Presented by Miss R. Pattnayak, President:-
(1) Alleging deficiency and negligence in service against the Opposite Parties, the present complaint is filed claiming for the settlement of the Medi-claim amount of Rs.40,639/-(Rupees forty thousand six hundred thirty nine)only along with compensation of Rs.25,000/-(Rupees twenty five thousand)only towards mental agony and monetary loss.
(2) Brief facts of the case is that, the Complainant has taken an Health Insurance Policy, which is titted as “Universal Health Insurance Policy” under the Opposite Parties for a total sum insured of Rs.30,000/-(Rupees thirty thousand)only bearing policy No. 550901/34/08/66/00000024 for the period commencing from Dt.25/02/2009 to Dt.24/02/2010 on payment of requisite premium and other charges.
(3) During subsistence of the said policy, the Complainant was admitted at Seven Hills Hospital, Visakhapatnam for his treatment from Dt.11/03/2009 to Dt.15/03/2009. Prior to his admission as on indoor patient, different pathological tests were also conducted on him. After the treatment also he was taking regular medicines on consulting with the doctors of the said hospital till his complete recovery. In the entire process, the Complainant has spent about Rs.40,639/-(Rupees forty thousand six hundred thirty nine)only towards his treatment.
(4) After complete recovery from his ailment, the Complainant placed his claim before the Opposite Party No.1(one) vide letter dated 11/01/2010 fulfilling the requisite necessary for the same and all other documents and prescription etc. The Opposite Party No.1(one) instead of settling total claim of the Complainant was deferring the matter on different context till Ist week of April-2010 and grant a meagres amount of Rs.5,000/-(Rupees five thousand)only to the Complainant in lieu of his claim.
(5) As the disbursement of the claim amount was arbitrary and unjust count, the Complainant could not able to accept the same and finally served pleader's notice on the Opposite Party No.1(one) on Dt.04/06/2010 through his Advocate calling upon to pay the total claim amount along with compensation there of to which the Opposite Party No.1(one) sent a reply on Dt.29/06/2010 justifying its stand with some baseless averments, mentioning the ground that the settlement in accordance to policy condition is in order.
Hence being aggrieved, the Complainant has filed this case for payment of the said amount under hospitalization claim under the insurance policy and compensation etc., as the act and conduct of the Opposite Parties is quite unethical and amount to deficiency in rendering service towards the Complainant.
(6) The Complainant in support of his case has filed the following documents:-
Pleader's Notice Dt.04/06/2010 along with postal receipts and postal A.D. Dt.09/06/2010.
Copy of reply Dt.29/06/2010 send by the Opposite Party No.1(one). The Complainant also filed affidavit and written argument which are attached to the case record.
(7) Notice were duly served on the Opposite Parties and after Notice being served, the Opposite parties entered their appearance on Dt.17/09/2010 and on Dt.24/11/2011 and filed their written version on Dt.17/09/2010 and Dt.12/01/2012 respectively denying the allegations made in the complaint.
(8) The Opposite Party No.1(one) in his version has submitted that as only a third party Administrator, they are only authorized to process the claim files and determine the liability of the claim but the insurance company it self collects premium and issues policy enumerating clauses and conditions.
The Opposite Party No.1(one) had admitted the policy and claim there of but disputed the count of claim justifying the amount of Rs.5,000/-(Rupees five thousand)only to be proper. He submitted that the policy of the insured is limit to Rs.30,000/-(Rupees thirty thousand)only with specific bifurcated limit for bed charges, Doctor's and other account. However, further liability of Rs.4,200/-(Rupees four thousand two hundred)only can be admitted subject to compliance of money receipt from concerned physician. The Opposite Party No.1(one) has pleaded that no deficiency or negligence in rendering service has been done by him to the Complainant as we have made correspondence twice i.e. once requesting to submit original discharge summary on Dt.01/03/2010 and the second one on Dt.29/06/2010. So he prayed before this Forum to dismiss the case as there is no merit in this case.
(9) In support of his case, the Opposite Party No.1(one) has filed the following documents:-
Copy of Receipt of premium towards Universal Health Insurance Policy from the Complainant by the New India Assurance Company Limited.
Copy of Health Insurance Policy bearing No. 550901/34/08/66/00000024 issued by the New India Assurance Company Limited.
Copy of letter dated 29/06/2010 issued by Opposite Party No.1(one) to the Complainant.
(10) The Opposite Party No.2(two) while admitting the policy has submitted in his version that the total expenses incurred for any one illness is limited to Rs.15,000/-(Rupees fifteen thousand)only and is also restricted to the amount as mentioned in Sec. 1 (1.2) of the Policy. Hence the claim was rightly settled at Rs.5,000/-(Rupees five thousand)only and no claim what so ever is maintainable under this policy. So he prayed before this Forum for dismissal of the case as it is not maintainable.
In support of his case the Opposite Party No.2(two) has filed the following documents.
Xerox copy of the Policy conditions of Universal Health Insurance Policy.
Relying on the pleading of the Parties, we take up the following issues for adjudication.
-: I S S U E S :-
Whether the Complainant is a consumer of the Opposite Parties and whether the case is maintainable ?
Are the Opposite Parties guilty of deficiency in rendering services to the Complainant ?
To what relief the Complainant is entitled for ?
Answers of Issues No.1(one) No.2(two) and No.3(three).
On careful consideration of the complaint petition, version and written argument of Opposite Parties and after hearing both the Parties, we found that, the Opposite Parties have not disputed about the Complainant as a consumer. The Complainant has done health insurance under the Opposite Parties in payment of requisite premium and other dues and as such the policy was issued by the Opposite Parties to which, the Opposite Parties have admitted in their version about the factum of insurance done by the Complainant on requisite payment of premium which is also proved further through the documentary evidence i.e. from copy of the policy and copy of receipt of premium annexed in the case record. So admitted fact need not be proved.
As because during the coverage period of the policy, the Complainant was admitted at Seven Hills Hospital, Visakhapatnam for his treatment and in the entire process of treatment Complainant sustained expenses towards the hospitalization treatment the claim has to be met by the Opposite Parties. So, the complaint petition has primafacie case and it is maintainable under the Consumer Protection Act-1986.
The Complainant was admitted in the Seven Hills Hospital, Visakhapatnam for treatment from Dt.11/03/2009 to Dt.15/03/2009, which has not been disputed by the Opposite Parties.
The only disputed is that, the Complainant has claimed insurance for a sum of Rs.40,639/-(Rupees forty thousand six hundred thirty nine)only as amount spent towards the entire process of treatment to which the Opposite Parties denies submitting that, the policy was issued only subject to terms and conditions mentioned in the policy. The Opposite Party No.2(two) in his version has submitted that as per the policy, the total expenses incurred for any the illness is limited to Rs.15,000/-(Rupees fifteen thousand)only and is also restricted to the amount as mentioned in Sec.1(1.2) of the policy. Hence the claim was rightly settled at Rs.5,000/-(Rupees five thousand)only.
The Opposite Parties further denies that there was no deficiency on the part of the Opposite Parties in rendering services to the insured. During the currency of the policy, the insured intimated about his treatment. The Opposite Party No.1(one) being a third party Administrator appointed under the Rules settled the claim at Rs.5,000/-(Rupees five thousand)only taking into account the treatment, hospitalization and other claims of the insured as well as the limitation of the policy of insurance.
We perused the policy bond where it is clearly mentioned the name of the insured is the Complainant and the policy period is from Dt.25/02/2009 to Dt.24/02/2010 and at Section-1, it is clearly mentioned that the sum insured for hospitalization benefit is Rs.30,000/-(Rupees thirty thousand)only per family and limit for any one illness is Rs.15,000/-(Rupees fifteen thousand)only.
We also perused the terms and conditions of the policy, where in Section-1(1.1) and (1.2) it is clearly mentioned that, if any insured person shall suffers from any illness and admitted in hospital for treatment as an in patient, the company will pay through TPA (Third Party Administrator) to the hospital/ N.H./ insured person as the case may be, the amount of such expenses subject to limits as below but not exceeding the sum insured for that person family in one period of insurance.
Hospitalisation Benefits | Limits |
|---|
A | (i) Room, Boarding expenses as provided by the Hospital/Nursing Home. (ii) If admitted in IC Unit. | (i) Upto to 0.5% of Sum Insured per day. (ii) Upto 1% of Sum Insured per day. |
B | Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialists Fees, Nursing Expenses. | Upto Rs.15% of Sum Insured per illness/Injury |
C | Anesthesia, Blood, Oxygen, OT charges, Surgical appliance, Medicines, drugs, Diagnostic material & X-Ray, Dialysis, Chemotherapy, Radiotherapy, cost of pacemaker, artificial limbs. | Upto 15% of Sum Insured per illness/Insury. |
As it is admitted by both the parties that the insured was admitted in the hospital for his treatment from Dt.11/03/2009 to Dt.15/03/2009 which is five days. So the Forum calculated that as per the policy condition, for room, boarding expenses as provided by the Hospital which is upto 0.5% of sum insured per day comes to Rs.150/-(Rupees one hundred fifty)only. As per the policy condition expenses of Hospitalisation for minimum period of 24(twenty four) hours are admissible. As per the letter Dt.29/06/2010, the Opposite Party mentioned that the insured was admitted at hospital from on Dt.11/03/2009 at 07: 01: 20 to 15/03/2009 at 15: 41:46. Since no document was filed by the Complainant regarding the admission and discharge of the insured, so we rely on the version of Opposite Parties. So accordingly for 4.5 day, the calculation comes to 150 x 4.5 = 675. Hence this charges is in order.
As per condition No.1.2(B), the expenses to wards doctor is upto Rs. 15%(fifteen percent) of the sum insured per illness, which in his case comes to Rs. 4,500/-(Rupees four thousand five hundred)only but the Opposite Party has calculated only Rs.300/-(Rupees three hundred)only could be given as there invalid money receipt filed by the Complainant.
As per condition No.1.2(c), the other diagnostic matters were consider upto 15%(fifteen percent) of sum insured per illness which comes to Rs.4,500/-(Rupees four thousand five hundred)only.
So the total, comes to Rs.9,675/-(Rupees nine thousand six hundred seventy five)only but in this case the Opposite Party only calculated Rs.5,000/-(Rupees five thousand)only which is unjust and counted arbitrary. This act and conduct of the Opposite Parties towards the Complainant is definitely, deficient and negligent in rendering proper service because the Complainant has placed his claim before the Opposite Party No.1(one) submitting the claim form. To justify their calculations the Opposite Party have also not produce the claim form and the documents filed by the Complainant before the Forum for perusal. Due to this act of Opposite Parties the very purpose of the insurance policy done by the Complainant has also frustrated. So, the Complainant is entitled for the claim amount as calculated by the forum as per the policy condition and also the Opposite Party are liable to compensate the Complainant for his suffering from all count.
Hence ordered.
The Opposite Parties are directed, jointly and severally, to pay a sum of Rs. 9,675/-(Rupees nine thousand six hundred seventy five)only to the Complainant towards the Hospitalisation claim with interest @ 9%(nine percent) per annum from the date of repudiation i.e. Dt.29/06/2010 till the date of Order i.e. Dt.28/10/2013, along with compensation of Rs. 2,000/-(Rupees two thousand)only for mental agony, harassment within thirty days from the date of Order, failing which the awarded amount shall carry interest @ 12%(twelve percent) per annum till the realization of the same.
The complaint is allowed and disposed off accordingly.
Typed to my dictation
and corrected by me.
I agree, I agree, I agree,
(Miss Rajlaxmi Pattnayak) (Smt. Anjali Behera) (Sri Pradeep Kumar Dash)
P r e s i d e n t M e m b e r. M e m b e r.
