 2168612319, the date being 06/05/2022 for an amount of Rs.79,300/- with payment date 19/05/2022 and complainant also produced a document which is said to have been issued by respondent No. 2 (Page-12 of complainant’s document) where the settlement of claim number is shown as 211300370253 against the requested amount of Rs.18,099/- and an amount of Rs.16,513/- was approved. This amount of Rs.16,513/- is found to be the amount against the said requested amount which according to the complainant, was a claim for expenses relating to post-hospitalization in respect of which she made no complaint in this case. On the other hand, the respondent No. 3 though claimed to have paid Rs.16,093/- towards pre-hospitalization expenses but not a single document could be produced by them to show the aforesaid payment was made against the claim pre-hospitalization expenses of R.17,639.07/-. Apart from this, we find out of claim for expenses during-hospitalization of Rs.97,023/-, they paid Rs.63,207/- but how and in what manner they ascertained the said amount, was not made clear even during hearing. In this regard, we find the treatment underwent by the complainant is “hysterescopy, bilateral ovarian cystectomy, Mirena insertion, reconstruction of both ovaries, pipelle curettage”. Complainant also alleged that all these were misrepresented as Hysterectomy by the Opposite Parties. So, we are compelled to say that the respondents particularly respondent No. 3 failed to satisfy with cogent reasons as to how they could deduct the amount of Rs.35,362/- and complainant in this case has claimed the said amount from the respondents along with Rs.15,000/- for compensation etc. on account of deficiency in service and mental harassment and agony. There was no argument on behalf of the respondents that the amount of claim made by the complainant is beyond the sum insured by the policy document. Therefore, on going through the materials on record and hearing the contention of both the parties, we opine that the complainant should get the said amount of Rs.35,362/- along with interest @ 9% p.a. on and from 19/05/2022 when the last payment was made by the respondent No. 3 until realization. This apart, complainant is also entitled to Rs.3,000/- towards cost of litigation. Be it noted here, as no specific allegation is there against the agent i.e. respondent No. 1, the instant complaint is liable to be dismissed against him. Respondent Nos. 2 & 3 are liable to satisfy all the aforesaid reliefs. Considering the order of payment of interest and the rate thereof, no separate amount for compensation is allowed. Hence, it is ORDERED That the instant case be and the same is allowed on contest against respondent/Opposite Party Nos. 1 and 3 and ex parte against respondent No. 2. Respondent Nos. 2 and 3 are directed to pay Rs.35,362 (Rupees Thirty-Five Thousand and Three Hundred Sixty-Two Only) along with interest @ 9% p.a. on and from 19/05/2022 until realization to the complainant.. They are also to pay Rs.3000/- (Rupees Three Thousand Only) for litigation cost to the complainant. Both the respondent Nos. 2 & 3 are jointly and severally liable to pay the awarded amount as stated above within 45 days from the date of this order, failing which complainant shall be at liberty to proceed in accordance with law. Dictated and corrected by me. President | 
