Order No.                 .

This is an application u/s.12 of the C.P. Act, 1986.

          Complainant by filing this complaint has submitted that he purchase one Mediclaim Policy namely Sampoorna Arogya Bima Policy being Policy No.100100/48/12/8500002410 to cover the health of her own and her husband of the period of 26-12-2012 to 25-12-2013 with the sum insured of Rs.1 lakh  for each policy holder. 

          Within the span of coverage period, complainant Gopa Ghoshal became seriously ill and examined by Dr. D. Das, R.M.O. of T.R.A. General Hospital who after examination advised her for urgent/immediate admission for treatment and referred to Dr. S. Chakraborty on 20-12-2013 and the complainant at TRA General Hospital on 20-12-2013 under the care of Dr. S. Chakraborty and his diagnosis was that the patient was suffering from severe P.Vivox Malaria and severe Urinal sepsis and after proper treatment she was discharged on 29-12-2013.  On her discharge from hospital she lodged a claim with OP2 for reimbursement of her medical expenditure along with claim form including document on 03-01-2013 and thereby submitted a claim of Rs.57,743/- incurred by her during hospitalization treatment but even after that complainant requested on number of times, for releasing the same and also contacted with the OP but subsequently she came to learn that her claim for Rs.14,143/- was settled so complainant sent a letter of refusal of the settlement of claim amount of Rs.14,143/- to the OPs1 and 2 and they received the same on 21-01-204 but they are remained silent and did not give any reply to the complainant. 

          Thereafter, OPs1 and 2 transfer the settled amount of Rs.14,143/- to the complainant’s SB Account through RTGS/NEFT on 24-01-2014 against that on 06-03-2014 the complainant sent a letter requesting the OPs 1 and 2 to reconcile the settlement regarding the rest amount of Rs.43,662/- out of the total claim amount of Rs.57,743/- but OP did not release it and did not given any reply and considering the act of the OPs tantamount to gross negligence and deficiency of service and also it is an unfair trade practice and getting no redressal complainant prays for relief before this Forum.

          On the other hand, OPs Insurance Company by filing written statement submitted that the entire claim of the complainant is false, fabricated and in the complaint complainant has suppressed the truth of receiving Rs.49,146/- and Rs.71,773/- i.e. a total of Rs.1,20,919/- for other two claims made by the complainant during subsistence and validity of the said policy and truth is that as per policy sum insured is Rs.1 lakh and cumulative bonus accrued thereon.  So, in a year complainant is entitled to get refund of Rs.1,35,000/-  for total claim against her treatment further it is submitted that Rs.49,146/- was paid on 09-12-2013 against her previous claim No.hh111408022 which was settled on 07-10-2013 and in that case she was treated for acute urinary infection with urocepsis septicaemia, similarly vide claim No.HH111314737 complainant submitted one claim for her treatment urosepsis with endotoxic shock with dyselectremia and that claim was settled on 08-03-2013 and sum of Rs.71,773/- was paid on 25-04-2013 and thus a sum of Rs.1,20,919/- had already been paid during the subsistence and validity period of the present policy but the present claim was registered as HH111411150 for treatment of plasmodium vivex malaria with severe urinary sepsis and that claim was filed on 20-12-2013 and on 29-12-2013 it was settled and amount paid was Rs.14,081/- out of total claim of Rs.57,743/- on the ground complainant is entitled to Rs.1,35,000/- as insure i.e. including compensation but already she has received Rs.1,20,919/- for which balance amount of Ra.14,081/- was paid and in total the total insure amount of Rs.1,35,000/- is paid and for which the complainant is not entitled to any further reimbursement of the balance amount of the claim because he has already realized entire insured amount and there is no scope to grant any further amount when entire amount has already been paid to the complainant.  but most interesting factor is that complainant appeared before this Forum with false allegation and releasing entire insured amount for the validity period of the present mediclaim policy and entire complaint is a suppression of fact and vexatious for which it shall be dismissed.

Decision with Reasons

After proper study of the complaint and the written version and also considering the fact of admitting of the complainant that complainant is entitled to Rs.1,35,000/- as total sum insured including bonus for the period from 26-12-2012 to 25-012-2013 against the policy No.100100/48/12/8500002410.  But it is proved beyond any manner of doubt that this complainant for the above validity period of mediclaim policy on earlier occasion on 09-12-2013 was paid Rs.49,146/- against the mediclaim vide claim no.HH111408022 for his treatment acute urinary infection with urocepsis septicaemia and further a sum of Rs.71,773/- was also paid on 25-04-2013 was also paid on 25-04-2013 against his mediclaim application No.FF111314737 for his treatment urosepsis with endotoxic shock with dyselectremia and fact remains complainant has failed to deny this fact that he received such amount not only that complainant did not produce the said account against such account the said amount had already been transferred and complainant had his scope to produce the bank account and deny this fact but that has not been done and no doubt it is proved that complainant already received disbursement in respect of the said two mediclaims i.e. a total amount of Rs.1,20,919/- was in a year for the said mediclaim policy and validity period is entitled to get only balance amount of Rs.14,081/- out of total sum assured including bonus i.e. Rs.1,35,000/- but after proper assessment of the documents and materials it is found that the present claim being No.HH111411150 was submitted by the complainant for a sum of Rs.57,473/- but as because she is entitled to only Rs.14,081/- out of total sum assured with bonus Rs.1,35,000/- the insurance company release that amount that is Rs.14,081/- in the present claim because his total sum insured amount is enhanced after payment of this part payment of Rs.14,081/- because previously within the validity period of the said mediclaim policy complainant already received 1,20,919/-.

          Most interesting factor is that in some cases before to this present President’s joining in such a manner some claims were released by this Forum but fact remains documents were not properly determined so such order had been passed but in this case truth is that complainant suppressed the vital truth that out of total sum insure with bonus i.e. Rs.1,35,000/- has already been enjoyed Rs.1,20,919/- against two mediclaims for the said one year validity period of mediclaim policy so for which she is only entitled to Rs.14,081/- against another claim because her sum insured has been covered already to the extent of Rs.1,20,919/- out of Rs.1,35,000/- and considering the above facts and present act of the OP we are convinced that the insurance company rightly released Rs.14,081/- out of total claim of Rs.57,773/- on the ground only after release of 14,081/- against the present claim her sum insured of Rs.1,35,000/- shall cross limit of sum insured as per provision of law.  Complainant is not entitled to enjoy sum assured of Rs.1,35,000/- i.e. including bonus in a particular year of insurance but adopting some unscrupulous method complainant has tried to release the entire claim of this complainant which was submitted by the complainant by the claim No.HH111411150.  So, it is clear that there was no laches, negligence or deficiency of service or any manner of unfair trade practice made by the OP but malpractices had been adopted by the complainant and only to grab more money filed this complaint only to harass the OP and only to waste the time of the Forum and fact remains complainant must be a honest consumer but in this case the consumer has adopted dishonest practice and file this complaint and for which this complaint is found vexatious and false one and for which the complaint fails with cost.

Hence,

Ordered

That the case be and the same is dismissed on contest against the OPs and complainant is directed to deposit a sum of Rs.5,000/-(Rupees Five thousand only) to this Forum for filing such vexatious and false claim even after enjoying total sum insured during the validity of her mediclaim policy being No.100100/48/12/8500002410 valid from 26-12-2012 to 25-12-201.  Complainant is directed to deposit amount to this Forum within one month from the date of this order failing which penal action shall be started against her to realize the same.