Order-23.

Date-10/08/2015.

In this complaint Complainant Surya Kanta Khemkaby filing this complaint has submitted that complainant purchased a Private Mediclaim Hospitalisation Benefit Policy from op no.1 vide Policy No. 101100/48/12/850007884 and had paid a premium of Rs. 9,517/- and the said Insurance Policy was valid for the period from 03.11.2012 to mindnight of 02.11.2013 for a sum insured of Rs. 5 lakhs.

During the pendency of the said policy, complainant fell ill and was diagnosed with Hernia by Dr. Mehli A. Nazir on 03.06.2013 and was advised for hospitalization for removal of abdominal wall Hernia on 04.06.2013 BY surgery and accordingly complainant was admitted to Breach Candy Hospital Trust on 04.06.2013 with diagnosis of Abdominal Wall Hernia and the Hernia operation was done and treated by Dr. Mehlia A. Nazir as in patient being no. 1304375, bed no. 673925 and thereafter he was discharged from the said hospital on 09.06.2013 and for such treatment, complainant has incurred expenses of Rs. 3,70,317.92 paisa as towards his medical treatment cost including post hospitalization charges.

After that complainant submitted his claim for Rs. 3,70,317.92 paisa vide claim No. NI-6118517 before the TPA Genins India TPA Ltd. For settlement of his claim along with all original documents, cash memo, receipt, pathological reports, hospital bills, hospital money receipt and money receipts etc.Op no.2 TPA received the claim along with all enclosures.But TPA op no.2 made a payment of Rs. 1,52,704/- out of Rs. 3,70,318/- through Electronic Fund Transfer to the Bank account of the complainant on 21.09.2013 vide A/c no. 9502010002132.In fact op nos. 1 & 2 unjustifiably deducted the claim of the complainant and thereafter complainant sent a letter to the op no.2 for disbursement of rest of the claimed amount.But op no.2 refused to make any payment, though complainant is a bona fide claimant as per policy’s terms and conditions and when ops have not paid the balance amount of Rs. 2,17,613.92 paisa against the insured amount, then for the negligence and deficient manner of service on the part of the op, op may be directed to pay the same along with compensation for mental harassment by the ops to the complainant.

On the other hand Insurance Company by filing written statement submitted that no doubt complainant purchased a Private Mediclaim Hospitalisation Benefit Policy from op no.1 on 01.11.2012 and said policy was valid for the period from 03.11.2012 to midnight 02.11.2013 and policy was issued by the op no.1 and during the pendency of the said policy complainant fell ill and was diagnosed by Dr. Mehli A. Nazir on 03.06.2013 and he was admitted to Breach Candy Hospital Trust on 04.06.2013 and was discharged on 09.06.2013and on that occasion complainant incurred a sum of Rs. 3,70,317.92 paisa as expenses towards his medical treatment including post hospitalization charges and submitted his claim of the same amount and that claim was received by the op no.2 and op no.2 settled the claim as per terms and conditions of the policy.

It is specifically mentioned by the op Insurance Company that at the time of said payment, op no.2 clearly explained the nature of payment which are applicable to policy conditions and which are not applicable to policy conditions were duly explained in detail but the complainant made a remark as the same are unjustified and asked for full payment but the op no.1 submitted that TPA made the payment in terms of policy conditions rightly and deduction as made by the op no.2 was justified and further it is mentioned that Dr. Mehli A. Nazir issued a certificate dated 14.06.2013 in favour of Mr. S. Khemka that total expenses incurred of Rs. 2 lakhs for clinic and Rs. 34,000/- for hospital fees.But the complainant stated in his claim that he has paid Rs. 3,70,317.92 paisa.

So, it differs from the certificate of Dr. Mehli A. Nazir who has stated in his certificate dated 14.06.2013 otherwise there are difference between the claim form and the doctor certificate.Even then op no.2 has paid the bill as per policy conditions and rules frame thereunder and there is no act illegal action without any reason, so there is no negligence on the part of the op.In the circumstances, the present complaint should be dismissed.

On the other hand op no.2 by filing written statement submitted that they act as administrator of the op no.1 and the claim of the complainant was duly considered and again it was reviewed but the contention of the complainant is not valid and not sustainable and moreover hospital bill of Rs. 12,600/- is included in the main bill and the remaining portion of Rs. 71,400/- charged separately on behalf of doctor as doctor’s fees, though surgical fees is being included in the hospital billing.But as per policy condition, separate charges incurred if any by complainant towards the same outside the hospital billing is not tenable and has no basis and it is not a portion of treatment and further they have stated that doctor’s fees has been fully paid but the money as taken by the doctor separately outside hospital is not acceptable as per policy condition.

So, there is no negligence and deficiency on the part of the op no. 2 to settle the said claim and settlement was made as per policy condition.So, the complaint should be dismissed against op no.2 also.

Decision with reasons

On proper consideration of the complaint and written version and also considering the policy condition, it is clear that only the hospitalization bill shall be entertained by the Insurance Company for settlement of claim.At the same time it is noted against clause 2.1.1 (Note) that complainant’s liability would arise if the treatment of disease or injury contracted suffered is incepted during the policy period.Total expenses incurred for any one illness is limited to 50 percent of overall sum insured per family.Company’s liability in respect of an insurance shall not exceed the sum insure mentioned in the schedule and considering that fact, it is clear that from the substance of the present policy for each illness only50 percent of this total sum insured shall be considered for settlement of claim.But above all there are other conditions.It is specifically mentioned that only for the hospitalization period and treatment fees which shall be included in the hospital bill that shall be considered.At the same time there are some other conditions that already noted in clause 1.0.

So, considering all those fact and including the assessment of bill as made by the op no.2, it is clear that deductions were made as per clause of the policy.Moreover it is found that admittedly op already paid an amount of Rs. 1,52,704/- to the insured out of his claim of Rs. 3,70,318/-.Truth is that hospitalization period was from 04.06.2013 to 09.06.2013 and total sum insured is Rs. 5,00,000/- and complainant claimed of Rs. 3,70,318/- and out of that op no.2 deducted of Rs. 2,17,614/- on the ground that excess clause was not applicable and as per said Note of the policy initially the sum insured shall be 50 percent i.e. Rs. 2.5 lakhs shall be the highest payment.But from the assessment chart of the op no.2, it is clear that complainant is entitled to Rs. 25,000/- as shown in the hospital bill and Rs. 84,000/- for consultation, so paid Rs. 1,25,000/- and for other item Rs. 43,704/- was paid out of Rs. 2.5 lakhs and some other items is not admissible that is also noted.

So, considering all the entire materials, it is found that op rightly decided the claim pointing out detail the cause of deduction because outside hospitalization period, complainant cannot claim for any further amount when same were not included in the hospital bill because it is completely policy of hospitalization reimbursement.

Anyhow in the bill, it is specifically noted the doctor’s fees are for the entire service during the patient stayed in the hospital.Then invariably after that complainant cannot claim any further bill for the doctors, though complainant procured such bill, but it is not entertained by the op no doubt as per terms and conditions of the said policy.

So, considering all the above fact and materials, we are convinced to hold that ops did not act illegally and arbitrarily.But they decided the settlement of claim of the complainant duly applying the terms and conditions of the policy and paid of Rs. 1,52,704/- out of the claim amount of Rs. 3,70,318/- and so the complainant’s claim for reimbursement of balance amount is found in the eye of law not maintainable and in fact complainant is bound by the terms and conditions of the policy as claim for reimbursement was decided rightly and a sum of Rs. 1,52,704/- was released but more than that complainant is not entitled to any further amount.In this context it is to be mentioned that some fora are granting some excess amount on settlement of claim on the ground of equity.Even higher Fora is also passing such order, but already State Commission of West Bengal and National Commission have confirmed that some Fora including Supreme Court authority shall have to decide the claim as per terms and conditions of the policy and there is no scope on the part of any Forum to consider any extra claim on the ground of equity and no exception or relaxation can be made on the ground of equity.Supra 213 (4) CPR 165 NC and relying upon that ruling and also ruling of the State Commission, we are convinced that there is no scope to show any equity in the present case to the complainant.

In the result, complaint fails.

Hence, it is

That the complaint be and the same is dismissed on contest with cost of Rs. 5,000/- against the op.

Complainant shall have to pay the said cost to this Forum and even if it is not paid by the complainant within one month from the date of this order, in that case penal action shall be started against him.